Disseminating Practice Guidelines to Physicians

The overall objective was to provide insight into clinical practice guidelines, their development and their implementation. The main focus was the conduction of a thorough literature review of all issues related to dissemination of clinical practice guidelines to physicians, and their eventual use. We offer that the reflections provided herein have done justice to the tasks originally defined. What follows is a summary of the salient points.

An enormous amount of attention has been devoted to clinical guidelines in the past ten years. Clinical guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Their successful implementation should improve quality of care by decreasing inappropriate variation and expediting the application of effective advances to everyday practice. Guideline development in general has accelerated markedly since the mid-1980s. The movement to develop and disseminate clinical practice guidelines is rooted somewhat in the need to curtail or restrict practice variation in the United States health care system, and is clearly linked to the evidence-based medicine movement.

The increase in the number of clinical guidelines produced and published in different countries has stimulated discussion on their value. Reports critiquing the validity of randomised trials, meta-analyses, diagnostic test studies, and economic evaluations have challenged researchers to improve the conduct of their studies, and encouraged readers to interpret them carefully. It is now widely understood that the findings of research do not flow simply and automatically from the literature into routine clinical practice. It is much less widely recognised how resistant this problem is to any simple solution. The traditional assumption of continuing professional development – that conscientious practitioners would keep themselves “up to date with the literature” – has long since become untenable. This failure has frustrated clinicians interested in improving their own practices, policy makers, administrators, leaders in managed care, quality assurance, those interested in health-care policy, researchers in this area and organisations funding quality-improvement efforts. However, physicians’ fervour, generated by keen interest in evidence based practice, has not dissuaded them from using these techniques, and as such, dissemination of guidelines remains an important, exploitable research resource.

Dissemination is defined as a communication of information so that clinicians can improve their knowledge or skills. It is an active process, as opposed to diffusion, and it targets specific clinician groups. Although this definition seems intuitively simple and appealing, its application is far from effortless. Using this definition, theories and models aimed at changing clinician behaviour for the purpose of improving their knowledge and skills, have evolved over several decades.

In 1997, Richard Grol published an overview of approaches and strategies in the British Medical Journal; this overview has become a cornerstone in the field of evidence in changing clinical practice. In 1999, Moulding et al. reviewed several systematic reviews of the evidence relating to clinical practice guideline adoption and summarised 8 key theoretical concepts for encouraging and maintaining guideline adoption. These key concepts were extrapolates of Grol’s theories. Theory from social and behavioural science furthered the understanding of the interplay of factors which influence practitioners to use guidelines, and helped to explain why some dissemination and implementation strategies are more effective than others. Moulding et al. applied these ideas in order to create a conceptual framework aimed at enhancing the effective use of such strategies. Solberg et al. continued to build upon this framework, and concluded that implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organisation, and external environment. The derivation of the medical group component in Solberg et al.’s framework was an important addendum to Moulding et al.’s original work.

In 1999, Cabana et al. reviewed barriers to physician adherence to practice guidelines. They extended the theories, models and frameworks mentioned above, to provide practical knowledge that could help developers of guidelines, practice directors, and health care service researchers design effective interventions to change physician practice. The barriers affected physicians’ knowledge (lack of awareness, lack of familiarity), attitudes (lack of agreement, lack of self -efficacy, lack of outcome expectancy, inertia of previous practice), or behaviour (external barriers). Each barrier holds specific importance when thinking about practical designs for interventions.

Attempts to change clinical practice tend to be successful only to the extent that they recognise and engage actively with the real world in which clinicians operate, whether or not they do so explicitly. The real world of clinical decision making is, of course, a complex, often contradictory and changing one in which the interaction between clinician and patient may be the simplest, and least contradictory element. There is a wide range of practical strategies used to disseminate guidelines to physicians in the hopes of promoting adoption and change. Several reviews of reviews have appeared in the past decade that qualify these strategies. Recent papers of this nature have looked at hundreds, if not thousands of previous studies, in total, including randomised clinical trials and meta-analyses of such trials. The table on the next page, found in the body of this document, summarises these strategies.

In 1997, Hayward et al. conducted a self -administered survey of a random sample of over 1800 Canadian physicians, to assess their preferences regarding clinical practice guidelines. They found that user friendliness of the guideline format was very important to the physicians. The preferred formats identified as most useful were pocket cards, concise pamphlets and journal article summaries. More discursive formats, as well as workshops and computer databases were not considered useful.

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2-550-38276-5
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