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Cited by 6,677Clinical practice guidelines implementationHealth Sciences Research and EducationHealth Policy Implementation Science

Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement

Cabana, Michael D., Rand, Cynthia S., Powe, Neil R., Wu, Albert W., Wilson, Modena H., Abboud, Paul-André C., Rubin, Haya R.·1999·JAMA
DOI 10.1001/jama.282.15.1458
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Abstract

CONTEXT: Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines. OBJECTIVE: To review barriers to physician adherence to clinical practice guidelines. DATA SOURCES: We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence. STUDY SELECTION: Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. DATA EXTRACTION: Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. 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 awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier. CONCLUSIONS: Studies on improving physician guideline adherence may not be generalizable, 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 guideline adherence and a framework for future research.

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  • Gaps between research and practice can result from multiple factors, including educational/knowledge deficiencies and/or disagreements, time constraints for practitioners, lack of decision support tools and feedback mechanisms, poorly aligned incentives, and organizational climate and cultural factors.

    “Thus far, the literature indicates that gaps between research and practice can result from multiple factors, including educational/knowledge deficiencies and/or disagreements,10,11 time constraints for practitioners,12,13 lack of decision support tools and feedback mechanisms,13 poorly aligned incentives,14 and a host of other organizational climate and cultural factors.2,15,16”

    From Effectiveness-implementation Hybrid Designs: Combining Elements of Clinical Effectiveness and Implementation Research to Enhance Public Health Impact (2012) · cites this paper as [13]

  • Concerns about reduced autonomy or trust, independence of practice or inability to practise to full scope impeded implementation.

    “Concerns about reduced autonomy or trust, independence of practice or inability to practise to full scope were all shown to impede implementation [16, 31, 35, 39, 54, 55].”

    From Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews (2015) · cites this paper as [39]

  • Interventions that were complex were often associated with lower adoption.

    “Interventions that were complex were often associated with lower adoption [3, 35, 39, 87, 88].”

    From Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews (2015) · cites this paper as [39]

  • Competing priorities, lack of motivation, and low awareness of the intervention were shown to impede implementation.

    “Competing priorities [42, 57, 59, 62, 63, 70, 82], lack of motivation [31, 39, 42, 57, 68, 81] and low awareness of the intervention [31, 35, 38, 39, 43, 44, 68, 75, 80, 81] were shown to impede implementation.”

    From Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews (2015) · cites this paper as [39]

  • Determinants of practice can be identified through formal assessment processes, theory or conceptual models, research literature, or informal approaches such as brainstorming.

    “While these determinants of practice could be identified through formal assessment processes, they could also be identified using theory or conceptual models e.g., [87], research literature e.g., [59,60,88-90], or more informal approaches such as brainstorming e.g., [55].”

    From Implementation strategies: recommendations for specifying and reporting (2013) · cites this paper as [59]

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Authors
Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P.-A. C., & Rubin, H. R.
Affiliations
Johns Hopkins University (US)
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
1999-10-20
Volume
282
Issue
15
Pages
1458
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.282.15.1458
OpenAlex
W1994307831
Cited by
6,677
References
100
Citations by year
2026: 161 · 2025: 156 · 2024: 181 · 2023: 181 · 2022: 243 · 2021: 288 · 2020: 292 · 2019: 286 · 2018: 302 · 2017: 300 · 2016: 330 · 2015: 332 · 2014: 396 · 2013: 334 · 2012: 327
FWCI
113.53
Type
journal article
Language
en
Open access
closed
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
  • Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Keywords
guideline adherence, barriers to adherence, physician behavior, self-efficacy, outcome expectations, physician attitudes, physician knowledge, clinical practice parameters, consensus statement
MeSH terms
Attitude of Health Personnel, Data Collection, Health Knowledge, Attitudes, Practice, Practice Patterns, Physicians', United States, Practice Guidelines as Topic, Guideline Adherence

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