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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

JAMA. 1999;282:1458-1465.

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.

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 Epidemiology (Dr Powe), the Johns Hopkins School of Hygiene and Public Health, Baltimore, Md. Dr Cabana is now working in the Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor.

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Robert M. Veatch, Alan A. Montgomery, Tim J. Peters, Tom Fahey, Keith Dahlberg, Michael D. Cabana, Cynthia S. Rand, Neil R. Powe, Albert W. Wu, Paul-Andre C. Abboud, and Modena H. Wilson
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