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Abstract
Background Clinical guidelines are important for ensuring quality of treatment and care. For this reason, it is essential that clinicians adhere to guidelines. Review studies conclude that barriers to using guidelines are context specific. Nevertheless, there is a lack of studies that compare the attitudes of different groups of doctors to guidelines.
Objectives To survey the attitudes of Norwegian medical practitioners to clinical guidelines and the reasons for any scepticism, and to compare general practitioners (GPs) with other medical doctors in Norway in this respect.
Method Postal questionnaire to a panel of 1649 Norwegian medical doctors.
Results 1072 doctors responded (65%). 97% claimed to be familiar with and following guidelines. A majority expressed confidence in guidelines issued by the health authorities and the medical association. GPs are significantly more uncertain about the legal status of, accessibility of and evidence in guidelines than other doctors. The most important barriers to guideline adherence are concerns about the uniqueness of individual cases and reliance on one's own professional discretion. Both groups rank attitudinal constraints higher than practical constraints, but GPs more often report practical issues as reasons for non-adherence.
Conclusion It is suggested that creating trust in guidelines could be more important than more efforts to improve guideline format and accessibility. It may also be worth considering whether guidelines should be implemented using different processes in generalist and specialist care.
- Clinical guidelines
- GPs
- Norway
- generalists versus specialists
- healthcare quality improvement
- primary care
- general practice
- evidence-based medicine
Statistics from Altmetric.com
- Clinical guidelines
- GPs
- Norway
- generalists versus specialists
- healthcare quality improvement
- primary care
- general practice
- evidence-based medicine
Clinical guidelines are used as a tool for controlling quality and resource allocation within the health services in most countries; however, their impact hinges on clinicians' adopting them in daily practice. For this reason, studies of why clinicians do not practise according to guidelines continue to draw attention academically and politically.1 In this study, we expand on earlier findings and take a closer look at the rationale behind clinicians' scepticism towards guidelines.
Barriers to accepting guidelines are frequently grouped into the following categories: (1) social factors, including patients' preferences; (2) the clinicians' attitudes; (3) the implementation process, accessibility and format of the guidelines; and (4) external barriers of a practical nature.1–6 A range of attitudinal barriers have been recorded, such as scepticism towards the authors or motives behind guidelines, doubt about the evidence base, concern about whether guidelines fit the individual patient and reluctance to use time in convincing sceptical patients.7–9 Reviews repeatedly conclude that barriers to guideline implementation depend on the problem area, the local organisational structures and the professional group involved6 10–14; however, there are still very few systematic empirical studies of the views of different groups of doctors about guidelines.
There is some evidence that general practitioners' (GPs) attitudes differ systematically from those of hospital consultants; however, studies comparing perceptions of guidelines between different groups of doctors are scarce, and the evidence is inconsistent. A few studies have explicitly compared attitudes to guidelines, and there are some indications that generalists are more reluctant to follow guidelines than their hospital colleagues.15–18
During the last decade, a few explorative studies point to underlying areas of conflict that inhibit the adoption of guidelines in general practice.8 Key themes are balancing the needs of the individual patient with the aggregated needs of the population and GPs' scepticism about the clinical evidence behind guidelines. While most of these studies were conducted in the UK, the USA or The Netherlands, a Norwegian focus group study supports the international findings.19 However, these findings are preliminary. Precise and explicit knowledge about the details and distribution of GPs' attitudes is lacking and need to be sought in quantitative and representative studies.
Building on the findings mentioned above, the dual aim of this study is (1) to survey Norwegian medical practitioners' attitudes to clinical guidelines and (2) to study the reasons behind scepticism towards guidelines. The study compares GPs with other medical doctors.
Materials and methods
The data are part of the 2008 Norwegian medical doctor survey—a longitudinal survey established in 1994. The panel is composed of a representative sample of 1600i Norwegian practising medical doctors. The sample is drawn from the Norwegian register of medical doctors, administered by the Norwegian Medical Association (NMA).
Questionnaire
The data were collected using a comprehensive questionnaire, of which the guidelines theme was only a minor part. The 2008 dispatch was the first time the respondents were asked about guidelines. The section was divided into two themes. The first included statements about general attitudes to guidelines (cited in table 1), and the second postulated different barriers to guideline adherence (cited in table 2). All questions were formulated as statements to which the respondents expressed the extent of their agreement or the significance for them on a four-point Likert scale: “completely” and “partly (dis-)agree” for the first group of statements, and “not”, “slightly”, “rather” and “very important” for the second. A “not relevant” category was included for all alternatives.
Proportion of samples who agree partly or totally with statements (240 GPs and 725 other doctors)
Proportion of samples who find statements to be fairly or very important (240 GPs and 725 other doctors)
The specific statements regarding attitudes to guidelines in the questionnaire were extracted from the results of international reviews of guideline implementation,1 5 8 13 20 and a recent Norwegian qualitative focus group study of GPs' attitudes to guidelines.19 For example, repeated studies suggest that the source of the guideline influences doctors' confidence, and that guideline authors from doctors' own professional group are trusted the most. The studies referred also find that the volume, format and accessibility of guidelines are associated with attitudes and use of guidelines. Thus, building on international research, the statements in the questionnaire reflect earlier knowledge.
Statistical analysis
Responses are reported as proportions of doctors who chose the different response alternatives. The grouping variable is whether or not the respondent is a GP. The differences between the two groups are reported as percentage differences, and the corresponding p values calculated using the Mann–Whitney U test. Logistic regressions were used to control for age and gender. The data were analysed with SPSS software (v.16.0).
Results
Of the samples, 1072 of 1649 answered after one reminder, giving a response rate of 65%; 25.7% of the doctors in the samples are GPs, whereas the proportion of GPs in the Norwegian working doctor population is 25.5%. The proportion of females in the sample is 32.2%; in the population, it is 33.5%. The mean age is 48.8 years in the sample and 49.2 years in the population.ii The regression analyses showed no significant effects of age or gender on the results.
Table 1 provides the results concerning agreement to a number of statements about guidelines.
There are several statistically significant differences in attitudes between GPs and other doctors.
Knowledge and adherence
The table shows that a majority of doctors claim to be familiar with guidelines and mostly follow them. More GPs than other doctors feel the need to look up guidelines.
Confidence in source
A majority have confidence in guidelines issued by the health authorities. GPs have relatively more confidence in guidelines from the NMA. The GPs are relatively more likely to distrust guidelines from the pharmaceutical industry, although both groups generally demonstrate the lowest confidence in guidelines from the industry.
Uncertainty and confusion
GPs differ systematically from other doctors in their views on the volume, legal status, accessibility, evidence base and clarity of guidelines. GPs demonstrate more uncertainty and confusion than other doctors on all these issues.
Reasons for not following guidelines
Table 2 shows the results from the statements about why doctors decide to ignore guidelines.
Summing up the results in table 2, it appears that a majority of all medical doctors prefer to use clinical judgement to adjust practice to the patient's individual needs, which often means deviating from the guidelines. Also, scepticism about the weight of economic calculations and the evidence base are frequently mentioned as reasons for disregarding guidelines.
There are no significant differences between the two groups concerning the most important reasons for not following guidelines. However, GPs significantly more often report practical issues and time constraints as reasons for ignoring guidelines.
Discussion
Knowledge and adherence
There are significant differences between GPs and other doctors in their attitudes to clinical guidelines. However, before we discuss these differences, we should note that almost all the doctors claim to have good knowledge of guidelines and to adhere to them. While these findings indicate an overall positive attitude to guidelines, it is important to note that they do not tell us anything about adherence rates. Still, it is interesting that nearly all doctors claim to be capable of and willing to follow guidelines. Studies comparing observational data and self-reported data about adherence to guidelines frequently find that self-reported adherence significantly exceeds the observed adherence—on average, to a degree of 27%, according to a review of this literature.21
The positive attitude towards guidelines partly contrasts with the findings of an earlier study of Norwegian GPs.22 Treweek and colleagues surveyed knowledge and alleged use of specific guidelines, and found substantial variation among GPs regarding knowledge and use. The difference in findings could be due to a tendency to give positive answers to general questions such as those used in table 1. This argument is plausible given that an international review including more than 11 000 doctors found that more than 70% of doctors answered positively when asked general questions about the usefulness of guidelines.20
Confidence in source
Both groups of doctors apparently trust official guidelines, and even more those issued by the medical association, although GPs are more positive to NMA guidelines than other doctors. The findings support international studies, although the Norwegian doctors are generally more positive.1 5 20 Again, this may be due to methodological differences between our general study and studies of specific guidelines. Only a minority of doctors trust guidelines issued by the pharmaceutical industry. This is also as expected as it is agrees with findings from the recent Norwegian qualitative study.19
Uncertainty and confusion
The majority of GPs are unsure about the legal status of different types of clinical advice, find inconsistent guidelines confusing, frequently find guidelines difficult to access and would like a comprehensive, definitive source. For each of our suggested statements, there are significantly more GPs than other doctors who agree. This confirms earlier studies that suggest that GPs are less knowledgeable about the latest evidence in the relevant fields and are slower to adopt new therapies.23 24 This seems plausible as it reflects the GPs' working situation covering the whole breadth of clinical fields. The volume of guidelines relevant to GPs is much greater, and this could explain the more frequent reports of uncertainty or confusion among GPs.
Reasons for not following guidelines
The reasons suggested for not following guidelines were drawn from the international qualitative literature on guideline adherence as well as the qualitative prestudy among Norwegian GPs.19 The findings largely support international studies of barriers to guideline adherence.20 We note that practical constraints are less important than opinions about the evidence or motivation behind guidelines, although the GPs give more weight to practical barriers than other doctors. This is also plausible given the more varied and independent clinical environment of general practice.
Methodological considerations
The survey method has several limitations. Self-report versus actual practice has already been mentioned. An interesting follow-up study would be an observational study of Norwegian doctors' practice compared to guideline recommendations.
The questionnaire was partly based on a qualitative study. The respondents in the survey demonstrate more positive attitudes towards guidelines than the focus group participants did. This discrepancy might be explained by different factors, such as the rather superficial nature of a survey or that a discussion group may be more focused on problems.iii
Although the sample is representative of Norwegian medical doctors and the response rate is acceptable, the findings are not automatically valid in other countries. The regulations, distribution and implementation procedures for guidelines in different national healthcare systems vary, and this may influence attitudes and use. Cross-country surveys tend to find substantial differences in attitudes to and in reported use of guidelines.25 26 Nevertheless, the issues and barriers investigated in this study were based on the international literature and were generally confirmed to be of importance among Norwegian doctors.
Conclusions
As far as we know, attitudinal barriers have not been measured and ranked in a comparison between generalists and other doctors before. We looked at the most prevailing reasons for deviating from clinical guidelines that had been reported in previous studies. Our findings yield some interesting implications.
This study indicates that the degree of trust doctors have in the sources, evidence and motivation behind guidelines has a greater impact on guideline adoption than practical issues such as lack of time or accessibility. Hitherto, academic discussion and policy efforts have largely concentrated on the improvement of content, formats and accessibility of guidelines. Our study suggests that it could be worth creating more trust in guidelines and in the institutions or groups that produce them.
There is also reason to consider whether the implementation process for guidelines should differ between generalist and specialist care. GPs are more confused about the evidence base and the legal status of the vast array of guidelines relevant to their practice, and they experience more practical constraints to guideline implementation. This merits different processes.
Acknowledgments
The authors are grateful for funding and practical assistance from The Uni Rokkan Centre and The Research Institute of the Norwegian Medical Association.
References
Footnotes
Funding The Uni Rokkan Centre (Nygaardsgt 5, 5015 Bergen, Norway) and The Research Institute of the Norwegian Medical Association (PO Box 1152 Sentrum, 0107 Oslo, Norway).
Competing interests None.
Ethics approval Regarding ethical considerations, the survey has obtained licence from the Privacy Ombudsman against the licence requirements of the Data Inspectorate in relation to the Personal Data Act and Health Register Act. The Privacy Ombudsman decided that it was not relevant to apply for ethical permission from the Regional Committees for Medical Research Ethics as the project is not within biomedical research and is not including patient data.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i The exact number varies from year to year. In 2008, it was 1649.
↵ii The population values are collected from the register of medical doctors, NMA, 2006.
↵iii The general statements of the questionnaire invite respondents to make quick and positive answers while the focus discussions may encourage introspection but may also lead participants to exaggerate common problems.