Connect
MJA
MJA

Clinicians' attitudes to clinical practice guidelines: a systematic review

Cynthia M Farquhar, Emma W Kofa and Jean R Slutsky
Med J Aust 2002; 177 (9): 502-506.

Summary

Objective: To systematically review surveys of clinicians' attitudes to clinical practice guidelines.

Data sources: MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000.

Study selection: We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%.

Results: Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%–75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%–83%), good educational tools (71%; 63%–79%) and intended to improve quality (70%; 60%–80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%–36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%–47%), would increase litigation (41%; 32%–49%) and were intended to cut healthcare costs (52.8%; 39%–66%).

Conclusions: Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.

Please login with your free MJA account to view this article in full

  • Cynthia M Farquhar1
  • Emma W Kofa2
  • Jean R Slutsky3

  • Centre for Practice Technology Assessment, Agency for Healthcare Research and Quality, Rockville, MD, USA.

Correspondence: c.farquhar@auckland.ac.nz

Acknowledgements: 

Dr C M Farquhar was supported by the Commonwealth Fund of New York. Ms Kofa was sponsored as a Summer Intern by the Department of Health and Human Services, Washington DC.

Competing interests:

None identified.

  • 1. Field M, Lohr KN. Attributes of good practice guidelines. In: Field M, Lohr KN, editors. Clinical practice guidelines: directions for a new program. Washington, DC: National Academy Press, 1990: 53-77.
  • 2. Carnett WG. Clinical practice guidelines: a tool to improve care. Qual Manag Health Care 1999; 8: 13-21.
  • 3. Handley MR, Stuart ME, Kirz HL. An evidence-based approach to evaluating and improving clinical practice: implementing practice guidelines. HMO Pract 1994; 8: 75-83.
  • 4. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ 1999; 318: 593-596.
  • 5. Woolf S. Practice guidelines: a new reality in medicine II. Methods of developing guidelines. Arch Intern Med 1992; 152: 946-952.
  • 6. Eisenberg J, Power E. Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality. JAMA 2000; 284: 2100-2107.
  • 7. Woolf SH, Grol R, Hutchinson A, et al. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318: 527-530.
  • 8. Grol R, Dalhuijsen J, Thomas S, et al. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998; 317: 858-861.
  • 9. Appraisal of Guidelines Research and Evaluation in Europe. The AGREE Collaboration. <http://www.agreecollaboration.org/> Accessed 24 September 2002.
  • 10. McLaughlin TJ, Soumerai SB, Wilson DJ, et al. Adherence to national guideline for drug treatment of suspected acute myocardial infarction: evidence for undertreatment in women and the elderly. Arch Intern Med 1996; 156: 799-805.
  • 11. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1322.
  • 12. Thomas L, Cullum N, McColl E, et al. Guidelines in professions allied to medicine [Cochrane Review]. In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software, 2002.
  • 13. Soumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997; 277: 115-121.
  • 14. Armstrong D, Fry J, Armstrong P. General practitioners' views of clinical guidelines for the management of asthma. Int J Qual Health Care 1994; 6: 199-202.
  • 15. Audet AM, Greenfield S, Field M. Medical practice guidelines: current activities and future directions. Ann Intern Med 1990; 113: 709-714.
  • 16. Deutsch SC, Denton M, Borenstein J. Clinical practice guidelines: a tool to help provide quality care. Geriatrics 1998; 53: 57, 61-64, 70, 73-74.
  • 17. Delmothe T. Wanted: guidelines that doctors will follow. BMJ 1998; 307: 218.
  • 18. Tunis SR, Hayward RS, Wilson MC, et al. Internists' attitudes about clinical practice guidelines [see comments]. Ann Intern Med 1994; 120: 956-963.
  • 19. Grol R. National standard setting for quality of care in general practice: attitudes of general practitioners and response to a set of standards. Br J Gen Pract 1990; 40: 361-364.
  • 20. American Cancer Society. 1989 Survey of physicians' attitudes and practices in early cancer detection. Cancer 1990; 40: 77-101.
  • 21. Nowells D. Features of clinical practice guidelines that influence physician perceptions of credibility. Conducted 1992. MPH thesis 1997. Washington, DC: University of Washington.
  • 22. Madhok R, Thomson RG, Mordue A, et al. An audit of distribution and use of guidelines for management of head injury. Qual Health Care 1993; 2: 27-30.
  • 23. Shye D, Brown JB. Primary care HMO clinicians' opinions about clinical practice guidelines. HMO Pract 1995; 9: 111-115.
  • 24. Mansfield CD. Attitudes and behaviours towards clinical guidelines: the clinicians' perspective. Qual Health Care 1995; 4: 250-255.
  • 25. Hormbrey P, Todd BS, Mansfield CD, et al. A survey of teaching and the use of clinical guidelines in accident and emergency departments. J Accid Emerg Med 1996; 13: 129-133.
  • 26. Grilli R, Penna A, Zola P, et al. Physicians' view of practice guidelines. A survey of Italian physicians. Soc Sci Med 1996; 43: 1283-1287.
  • 27. Ferrier BM, Woodward CA, Cohen M, et al. Clinical practice guidelines. New-to-practice family physicians' attitudes. Can Fam Physician 1996; 42: 463-468.
  • 28. Pathman DE, Konrad TR, Freed GL, et al. The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations. Med Care 1996; 34: 873-889.
  • 29. Hayward RS, Guyatt GH, Moore KA, et al. Canadian physicians' attitudes about and preferences regarding clinical practice guidelines [see comments]. CMAJ 1997; 156: 1715-1723.
  • 30. Gupta L, Ward J, Hayward RS. Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact. Med J Aust 1997; 166: 69-72.
  • 31. Salem-Schatz SR, Gottlieb LK, Karp MA, et al. Attitudes about clinical practice guidelines in a mixed model HMO: the influence of physician and organizational characteristics. HMO Pract 1997; 11: 111-117.
  • 32. Alston RP. Guidelines and cardiac anaesthesia. Anaesthesia 1997; 52: 328-331.
  • 33. Dodek P. Attitudes to guidelines for arterial blood gas measurements. Presentation to staff of Division of Critical Care Medicine, St Paul's Hospital and University of British Columbia, BC, Canada. 1997.
  • 34. Olesen F, Lauritzen T. Do general practitioners want guidelines? Attitudes toward a county-based and a national college-based approach. Scand J Prim Health Care 1997; 15: 141-145.
  • 35. Woolf M, Bower DJ, Marbella AM, Casanova JE. US Family Physicians' experiences with practice guidelines. Fam Med 1998; 30: 117-121.
  • 36. Carrick SE, Bonevski B, Redman S, et al. Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer. Med J Aust 1998; 169: 300-305.
  • 37. Browman GP, Newman TE, Mohide EA, et al. Progress of clinical oncology guidelines development using the practice guidelines development cycle: the role of practitioner feedback. J Clin Oncol 1998; 16: 1226-1231.
  • 38. Halm EA, Atlas SJ, Borowsky LH, et al. Understanding physician adherence with a pneumonia practice guideline: effects of patient, system, and physician factors. Arch Intern Med 2000; 160: 98-104.
  • 39. Girgis S, Ward JE, Thomson CJH. General practitioners' perception of medicolegal risk. Med J Aust 1999: 171: 362-366. http://www.mja.com.au/public/issues/171_7_041099/girgis/girgis.html
  • 40. Grilli R, Trisolini R, Labianca R, et al. Evolution of physicians' attitudes towards practice guidelines. J Health Serv Res Policy 1999; 4: 215-219.
  • 41. Cotton P, Sullivan F. Perceptions of guidelines in primary and secondary care: implications for implementation. J Integrated Care 1999; 3: 79-83.
  • 42. Shah S, Tonkin A, Ward J, Harris P. Implementation of nationally developed guidelines in cardiology: a survey of NSW cardiologists and cardiothoracic surgeons. Aust N Z J Med 1999; 29: 678-683.
  • 43. Costantini O, Papp KK, Como J, et al. Attitudes of faculty, housestaff, and medical students toward clinical practice guidelines [published erratum appears in Acad Med 1999; 74: 1322]. Acad Med 1999; 74: 1138-1143.
  • 44. Harris JS, Mueller KL, Low P, et al. Beliefs about and use of occupational medicine practice guidelines by case managers and insurance adjusters. J Occup Environ Med 2000; 42: 370-376.
  • 45. Dye TD, Alderdice F, Roberge E, et al. Attitudes toward clinical guidelines among obstetricians in Northern Ireland. BJOG 2000; 107: 101-107.
  • 46. Graham ID, Evans WK, Logan D, et al. Canadian oncologists and clinical practice guidelines: a national survey of attitudes and reported use. Oncology 2000; 59: 283-290.
  • 47. Vinker S, Nakar S, Rosenberg E, et al. Attitudes of Israeli family physicians towards clinical guidelines. Arch Fam Med 2000; 9: 835-840.
  • 48. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002; 324: 1183-1192.
  • 49. Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q 1998; 76: 509, 517-563.
  • 50. Poses RM. One size does not fit all: questions to answer before intervening to change physician behavior. Jt Comm J Qual Improv 1999; 25: 486-495.
  • 51. Merritt TA, Gold M, Holland J. A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs? Eval Clin Pract 1999; 5: 169-177.
  • 52. Rappolt SG. Clinical guidelines and the fate of medical autonomy in Ontario. Soc Sci Med 1997; 44: 977-987.
  • 53. Hyams AL, Brandenbrug JA, Lipsitz SR. Practice guidelines and malpractice litigation: a two way street. Ann Intern Med 1995; 122: 450-455.
  • 54. Hurwitz B. Legal and political considerations of clinical practice guidelines. BMJ 1999; 318: 661-664.
  • 55. Brushwood DB. Clinical practice guidelines and the standard of care. Am J Health Syst Pharm 2000; 57: 159-161.
  • 56. National Health Service Executive. Clinical guidelines. Leeds: NHSE, 1996: 10.
  • 57. Miller FH. The legal ramifications of the NCCN practice guidelines. Oncology 1996; 10: 35-39.
  • 58. Vollman K, Sprung P, Posa S. Strategies for reducing material costs through implementation of clinical guidelines. J Soc Health Syst 1998; 5: 69-73.
  • 59. Pitimana-aree S, Forrest D, Brown G. Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care. Intensive Care Med 1998; 24: 217-223.
  • 60. Greco PJ, Eisenberg JM. Changing physicians' practice. N Engl J Med 1993; 329: 1271-1273.
  • 61. Farquhar CM, Stryer D, Slutsky J. Translating research into practice: the future ahead. Int J Qual Health Care 2002. 14: 233-249.
  • 62. National Health and Medical Research Council. Guidelines for the development and implementation of clinical practice guidelines. Canberra: NHMRC, 2001.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.