Why don't physicians follow clinical practice guidelines? A framewouk for improvement

Context Despite wide promulgation, clinical practice guidelines have had li mited effect on changing physician behavior. Little is known about the proc ess and factors in; in changing physician practices in response to guidelin es. Objective To review barriers to physician adherence to clinical practice gu idelines. Data Sources We searched the MEDLINE, Educational Resources Information Cen ter (ERIC), and HealthSTAR databases (January 1966 to January 1998); biblio graphies; textbooks on health behavior or public health; and references sup plied by experts to find English-language article titles that describe barr iers to guideline adherence. Study Selection Of 5658 articles initially identified, we selected 76 publi shed studies describing at least 1 barrier to adherence to clinical practic e guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate article s, then 2 investigators independently reviewed the texts to exclude article s that did not match the criteria. Differences were resolved by consensus w ith a third investigator. Data Extraction Two investigators organized barriers to adherence into a fr amework according to their effect on physician knowledge, attitudes, or beh avior. This organization was validated by 3 additional investigators. Data Synthesis The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awarene ss (n = 46), familiarity (n = 31), agreement (n = 33), self-efficacy (n = 1 9), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendat ions (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 ty pe of barrier. Conclusions Studies on improving physician guideline adherence may not be g eneralizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guide line adherence and a framework for future research.