The DOI matches its Crossref record; 100 of the 100 references it cites were found in a registry or an index.
Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement
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.
Overview
Integrity signals
Registry
Cites
Statistics
Verification
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
Citations
Cites
Rogers, E. M., Singhal, A., & Quinlan, M. M. (2019) · Routledge eBooks · doi:10.4324/9780203710753-35 · Cited by 37,668
(1985) · Medical Entomology and Zoology · Cited by 19,180
Stages and processes of self-change of smoking: Toward an integrative model of change.
Prochaska, J. O., & DiClemente, C. C. (1983) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.51.3.390 · Cited by 9,098
Guide to Clinical Preventive Services
Allen, T. W. (1991) · The Journal of the American Osteopathic Association · doi:10.1515/jom-1991-900515 · Cited by 2,141
Clinical practice guidelines : directions for a new program
Field, M. J., & Lohr, K. N. (1990) · Cited by 1,415
Do Practice Guidelines Guide Practice?
Lomas, J., Anderson, G. M., Pierre, K. D., Vayda, E., Enkin, M. W., & Hannah, W. J. (1989) · New England Journal of Medicine · doi:10.1056/nejm198911093211906 · Cited by 1,231
(1997) · Europe PMC (PubMed Central) · Cited by 1,226
Changing Physicians' Practices
Greco, P. J., & Eisenberg, J. M. (1993) · New England Journal of Medicine · doi:10.1056/nejm199310213291714 · Cited by 976
Publication bias—a problem in interpreting medical data
Begg, C. B., & Berlin, J. A. (1988) · Journal of the Royal Statistical Society. Series A (Statistics in Society) · doi:10.2307/2982993 · Cited by 814
The Awareness-to-Adherence Model of the Steps to Clinical Guideline Compliance
Pathman, D. E., Konrad, T. R., Freed, G. L., Freeman, V. A., & Koch, G. G. (1996) · Medical Care · doi:10.1097/00005650-199609000-00002 · Cited by 499
Cited by
Sorted by citations
Items 101–123 of 123
van Beurden, K. M., van der Klink, J. J. L., Brouwers, E. P. M., Joosen, M. C. W., Mathijssen, J. J. P., Terluin, B., & van Weeghel, J. (2015) · BMC Public Health · doi:10.1186/s12889-015-2125-3 · Cited by 40
“Specifically, the focus of the training was on overcoming the three main clusters of barriers to guideline adherence: lack of knowledge, negative attitudes, and practical barriers [31].”
Lehmann, M., Pohontsch, N. J., Zimmermann, T., Scherer, M., & Löwe, B. (2021) · BMC Family Practice · doi:10.1186/s12875-021-01397-w · Cited by 37
Godbee, K., Gunn, J., Lautenschlager, N. T., Curran, E., & Palmer, V. J. (2019) · Primary Health Care Research & Development · doi:10.1017/s1463423619000744 · Cited by 33
Kerins, C., McHugh, S., McSharry, J., Reardon, C. M., Hayes, C., Perry, I. J., Geaney, F., Seery, S., & Kelly, C. (2020) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-020-00948-1 · Cited by 30
Konijnendijk, A. A. J., Boere-Boonekamp, M. M., Fleuren, M. A. H., Haasnoot, M. E., & Need, A. (2016) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2015.11.006 · Cited by 28
The Apache Study Group, Giusti, A., Spila Alegiani, S., Ciofi degli Atti, M. L., Colaceci, S., Raschetti, R., Arace, P., Spiazzi, R., & Raponi, M. (2016) · BMC Pediatrics · doi:10.1186/s12887-016-0739-y · Cited by 27
Sticky apps, not sticky hands: A systematic review and content synthesis of hand hygiene mobile apps
Gasteiger, N., Dowding, D., Ali, S. M., Scott, A. J. S., Wilson, P., & van der Veer, S. N. (2021) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocab094 · Cited by 26
Michel, J., Manns, A., Boudersa, S., Jaubert, C., Dupic, L., Vivien, B., Burgun, A., Campeotto, F., & Tsopra, R. (2024) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2024.105347 · Cited by 26
Sepsis guideline implementation: benefits, pitfalls and possible solutions
Kissoon, N. (2014) · Critical Care · doi:10.1186/cc13774 · Cited by 25
Evaluation of an electronic clinical decision support tool for incident elevated BP in adolescents
Kharbanda, E. O., Asche, S. E., Sinaiko, A., Nordin, J. D., Ekstrom, H. L., Fontaine, P., Dehmer, S. P., Sherwood, N. E., & O'Connor, P. J. (2018) · Academic Pediatrics · doi:10.1016/j.acap.2017.07.004 · Cited by 24
Raucci, U., Scateni, S., Tozzi, A. E., Drago, F., Giordano, U., Marcias, M., Faa, F., & Reale, A. (2014) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2014.06.064 · Cited by 24
Woiski, M. D., Belfroid, E., Liefers, J., Grol, R. P., Scheepers, H. C., & Hermens, R. P. (2015) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-015-0707-9 · Cited by 22
Lau, R., Stevenson, F., Ong, B. N., Dziedzic, K., Eldridge, S., Everitt, H., Kennedy, A., Kontopantelis, E., Little, P., Qureshi, N., et al. (2014) · BMJ Open · doi:10.1136/bmjopen-2014-005548 · Cited by 26
Aakhus, E., Oxman, A. D., & Flottorp, S. A. (2014) · Scandinavian Journal of Primary Health Care · doi:10.3109/02813432.2014.984961 · Cited by 19
Hasebrook, J. P., Michalak, L., Kohnen, D., Metelmann, B., Metelmann, C., Brinkrolf, P., Flessa, S., & Hahnenkamp, K. (2023) · PLOS ONE · doi:10.1371/journal.pone.0280956 · Cited by 19
Vaccaro, L., Shaw, J., Sethi, S., Kirsten, L., Beatty, L., Mitchell, G., Kissane, D., Kelly, B., & Turner, J. (2019) · Psycho-Oncology · doi:10.1002/pon.5165 · Cited by 17
Dahne, J., Wahlquist, A. E., Boatright, A. S., Garrett-Mayer, E., Fleming, D. O., Davis, R., Egan, B., & Carpenter, M. J. (2018) · Contemporary Clinical Trials · doi:10.1016/j.cct.2018.07.008 · Cited by 16
Hayes, R. P., Baker, D. W., Luthi, J.-C., Baggett, R. L., McClellan, W., Fitzgerald, D., Abrams, F. R., Bratzler, D., & Ballard, D. J. (2002) · American Journal of Medical Quality · doi:10.1177/106286060201700605 · Cited by 15
Dankers, M., van den Berk-Bulsink, M. J. E., van Dalfsen-Slingerland, M., Nelissen-Vrancken, H. J. M. G., Mantel-Teeuwisse, A. K., & van Dijk, L. (2022) · BMC Primary Care · doi:10.1186/s12875-022-01760-5 · Cited by 7
Edward, A., Kagaruki, G. B., Manase, F., Appel, L. J., & Matsushita, K. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-08064-5 · Cited by 6
Folks, B., LeBlanc, W. G., Staton, E. W., & Pace, W. D. (2011) · Implementation Science · doi:10.1186/1748-5908-6-65 · Cited by 5
Wang, R., Shaw, I., & Middleton, H. (2015) · Mental Health Review Journal · doi:10.1108/mhrj-03-2014-0008 · Cited by 3
Akkus Yildirim, B., Tutun, B., Durak, G., Yildirim, E. B., Uysal, E., Erturk, S. M., & Bagci, U. (2025) · Communications Medicine · doi:10.1038/s43856-025-01315-6 · Cited by 2
Metadata
- 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)
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 1999-10-20
- Volume
- 282
- Issue
- 15
- Pages
- 1458
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- 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
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
