Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement Michael D. Cabana, MD, MPH Cynthia S. Rand, PhD Neil R. Powe, MD, MPH, MBA Albert W. Wu, MD, MPH Modena H. Wilson, MD, MPH Paul-André C. Abboud, MD Haya R. Rubin, MD, PhD

C LINICAL PRACTICE GUIDE- lines are “systematically de- veloped statements to assist practitioner and patient de-

cisions about appropriate health care for specific clinical circumstances.”1 Their successful implementation should im- prove quality of care by decreasing in- appropriate variation and expediting the application of effective advances to ev- eryday practice.2,3

Despite wide promulgation, guide- lines have had limited effect on chang- ing physician behavior.4-7 In general, little is known about the process and factors responsible for how physi- cians change their practice methods when they become aware of a guide- line.8,9 Physician adherence to guide- lines may be hindered by a variety of barriers. A theoretical approach can help explain these barriers and possi- bly help target interventions to spe- cific barriers.

In this article, we review barriers to physician adherence to practice guide- lines. Such knowledge can help devel- opers of guidelines, practice directors, and health care services researchers de- sign effective interventions to change physician practice.

METHODS Data Sources We conducted a systematic review of the literature to identify barriers to

guideline adherence. We searched all articles, limited to the English lan- guage and human subjects, published from January 1966 to January 1998

Author Affiliations: Departments of Pediatrics (Drs Cabana, Wilson, and Abboud), Medicine (Drs Rand, Powe, Wu, and Rubin), Psychiatry (Dr Rand), and the Robert Wood Johnson Clinical Scholars Program (Drs Cabana, Powe, Wu, Wilson, and Rubin), the Johns Hopkins School of Medicine; the Departments of Health Policy and Management (Drs Powe, Wu, Wilson, and Rubin) and Epidemiol- ogy (Dr Powe), the Johns Hopkins School of

Hygiene and Public Health, Baltimore, Md. Dr Cabana is now working in the Division of General Pe- diatrics, Department of Pediatrics and Communi- cable Diseases, University of Michigan Health Sys- tem, Ann Arbor. Corresponding Author: Michael D. Cabana, MD, MPH, Division of General Pediatrics, D3255 Medical Profes- sional Bldg, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0718 (e-mail: [email protected]).

Context Despite wide promulgation, clinical practice guidelines have had limited ef- fect on changing physician behavior. Little is known about the process and factors in- volved 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; text- books on health behavior or public health; and references supplied by experts to find En- glish-language article titles that describe barriers to guideline adherence.

Study Selection Of 5658 articles initially identified, we selected 76 published stud- ies describing at least 1 barrier to adherence to clinical practice guidelines, practice pa- rameters, 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 frame- work 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 po- tential barriers to physician guideline adherence, including awareness (n = 46), familiar- ity (n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), abil- ity 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) ex- amined only 1 type of barrier.

Conclusions Studies on improving physician guideline adherence may not be gen- eralizable, since barriers in one setting may not be present in another. Our review of- fers 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. JAMA. 1999;282:1458-1465 www.jama.com

using the MEDLINE, Educational Re- sources Information Center (ERIC), and HealthSTAR databases. To find candidate titles that describe barriers to adherence, we included titles that ap- peared in 2 searches. The first used medical subject heading (MeSH) de- scriptors clinical practice guidelines or physicians’ practice patterns. The sec- ond used the descriptors behavior, knowledge, attitudes, and practice, atti- tude of health personnel, guideline ad- herence, or the text words behavior change. We also examined candidate titles of papers describing theories of physician behavior change to find con- structs useful in describing barriers. We used candidate titles with the MeSH descriptor or text words behavior and 1 of the following terms: “model, orga- nizational,” “model, theoretical,” “model, psychological,” or “model, educa- tional.” We identified additional can- didate articles by reviewing the bibli- ographies of articles from the search; contacting experts in psychology, man- agement, and sociology; and review- ing bibliographies of textbooks of health behavior and public health.

Data Selection We included articles that focused on clinical practice guidelines, practice pa- rameters, clinical policies, national rec- ommendations or consensus state-

ments, and that examined at least 1 barrier to adherence. A barrier was de- fined as any factor that limits or re- stricts complete physician adherence to a guideline. We focused on barriers that could be changed by an intervention. As a result, we did not consider age, sex, ethnic background, or specialty of the physician as barriers. In many of the ar- ticles, respondents indicated barriers via responses to survey questions. For qualitative studies, major themes from focus groups or interviews identified barriers.

One investigator (M.D.C.) screened titles and/or full bibliographic cita- tions to identify candidate articles. Two investigators (M.D.C. and P.-A.C.A.) then independently reviewed the full text to exclude articles that did not ful- fill our criteria. Differences were re- solved by consensus with a third in- vestigator (H.R.R.).

Data Extraction T w o i n v e s t i g a t o r s ( M . D . C . a n d P.-A.C.A.) then abstracted the follow- ing information from each article: description of barrier, description of the guideline, the percentage of respon- dents describing the barrier, demo- graphics of the respondents, and study characteristics. If possible, we calcu- lated the percentage of respondents affected by a barrier as the difference

between 100% and the sum of the per- centage with no opinion and those not affected.

All barriers abstracted from the ar- ticles were grouped into common themes, then further organized into groups based on whether they affected physician knowledge, attitude, or be- havior. The organization of these cat- egories was validated by 3 additional in- vestigators (A.W.W., N.R.P., and C.S.R.) and was based on a model that de- scribes an ideal, general mechanism of action for guidelines, the knowledge, at- titudes, behavior framework6 (FIGURE). Before a practice guideline can affect pa- tient outcomes, it first affects physician knowledge, then attitudes, and finally behavior. Although behavior can be modified without knowledge or atti- tude being affected, behavior change based on influencing knowledge and at- titudes is probably more sustainable than indirect manipulation of behavior alone.

Factors limiting adherence through a cognitive component were consid- ered barriers affecting knowledge, through an affective component were considered barriers affecting attitude, and through a restriction of physician ability were considered barriers affect- ing behavior.

Based on previous work by Davis and Taylor-Vaisey,10 the following terms were used: adoption refers to a provid-

Figure. Barriers to Physician Adherence to Practice Guidelines in Relation to Behavior Change

Sequence of Behavior Change

Barriers to Guideline Adherence

External Barriers Patient Factors

Inability to Reconcile Patient Preferences With Guideline Recommendations

Guideline Factors Guideline Characteristics Presence of Contradictory Guidelines

Environmental Factors Lack of Time Lack of Resources Organizational Constraints Lack of Reimbursement Perceived Increase in Malpractice Liability

Lack of Agreement With Specific Guidelines

Interpretation of Evidence Applicability to Patient Not Cost-Beneficial Lack of Confidence in Guideline Developer

Lack of Agreement With Guidelines in General

"Too Cookbook" Too Rigid to Apply Biased Synthesis Challenge to Autonomy Not Practical

Lack of Outcome Expectancy Physician Believes That Performance of Guideline Recommendation Will Not Lead to Desired Outcome

Lack of Self-Efficacy Physician Believes that He/She Cannot Perform Guideline Recommendation

Lack of Motivation/ Inertia of Previous Practice

Habit Routines

Lack of Familiarity Volume of Information Time Needed to Stay Informed Guideline Accessibility

Lack of Awareness Volume of Information Time Needed to Stay Informed Guideline Accessibility

Knowledge Attitudes Behavior

WHY DON’T PHYSICIANS FOLLOW CLINICAL PRACTICE GUIDELINES?

er’s commitment and decision to change practice, diffusion is the distribution of information and the unaided adop- tion of recommendations, dissemina- tion is more active than diffusion and is the communication of information to improve knowledge or skills, and imple- mentation refers to active dissemina- tion, involving strategies to overcome barriers.

Lack of familiarity included the in- ability of a physician to correctly an- swer questions about guideline con- tent, as well as self-reported lack of familiarity. When studies reported the percentage of physicians answering questions incorrectly, the highest per- centage of incorrect answers was used to measure lack of familiarity. Lack of awareness was the inability to cor- rectly acknowledge a guideline’s exis- tence.

RESULTS Search Yield

We found 5658 candidate titles possi- bly examining barriers to adherence. We excluded 5235 titles after examination of the bibliographic citation. After ex- amining the full text of 423 articles or chapters, 76 articles fulfilled our crite- ria. The k to measure interrater reliabil- ity for article selection was 0.93.

The 76 accepted articles included 5 qualitative studies and 120 different sur- veys asking a total of 293 questions ad- dressed to physicians regarding pos- sible barriers to guideline adherence. A survey was defined as at least 1 ques- tion to a group of physicians about bar- riers to adherence for a unique guide- line recommendation.

Type of Barriers After classifying possible barriers into common themes, we found that the 293 questions about barriers included 7 gen- eral categories of barriers (Figure). The barriers affected physician knowledge (lack of awareness or lack of familiar- ity), attitudes (lack of agreement, lack of self-efficacy, lack of outcome expec- tancy, or the inertia of previous prac- tice), or behavior (external barriers).

Comprehensiveness of Surveys We examined how often surveys con- sidered the full variety of barriers to physician adherence. Theoretically, a survey could examine up to 7 differ- ent types of barriers to adherence. Of the 120 surveys, 70 (58%) examined only 1 type of barrier, and the average number examined was 1.67 (median, 2). Of the remaining surveys, 30 (25%) examined 2, 11 (9%) examined 3, 8 (7%) examined 4 , and 1 (0.8%) exam- ined 5. None examined 6 or more types of barriers.

Characteristics of Physician Surveys The number and characteristics of the surveys examining each barrier are listed in Table 1, which is not in- cluded in the print version of this article but is available at http:// www.jama.com. We found that the sur- veys used a heterogeneous variety of physician populations (based on spe- cialty or location of practice) and investigated guidelines on a variety of subjects (immunization, preventive care, or treatment). The surveys also displayed a wide range of the percent- age of respondents reporting each bar- rier. A description of each category of barriers and the surveys that investi- gated these barriers, which are not in- cluded in the print version of this ar- ticle but are available online, are listed in Tables 2 through 11 and are dis- cussed below. Table 2 is available at http://www.jama.com and Tables 3 through 11 are available at http:// www.ped.med.umed.edu/RESEARCH /cabana/tables.htm or on request from the authors.

Adherence Barriers Identified by Studies

Lack of Awareness. Forty-six sur- veys5,11-40 measured lack of awareness as a possible barrier (Table 2). Sample size ranged from 69 to 2860 (median, 392), and the response rate ranged from 26% to 95% (median, 54.5%). The sample size and response rate were not reported in 1 of the studies.19 The per-

centage of respondents identifying lack of awareness as a barrier was as high as 84% (United States Preventive Ser- vices Task Force [USPSTF] guide- lines16) and as low as 1% (asthma guide- lines3 0 and measles immunization guidelines40) with a median of 54.5%. In 36 (78%) of the 46 surveys, at least 10% of the respondents were not aware of the guideline.

Lack of Familiarity. Thirty-one sur- veys12-15,41-50 measured lack of familiar- ity as a possible barrier. Sample size ranged from 69 to 1513 (median, 326), and the response rate ranged from 49% to 98% (median, 60%). The percent- age of respondents suggesting lack of familiarity as a barrier was as high as 89% (American College of Physicians exercise stress testing guidelines41) and as low as 0% (asthma guidelines46) with a median of 56.5%. In 28 (90%) of the 31 surveys, at least 10% of the respon- dents were not familiar with guideline recommendations.

Lack of Agreement. Thirty-three sur- veys15,16,28,38,40,41,43,48,51-64 investigated 47 possible reasons for lack of agreement as a barrier to adherence to specific guidelines. At least 10% of the respon- dents disagreed with a guideline due to differences in interpretation of the evi- dence (2/2 cases), the belief that the benefits were not worth patient risk, dis- comfort, or cost (9/11 cases), applica- bility to the practice population (5/7 cases), that guidelines were oversimpli- fied or “cookbook” (5/5 cases), or that guidelines reduced autonomy (1/1 case). In 18 cases, a reason for disagreement was not specified. In 8 of these cases, dis- agreement was reported by at least 10% of the respondents. Finally, 2 surveys in- vestigated disagreement due to lack of credibility by guideline authors and 1 in- vestigated the perception that the au- thors were biased. In all 3 cases, dis- agreement was less than 10%.

The percentage of respondents iden- tifying lack of agreement as a barrier for a specific guideline was as high as 91% (American Academy of Pediatrics riba- virin recommendations57) and as low as 1% (American Cancer Society Clinical Breast Examination53 and USPSTF

WHY DON’T PHYSICIANS FOLLOW CLINICAL PRACTICE GUIDELINES?

counseling of fat and cholesterol in- take56). In 29 (62%) of the 47 cases, at least 10% of the respondents reported lack of agreement.

Fifteen surveys5,15,17,20,41,65-74 investi- gated 43 possible examples of lack of agreement as a barrier to adherence to guidelines in general. At least 10% of the respondents disagreed with a guideline due to the perception that guidelines were oversimplified or “cookbook” (9/9 cases), would reduce autonomy (10/12 cases), were not practical (3/3 cases), were biased (4/4 cases), would de- crease physicians’ self-respect (1/1 case), were not applicable to a practice popu- lation (3/3 cases), would decrease flex- ibility (7/7 cases), lacked credible au- thors (1/1 case), or would make the patient-physician relationship imper- sonal (1/1 case). Thirty-eight percent of respondents reported a lack of agree- ment in 1 case for which a reason for dis- agreement was not specified.

The percentage of respondents iden- tifying lack of agreement as a barrier to adherence for guidelines in general was as high as 85% (lack of credibility) and as low as 7% (perceived reduction in autonomy). In 41 (95%) of the 43 cases, at least 10% of respondents reported lack of agreement as a barrier to adher- ence to guidelines in general.

Lack of Self-efficacy. Nineteen sur- veys18,21,51,62,63,75-77 measured lack of phy- sician self-efficacy as a possible bar- rier. Sample size ranged from 23 to 941 (median, 633), and the response rate ranged from 53% to 85% (median, 63%). The response rate was not re- ported in 3 studies. The percentage of respondents identifying this barrier was as high as 65% (nutrition education18) and as low as 1% (general exercise counseling76) with a median of 13%. In 15 (79%) of the 19 surveys, at least 10% of the respondents reported a lack of self-efficacy.

Lack of Outcome Expectancy. Eight surveys48,51,58,59,62,63,75,78 measured lack of outcome expectancy as a possible bar- rier. Sample size ranged from 97 to 480 (median, 237), and the response rate ranged from 47% to 85% (median, 69.5%). The percentage of respon-

dents identifying this barrier to adher- ence was as high as 90% (alcohol abuse prevention66) and as low as 8% (clini- cal breast examination51) with a me- dian of 26%. In 7 (88%) of the 8 sur- veys, at least 10% of the respondents reported a lack of outcome expec- tancy.

Inertia of Previous Practice. Four- teen surveys38,40,62,79 measured the in- ertia of previous practice as a possible barrier. Sample size ranged from 141 to 1421 (median, 745), and the re- sponse rate ranged from 66% to 81% (median, 67%). The percentage of re- spondents identifying this barrier was as high as 66% (infant sleeping posi- tion38) and as low as 23% (immuniza- tions40) with a median of 42%. In all the surveys more than 10% of the respon- dents reported the inertia of previous practice as a barrier.

External Barriers. Thirty-four sur- veys* investigated 85 possible exter- nal barriers that affect the ability to per- form a guideline recommendation. External barriers fell into 3 categories: guideline related (n = 23), patient re- lated (n = 17), and environmental (n = 45). At least 10% of respondents described guidelines as not easy to use (1/2 cases), not convenient (6/11 cases), cumbersome (2/4 cases), and confus- ing (2/6 cases). In all surveys of patient- related factors, at least 10% of the re- spondents indicated that the factor was a barrier. In all surveys about environ- mental factors, at least 10% of respon- dents indicated that the environmen- tal factors were barriers to adherence, except for lack of time (only 11/17 cases) and insufficient staff or consult- ant support (3/4 cases).

Qualitative Studies Five qualitative studies84-88 investi- gated barriers adherence. Four84,85,87,88 of the 5 studies emphasized external bar- riers (patient characteristics or time con- straints) as barriers to adherence. Lack of optimism in the success of counsel- ing, which suggests poor outcome ex-

pectancy, was a major barrier for Agency for Health Care Policy and Research smoking cessation guidelines.86

COMMENT Physician adherence is critical in trans- lating recommendations into improved outcomes. However, a variety of barri- ers undermine this process. Lack of awareness and lack of familiarity affect physician knowledge of a guideline. In terms of physician attitudes, lack of agreement, self-efficacy, outcome expectancy, and the inertia of previ- ous practice are also potential barri- ers. Despite adequate knowledge and attitudes, external barriers can affect a physician’s ability to execute recom- mendations.

Barriers to Physician Adherence Lack of Awareness. The expanding body of research makes it difficult for any physician to be aware of every ap- plicable guideline and critically apply it to practice.89,90 Although many guide- lines have achieved wide awareness (ie, immunization guidelines, recommen- dations for infant sleeping position), for 78% of the guidelines, more than 10% of physicians are not aware of their ex- istence.

Lack of Familiarity. Casual aware- ness does not guarantee familiarity of guideline recommendations and the ability to apply them correctly. Of 74 surveys that measured guideline aware- ness or familiarity, only 3 (4%) also measured both.12-14 In all cases, lack of familiarity was more common than lack of awareness.

Lack of Agreement. Physicians may not agree with a specific guide- line or the concept of guidelines in general. Although physicians com- monly indicate a lack of agreement w h e n a s k e d a b o u t g u i d e l i n e s i n theory, from this analysis and others, when asked about specific guide- lines, physician lack of agreement is less common.15 The results of studies that examine physician attitudes to guidelines in general should be inter- preted with caution when applied to specific guidelines.

*References 16-18, 23, 28, 29, 32, 36, 38, 40, 41, 43, 47, 48, 50, 51, 54, 58, 61- 63, 68, 70, 72, 75, 78, 80-83.

WHY DON’T PHYSICIANS FOLLOW CLINICAL PRACTICE GUIDELINES?

Lack of Self-efficacy. Self-efficacy is the belief that one can actually per- form a behavior. It influences whether a behavior will be initiated and sus- tained despite poor outcomes.91 For ex- ample, higher self-efficacy in prescrib- ing cholesterol-lowering medications was associated with physicians initiat- ing therapy consistent with national guidelines.92 Low self-efficacy due to a lack of confidence in ability or a lack of preparation may lead to poor adher- ence. Sixty-eight percent of the sur- veys that reported this barrier in- volved preventive health education and counseling, which suggests that poor self-efficacy may be a common barrier to adherence for such guidelines.

Lack of Outcome Expectancy. Out- come expectancy is the expectation that a given behavior will lead to a particu- lar consequence.91 If a physician be- lieves that a recommendation will not lead to an improved outcome, the phy- sician will be less likely to adhere. For example, the USPSTF recommends that physicians provide smoking cessation counseling.93 Although most physi- cians are aware of and agree with the recommendation,94 many smokers are not counseled to quit during a physi- cian visit.95,96 An important reason for physician nonadherence is a belief that the physician will not succeed.97,98

Although counseling may increase a population’s quit rate from 3% to only 5%,99 given smoking prevalence even this small change is enormously ben- eficial.100 However, since physicians see patients individually, they may not dis- cern success at the population level. Overlooking population-level suc- cesses can negatively influence out- come expectancy and lead to nonad- herence. Seventy-five percent of surveys reporting lack of outcome expec- tancy, such as those reporting lack of self-efficacy, involved preventive health counseling and education guidelines.

Inertia of Previous Practice. Physi- cians may not be able to overcome the inertia of previous practice, or they may not have the motivation to change. Al- though this barrier has not been inves- tigated as widely as others, for all 14 sur-

veys that examined this barrier, more than 20% of respondents indicated that it was a barrier to adherence.

The readiness for change model, de- veloped by Prochaska and DiCle- mente,101 describes behavior change as a continuum of steps that include pre- contemplation, contemplation, prepa- ration, action, and maintenance101 and was applied to physician attitudes to- ward cancer screening guidelines. The results suggest that close to half of phy- sicians surveyed were in a precontem- plation stage and not ready to change behavior (ie, adopt guideline recom- mendations).79 The change process model described by Geertsma et al102

and the theory of learning and change model described by Fox et al103 also sug- gest similar constructs, ie, a priming phase and the need for an initial force for change, professional, personal, and/or social.

External Barriers. Appropriate knowl- edge and attitudes are necessary but not sufficient for adherence.80 A physician may still encounter barriers that limit his/ her ability to perform the recommended behavior due to patient, guideline, or en- vironmental factors.

External barriers that limit the abil- ity to perform a recommended behav- ior are distinct from lack of self- efficacy. For example, well-trained physicians confident about their coun- seling skills can still be affected by ex- ternal barriers (time limitations, lack of a reminder system) that prevent them from adhering to a counseling guide- line. However, the persistence of these barriers may also eventually affect phy- sicians’ self-efficacy, outcome expec- tancy, or motivation (Figure).

Guideline-Related Barriers. Physi- cians were more likely to describe guidelines as not easy to use or not con- venient when asked about guidelines in theory. When physicians were asked about barriers for specific guidelines, a significant percentage (more than 10% of respondents) described them as in- convenient or difficult to use in only 6 (38%) of 16 cases.

Other guideline characteristics may also affect adherence. Guidelines rec-

ommending elimination of an estab- lished behavior may be more difficult to follow than guidelines that recom- mend adding a new behavior.104 Trial- ability of a guideline and its complex- ity are also described as significant predictors of adoption.105 Trialability is “the degree to which an innovation may be experimented with on a limited ba- sis.”106

Patient-Related Barriers. The inabil- ity to reconcile patient preferences with guideline recommendations is a bar- rier to adherence.107 Patients may be resistant or perceive no need for guide- line recommendations. In addition, a patient may perceive the recommen- dation as offensive or embarrassing. In all the surveys that included patient- related factors, more than 10% of physicians indicated them as a barrier to adherence.

Environmental-Related Barriers. Adherence to practice guidelines108

“may require changes not under phy- sician control, such as acquisition of new resources or facilities.”108,109 For example, unavailability of an anesthe- siologist 24 hours a day may interfere with physician ability to adhere to guidelines aimed at decreasing the rate of elective cesarean deliveries.109 Many factors described as barriers by more than 10% of respondents, such as lack of a reminder system, lack of counsel- ing materials, insufficient staff or con- sultant support, poor reimbursement, increased practice costs, and increased liability, may also be factors beyond phy- sician control.

With adequate resources or referral privileges, physicians may be able to compensate for other external barriers. Although lack of time is commonly de- scribed as a barrier to adherence by more than 10% of respondents (11/17 cases), time limitations were not a barrier for mammography referral or breast exami- nation guidelines (4 surveys), manage- ment of fever (1 survey), and hyperbili- rubinemia (1 survey).

Limitations Because this review only includes pub- lished articles, it is susceptible to pub-

WHY DON’T PHYSICIANS FOLLOW CLINICAL PRACTICE GUIDELINES?

lication bias.110 All included articles, except 5 qualitative studies84-88 were sur- veys using closed-ended questions, and the barriers examined were depen- dent on investigator selection. For ex- ample, physician discomfort with un- certainty, a compulsion to treat (despite the lack of effective interventions), opinion leaders who may have nonevi- dence-based opinions, pharmaceuti- cal representatives, and fear of stand- ing out may all be additional barriers but were not specifically investigated in the included studies.

In addition, surveys of barriers de- pend on physicians’ perceptions of them. The perceptions may not accu- rately reflect how problematic the bar- rier actually is. Whether the problem is actual or perceived may also affect the type of intervention needed to over- come the barrier.

Finally, barriers to adherence in dif- ferent situations may facilitate adher- ence. For example, although patient pressure may be a barrier to adher- ence in some cases, patient requests for mammograms may improve physi- cian adherence to mammography re- ferral guidelines.51

Implications Our results suggest several implica- tions for guideline implementation and research. This analysis offers a differential diagnosis of why physi- cians may not follow clinical practice guidelines. There are a variety of bar- riers to guideline adherence, which include lack of awareness, lack of familiarity, lack of agreement, lack of self-efficacy, lack of outcome ex- pectancy, the inertia of previous prac- tice, and external barriers.

Few studies consider the variety of barriers that must be overcome to achieve adherence. Although we found 76 articles that included 120 surveys in- vestigating possible barriers to guide- line adherence, 70 (58%) of the 120 sur- veys examined only 1 type of barrier. By not considering the variety of barriers, interventions to improve adherence are less likely to address these factors and are less likely to be successful.

In addition, the interpretation of suc- cessful interventions to improve phy- sician adherence should be reviewed carefully. Strategies successful in one setting (in which a single external bar- rier exists—eg, lack of a reminder sys- tem) may be less useful in a setting where barriers differ (eg, poor physi- cian knowledge and attitudes in addi- tion to the lack of a reminder system). This framework might be useful to standardize the reporting of barriers to adherence. Just as clinical trials report baseline patient comorbidities in treat- ment and control groups, interven- tions to improve adherence should report baseline barriers to adherence. The effectiveness of interventions to im- prove adherence is dependent not only on the intervention itself but also on the existence and intensity of baseline barriers.

It is difficult to compare any frame- work with other similar frameworks or checklists.41,42 However, this frame- work is based on a comprehensive re- view, which is specific to physician guideline adherence. In addition, it in- corporates different behavioral con- structs. Unlike the awareness to ad- herence model, which is based on immunization guideline adherence, this framework incorporates self-efficacy and outcome expectancy, which are im- portant considerations in improving ad- herence to other preventive health guidelines, besides immunizations.40

Focusing on barriers to adherence may also be more direct in improving phy- sician behavior, instead of investigat- ing predisposing factors, which may be too broad in helping select possible in- terventions.111

In summary, this review offers a dif- ferential diagnosis for why physicians do not follow practice guidelines. Few studies consider this diversity of bar- riers that we describe. By not entertain- ing the full spectrum of barriers, im- portant interventions to improve physician behavior might not be inves- tigated or implemented. This frame- work may also be useful to help docu- ment the generalizability of studies used to improve guideline adherence.

Funding/Support: This work was funded in part by the Robert Wood Johnson Foundation, Princeton, NJ. Previous Presentation: Portions of this work were pre- sented at the Annual Meeting of the Society for Pe- diatric Research, May 2, 1999, San Francisco, Calif.

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The beauty and genius of a work of art may be recon- ceived, though its first material expression be de- stroyed; a vanished harmony may yet again inspire the composer; but when the last individual of a race of living things breathes no more, another heaven and another earth must pass before such a one can be again.

—Charles William Beebe (1877-1962)

WHY DON’T PHYSICIANS FOLLOW CLINICAL PRACTICE GUIDELINES?

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