Table 1

Barriers to physician adherence to guidelines

Barriers to adherence
(taken from ref 3)
Contributory factors
Physician’s knowledgeLack of awareness or most commonly, lack of familiarity of a guidelinePoor IT provision and lack of rapid access to online resources in our National Health Service
Physician’s attitudesLack of agreement of guidelines in general (less common for specific guidelines due to interpretation of evidence or confidence in guideline developer)
Self-efficacy, that is, belief that one can perform a behaviour, especially with respect to preventive health measures
Outcome expectation, that is, the expectation or belief that a recommendation will lead to a particular consequence
Professional attitudes to guideline use
Francke et al 20 report that it is younger, less experienced doctors who are more likely to use guidelines.
The evidence for clinical guidelines is often imperfect. Publication bias, influence from commercial pharmaceutical companies and personal interests all infiltrate the very science that is used to develop guidelines. It is therefore easy to discredit guidelines as simplistic or inaccurate or based on the wrong evidence.
When clinicians have been involved in the development of a guideline, they are more likely to use it.21 22 Sheldon et al 8 also suggested that the greatest effect (on guideline adherence) is likely when opinion leaders, including the professional bodies and associations, adopt and promote the guidance.
Physician’s behaviourInertiaPersonal motivation to change practice is important. Prochaska and DiClemente23 developed the ‘readiness for change’ model, describing a continuum of steps that include precontemplation, contemplation, preparation, action and maintenance. Physicians are often in a precontemplation stage with regard to guidelines and not ready to change behaviour.23
External factorsPatient — inability to reconcile patient preferences
Guideline — ease of use and convenience
Environmental — lack of time or resources and organisational constraints)
These barriers can be addressed by involving patients in guideline development; by standardising simple, easy-to-read guideline formats, intelligent use of IT systems to improve accessibility to up-to-date guidelines, careful consideration of the guideline context (differentiating guidelines for general paediatric versus tertiary specialist settings); and by addressing guideline adherence as an organisational priority.
  • IT, information technology.