CoChat
Sign Up
Cited by 261Clinical practice guidelines implementationHealth Policy Implementation ScienceHealth Sciences Research and Education

Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews

Open access
Wang, Tao, Tan, Jing-Yu (Benjamin), Liu, Xian-Liang, Zhao, Isabella·2023·BMJ Open
DOI 10.1136/bmjopen-2022-062158PMC PMC9827241
Open this paper in CoChat — free accountOpen PDF

Abstract

Objectives: To identify the barriers and enablers to implementing clinical practice guidelines (CPGs) recommendations in primary care and to provide recommendations that could facilitate the uptake of CPGs recommendations. Design: An overview of systematic reviews. Data sources: Nine electronic databases (PubMed, Cochrane Library, CINAHL, MEDLINE, PsycINFO, Web of Science, Journals @Ovid Full Text, EMBase, JBI) and three online data sources for guidelines (Turning Research Into Practice, the National Guideline Clearinghouse and the National Institute for Health and Care Excellence) were searched until May 2021. Eligibility criteria: Systematic reviews, meta-analyses or other types of systematic synthesis of quantitative, qualitative or mixed-methods studies on the topic of barriers and/or enablers for CPGs implementation in primary care were included. Data extraction and synthesis: Two authors independently screened the studies and extracted the data using a predesigned data extraction form. The methodological quality of the included studies was appraised by using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Content analysis was used to synthesise the data. Results: Twelve systematic reviews were included. The methodological quality of the included reviews was generally robust. Six categories of barriers and enablers were identified, which include (1) political, social and culture factors, (2) institutional environment and resources factors, (3) guideline itself related factors, (4) healthcare provider-related factors, (5) patient-related factors and (6) behavioural regulation-related factors. The most commonly reported barriers within the above-mentioned categories were suboptimal healthcare networks and interprofessional communication pathways, time constraints, poor applicability of CPGs in real-world practice, lack of knowledge and skills, poor motivations and adherence, and inadequate reinforcement (eg, remuneration). Presence of technical support (‘institutional environment and resources factors’), and timely education and training for both primary care providers (PCPs) (‘healthcare provider-related factors’) and patients (‘patient-related factors’) were the frequently reported enablers. Conclusion: Policy-driven strategies should be developed to motivate different levels of implementation activities, which include optimising resources allocations, promoting integrated care models, establishing well-coordinated multidisciplinary networks, increasing technical support, encouraging PCPs and patients’ engagement in guideline development, standardising the reporting of guidelines, increasing education and training, and stimulating PCPs and patients’ motivations. All the activities should be conducted by fully considering the social, cultural and community contexts to ensure the success and sustainability of CPGs implementation.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1136/bmjopen-2022-062158

Cites

8 of 8 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

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?

  • The length of NICE guidelines can lead to a diminished utilisation rate, due to the long time needed to find relevant information in an already overburdened health system.

    “This can lead to a diminished utilisation rate, due to the long time needed to find relevant information in an already overburdened health system (Wang et al., 2023).”

    From Grounding Large Language Models in Clinical Evidence: A Retrieval-Augmented Generation System for Querying UK NICE Clinical Guidelines (2025) · cites this paper as Wang et al., 2023

    The Results (Barriers and enablers for CPGs implementation in primary care; page not provided) report that clinicians face information overload and that the volume of guidelines can make it difficult to read and assimilate them. They also identify time constraints and heavy workload as barriers. The paper does not specifically link the length of NICE guidelines, or time spent finding information within them, to diminished utilisation. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • The time required for clinicians to manually search through clinical guidelines has become a significant barrier to their use.

    “As noted by Wang et al. (2023), the time required for clinicians to manually search through these documents has become a significant barrier to their use.”

    From Grounding Large Language Models in Clinical Evidence: A Retrieval-Augmented Generation System for Querying UK NICE Clinical Guidelines (2025) · cites this paper as Wang et al. (2023)

    The Results section identifies time constraints as a frequent barrier and says the volume of guidelines can overwhelm clinicians who need time to read and assimilate them. It does not specifically identify the time spent manually searching through guideline documents as the barrier; the paper’s own database searches are part of its research methods, not clinicians’ guideline use. No page number is available in our copy. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 35

  1. [1]Franco JVA, Arancibia M, Meza N, et al. Clinical practice guidelines: concepts, limitations and challenges. Medwave 2020; 20: e7887. 10.5867/medwave.2020.03.7887 32428925 · DOI
  2. [2]Bierbaum M, Rapport F, Arnolda G, et al. Adherence to clinical practice guidelines (CpGs) for the treatment of cancers in Australia and the factors associated with adherence: a systematic review protocol. BMJ Open 2021; 11: e050912. 10.1136/bmjopen-2021-050912 PMC8458325 34548359 · DOI
  3. [3]Kredo T, Bernhardsson S, Machingaidze S, et al. Guide to clinical practice guidelines: the current state of play. Int J Qual Health Care 2016; 28: 122– 8. 10.1093/intqhc/mzv115 26796486 PMC4767049 · DOI
  4. [4]Brown PD. Adherence to guidelines for community-acquired pneumonia: does it decrease cost of care? Pharmacoeconomics 2004; 22: 413– 20. 10.2165/00019053-200422070-00001 15137880 · DOI
  5. [6]Glasziou P, Straus S, Brownlee S, et al. Evidence for underuse of effective medical services around the world. Lancet 2017; 390: 169– 77. 10.1016/S0140-6736(16)30946-1 28077232 · DOI
  6. [7]Villar-Álvarez F, Moreno-Zabaleta R, Mira-Solves JJ, et al. Do not do in COPD: consensus statement on overuse. Int J Chron Obstruct Pulmon Dis 2018; 13: 451– 63. 10.2147/COPD.S151939 29440883 PMC5799849 · DOI
  7. [8]Pepió Vilaubí JM, Orozco-Beltrán D, Gonçalves AQ, et al. Adherence to European clinical practice guidelines for secondary prevention of cardiovascular disease: a cohort study. Int J Environ Res Public Health 2018; 15: 1233. 10.3390/ijerph15061233 29891821 PMC6025527 · DOI
  8. [9]Schuster MA, McGLYNN EA, Brook RH. How good is the quality of health care in the United States? Milbank Q 2005; 83: 843– 95. 10.1111/j.1468-0009.2005.00403.x 16279970 PMC2690270 · DOI
  9. [10]Castillo RC, Heins S, Feldman D, et al. The impact of adherence to clinical practice guidelines on medical costs. J Occup Environ Med 2020; 62: 712– 7. 10.1097/JOM.0000000000001938 32890209 · DOI
  10. [12]Alañón Pardo MDM, Ferrit Martín M, Calleja Hernández Miguel Ángel, et al. Adherence of psychopharmacological prescriptions to clinical practice guidelines in patients with eating behavior disorders. Eur J Clin Pharmacol 2017; 73: 1305– 13. 10.1007/s00228-017-2287-2 28653297 · DOI
  11. [13]Francke AL, Smit MC, de Veer AJE, et al. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak 2008; 8: 1. 10.1186/1472-6947-8-38 18789150 PMC2551591 · DOI
  12. [14]Flottorp SA, Oxman AD, Krause J, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Sci 2013; 8: 35. 10.1186/1748-5908-8-35 PMC3617095 23522377 · DOI · Paper page
  13. [15]Gagliardi AR. "More bang for the buck": exploring optimal approaches for guideline implementation through interviews with international developers. BMC Health Serv Res 2012; 12: 404. 10.1186/1472-6963-12-404 23153052 PMC3561165 · DOI
  14. [16]Peters S, Bussières A, Depreitere B, et al. Facilitating guideline implementation in primary health care practices. J Prim Care Community Health 2020; 11: 215013272091626. 10.1177/2150132720916263 PMC7232877 32390499 · DOI
  15. [18]Grol R, Wensing M. What drives change? barriers to and incentives for achieving evidence‐based practice. Med J Aust 2004; 180: S57– 60. 10.5694/j.1326-5377.2004.tb05948.x 15012583 · DOI · Paper page
  16. [21]Johnston JL, Bennett D. Lost in translation? paradigm conflict at the primary–secondary care interface. Med Educ 2019; 53: 56– 63. 10.1111/medu.13758 30443926 · DOI
  17. [25]Wang T, Molassiotis A, Chung BPM, et al. Unmet care needs of advanced cancer patients and their informal caregivers: a systematic review. BMC Palliat Care 2018; 17: 1– 29. 10.1186/s12904-018-0346-9 PMC6057056 30037346 · DOI · Paper page
  18. [28]Ezeani NJ. Guideline use in asthma management in primary care settings: a systematic review. Doctoral dissertation: Walden University, 2016.
  19. [29]Mathieson A, Grande G, Luker K. Strategies, facilitators and barriers to implementation of evidence-based practice in community nursing: a systematic mixed-studies review and qualitative synthesis. Prim Health Care Res Dev 2019; 20: e6. 10.1017/S1463423618000488 30068402 PMC6476399 · DOI
  20. [30]Neale EP, Middleton J, Lambert K. Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review. BMC Nephrol 2020; 21: 1– 7. 10.1186/s12882-020-01731-x PMC7066820 32160886 · DOI
  21. [31]Rushforth B, McCrorie C, Glidewell L, et al. Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review. Br J Gen Pract 2016; 66: e114– 27. 10.3399/bjgp16X683509 26823263 PMC4723210 · DOI · Paper page
  22. [32]Slade S, Kent P, Patel S. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and meta-synthesis of qualitative studies. Arthritis & Rheumatology 2015; 67: 1794. PMC4410131 25900462
  23. [33]Smeets M, Van Roy S, Aertgeerts B, et al. Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis. BMJ Open 2016; 6: e013459. 10.1136/bmjopen-2016-013459 PMC5168518 27903565 · DOI
  24. [34]Swaithes L, Paskins Z, Dziedzic K, et al. Factors influencing the implementation of evidence-based guidelines for osteoarthritis in primary care: a systematic review and thematic synthesis. Musculoskeletal Care 2020; 18: 101– 10. 10.1002/msc.1452 31997576 · DOI
  25. [35]Tan K, Black BP. A systematic review of health care provider-perceived barriers and facilitators to routine HIV testing in primary care settings in the southeastern United States. J Assoc Nurses AIDS Care 2018; 29: 357– 70. 10.1016/j.jana.2017.12.006 29331504 PMC5911402 · DOI
  26. [36]Unverzagt S, Oemler M, Braun K, et al. Strategies for guideline implementation in primary care focusing on patients with cardiovascular disease: a systematic review. Fam Pract 2014; 31: 247– 66. 10.1093/fampra/cmt080 24367069 · DOI
  27. [37]Rubio-Valera M, Pons-Vigués M, Martínez-Andrés M, et al. Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography. PLoS One 2014; 9: e89554. 10.1371/journal.pone.0089554 24586867 PMC3938494 · DOI
  28. [38]Wood E, Ohlsen S, Ricketts T. What are the barriers and facilitators to implementing collaborative care for depression? A systematic review. J Affect Disord 2017; 214: 26– 43. 10.1016/j.jad.2017.02.028 28266319 · DOI
  29. [39]Bown MJ, Sutton AJ. Quality control in systematic reviews and meta-analyses. Eur J Vasc Endovasc Surg 2010; 40: 669– 77. 10.1016/j.ejvs.2010.07.011 20732826 · DOI
  30. [40]Loonen JJ, Blijlevens NMA, Prins J, et al. Cancer survivorship care: person centered care in a multidisciplinary shared care model. Int J Integr Care 2018; 18. 10.5334/ijic.3046 PMC5854087 29588641 · DOI
  31. [41]Davies C, Summersby E, Clarke V, et al. Enhancing cancer care Guideline development and implementation using formal guideline adaptation: methodology description. Int J Integr Care 2019; 19: 656. 10.5334/ijic.s3656 · DOI
  32. [42]Martin S. Co-production of social research: strategies for engaged scholarship. Public Money & Management 2010; 30: 211– 8. 10.1080/09540962.2010.492180 · DOI
  33. [43]Yao X, Ma J, Wang Q, et al. A comparison of agree and right: which clinical practice guideline reporting checklist should be followed by guideline developers? J Gen Intern Med 2020; 35: 894– 8. 10.1007/s11606-019-05508-3 31713037 PMC7080917 · DOI
  34. [44]Boltin D, Kimchi N, Dickman R, et al. Attitudes and practice related to Helicobacter pylori infection among primary care physicians. Eur J Gastroenterol Hepatol 2016; 28: 1035– 40. 10.1097/MEG.0000000000000659 27167452 · DOI
  35. [45]Lim BT, Butow P, Mills J, et al. Information needs of the Chinese community affected by cancer: a systematic review. Psychooncology 2017; 26: 1433– 43. 10.1002/pon.4347 27966240 · DOI

Cited by

Sorted by citations

Authors
Wang, T., Tan, J.-Y. (., Liu, X.-L., & Zhao, I.
Affiliations
  • Charles Darwin University (AU)
  • Queensland University of Technology (AU)
Corresponding author
Zhao, Isabella
ORCID
Venue
BMJ Open
Publisher
BMJ
Published
2023-01
Volume
13
Issue
1
Pages
e062158
ISSN
2044-6055 (ISSN-L)
DOI
10.1136/bmjopen-2022-062158
PMC
PMC9827241
OpenAlex
W4313649985
Cited by
261
References
8
Citations by year
2026: 109 · 2025: 94 · 2024: 44 · 2023: 14
FWCI
12.89
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ Open (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • Charles Darwin University (CDU) Institute of Advanced Studies (N/A)
  • the COVID-19 Supplementary Funding Pool (CSFP) Research Fund Scheme (N/A)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
Keywords
guideline implementation, barriers and facilitators, primary care, guideline uptake, patient engagement, interprofessional communication, health care networks, education and training, institutional support, multidisciplinary care, guideline applicability, time constraints, integrated care model, sociocultural factors, patient factors, behavioral regulation
MeSH terms
Systematic Reviews as Topic, Delivery of Health Care, Health Facility Environment, Health Personnel, Humans, Primary Health Care

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