Summary of main findings
The findings of this study suggest that GPs claim some reasons for not following guidelines more often than others. Concern for the individual patient's needs coupled with scepticism about applying research findings to individuals seem to be the most important arguments.
This meta-synthesis also shows that there are different barriers to guideline implementation according to whether the guideline is prescriptive or proscriptive. The difference between prescriptive and proscriptive studies was most evident in the themes relating to the doctor–patient relationship and professional responsibility.
Comparison with existing literature
The main themes identified in this study are similar to those found in quantitative studies of guideline adherence.3,5–7,11
The present findings offer reasons as to why some GPs do not follow guidelines; these mainly relate to individual patient needs. The findings fit well with studies of why evidence is not implemented in general practice,37–39
and echo the critique repeatedly made of evidence-based medicine compared with experience-based knowledge.40–42
Population-based trial results are difficult to transfer to the individual patient and this reflects ‘the inherent uncertainty of medical evidence’.43
GPs' concerns about the generalisability of trial results is an issue that has long been recognised and needs to be addressed by the scientific community.44
Proscriptive guidelines may entail rationing and denial of patients' requests, thereby jeopardising the doctor–patient relationship. This dilemma has been noted and debated;45–52
studies reporting this dilemma note that such rationing is both unpleasant and in conflict with the ideals of a patient-centred medicine and the economic incentives of competition for patients.
Prescriptive guidelines are essentially innovative and the implementation of such guidelines is likely to draw on models of the diffusion of innovation, such as those suggested by Eccles and Grimshaw,5
and earlier sociological work by Rogers et al
, which has informed action research in health promotion.53,54
This literature offers advice on how to overcome practical barriers.55
Strengths and limitations of the study
The focus of this study was confined to guideline adherence to ensure that there was a manageable number of comparable studies. As the aim of this study was to provide a synthesis that could complement studies assessing the effectiveness of guideline implementation, it was decided not to include studies of adjacent fields, such as GPs' attitudes to research evidence, or other health workers' attitudes to guidelines, although both of these fields of study have identified many of the same attitudes to implementation. Studies of low quality were also excluded. As noted previously, techniques for synthesising the findings of qualitative research are an emerging area of methodology. One field of discussion is whether and on what grounds studies should be excluded. Quality criteria vary in importance, but the failure by authors to show a clear connection or consistency between the primary data and the categories they have developed is a serious enough weakness to warrant exclusion.
While the goal of this review was to investigate GPs' experiences and attitudes towards guidelines, most of the studies focused on barriers to their use. It is possible that other data may have emerged if these studies had focused on GPs' experiences in general, or on facilitators to the use of guidelines.
It is worth noting that the distinction between proscriptive and prescriptive guidelines is not always clear or exclusive. For instance, guidelines recommending that patients who are using a particular medication switch to generic alternatives include rationing elements but possibly also innovative aspects as GPs and their patients are asked to try something that is perceived as new. Moreover, this study's categorisation of the guidelines is based on the way they are presented and interpreted in relation to current practice by the authors of the original papers. It was noted that information about how guidelines relate to current practice was lacking in several papers. Hopefully, the findings of the present study will prompt future authors to include such information.
The included studies describe GPs' justifications of why they do or do not follow guidelines. It is not possible, of course, to be certain that these accounts are truthful or that they reflect behaviours. GPs may attempt to rationalise lack of adherence to prescribing guidelines,29
and there is some evidence that there may be a bias towards over-reporting adherence to guidelines.56
Nevertheless, understanding the different arguments put forward by GPs, and the important distinction between proscriptive and prescriptive guidelines may help in the future development of guidelines and implementation strategies.
One limitation of narrative synthesis is that the quality of the synthesis depends on the quality of the included studies. Primary studies frequently offer insufficient information about the context of the study, including the interviewer's background and possible influence, and lack of reporting of the data. In this synthesis, a lack of information about the degree of structure in the interviews was also noted. It was frequently unclear whether the emerging barriers were results of free discussion or pre-presented categories. To overcome some of these limitations, studies were excluded if they did not demonstrate consistency between presented data and authors' interpretations.
Notwithstanding the above limitations, the authors would argue that this meta-study offers a bigger picture than would be gained from reading any one study in isolation; the synthesis augments the qualitative research process through a formal and auditable process, and this disputes the relativist position that synthesis is not legitimate because it destroys the integrity of individual studies. Studies were deliberately chosen from a similar setting (general practice) and attention was paid to the context, participants, and clinical topic of each study, but it was not possible to extract findings of interest beyond the individual studies. The synthesis allowed a demonstration of patterns that would otherwise have been missed, and provides hypotheses for further investigation.
Implications for future research or clinical practice
GPs' attitudes towards guidelines appear to be similar across countries and health topics. However, this synthesis of qualitative literature suggests that GPs' attitudes to guidelines may be influenced by the purpose of the guidelines. Literature on diffusion of innovation is likely to be helpful in increasing adherence to prescriptive guidelines, but adherence to proscriptive guidelines also needs to be understood in terms of the doctor–patient relationship and could perhaps be best addressed using economic and psychological theory.
While the challenges of face-to-face rationing as well as those arising from the introduction of new medical technologies have been highlighted, studies of guideline adherence have not taken into account the significance of different rhetoric used for prescriptive and proscriptive guidelines. Further research, for example, a subgroup analysis of the effects of interventions to promote the use of guidelines (such as the work of Grimshaw et al
may be able to detect behavioural differences that map onto these attitudinal findings.
This paper provides an example of how qualitative studies can be synthesised, and a novel understanding of the barriers to the use of guidelines in general practice. Hopefully this will inform synthesis methodology as well as the future development of clinical practice guidelines.