The main question in this study was whether there is a relationship between workload and guideline adherence. We did not find any differences in guideline adherence between GPs with a higher and those with a lower objective workload. However, we found marked differences between guideline recommendations that require a time investment and those that require no extra time. Recommendations that require an extra time investment were less well adhered to.
The expectation that the time spent on keeping up to date influences guideline adherence was not confirmed. Again, this is in line with previous results (Hutten [1
]). A possible explanation for the absence of this relationship is that the Netherlands has a mandatory credit points based system for CME. A minimum of 40 hours per year is required to retain registration as a GP. Besides, the recommendations in the guidelines are clearly described, easily accessible and mostly deal with frequently occurring complaints.
We did observe a small but statistically significant relationship between experienced lack of time (subjective workload) and guideline adherence. However, the finding runs contrary to our expectation: higher satisfaction with available time is found to be correlated to lower guideline adherence. Zantinge et al. [34
] found that GPs who experience a lack of time are less patient-centred. This could possibly lead to a tendency to fall back on guidelines and to provide more 'standard' care. The relationship is, however, very small. A better understanding of this relationship requires further investigation.
The relationship that we found between short-term time investment and adherence is in line with our expectation: recommendations that require more time investment are followed significantly less often; those that reduce the time investment are more often followed. These correlations are quite strong and are statistically significant. We also found that recommendations that are less likely to induce follow-up consultations are more often adhered to. Contrary to our expectation, recommendations that are likely to lead to follow-up consultations are likewise more often followed compared to the 'equal' category. Of course, the GP's choice whether or not to follow guidelines is constrained by medical considerations. Workload is only one factor in the decision process and despite their workload, GPs are obviously concerned for the wellbeing of their patients. This probably explains why recommendations that incur follow-up consultations are better adhered to.
Two important methodological considerations will be discussed here. First, we want to underline the importance of the cross-classified modelling we used. If we had not included the GAI-level, we would have concluded that some GPs have a higher adherence rate than others, without noticing that this is due to the simple fact that some GPs have a higher number of contacts that are related to GAIs that are better followed in general. We checked this by repeating the analyses without including GAI-level, which resulted in a considerable variation between GPs.
Second, in the literature about guideline adherence, sometimes a distinction is made between so-called 'dos' and 'don'ts'; recommendations that advise to do something and those that advise not to do something. It may appear obvious that doing something will generate more workload than not doing something and thus, that our expert panel rated the dos as more burdensome than the don'ts. This was, however not the case. Prescribing, for instance, often generates less workload than explaining why the patient does not get a prescription. There was no clear relationship between the expected workload and whether the recommendation was a 'do' or a 'don't'.
Some remarks will be made about the limitations of this study. First, it should be noted that guideline adherence is only a part of the quality of care. Many aspects of quality, such as communication style and organisation are beyond the scope of this study. There is no one-on-one relationship between guideline adherence and quality. In some cases, there are good reasons to deviate from guidelines. These reasons will often be related to patients or to morbidity, but not to GPs and practices. Previous studies have shown that comorbidity can be a reason to deviate from guidelines [15
]. This factor was not controlled for in this study. It is, however, unlikely that comorbid conditions will vary strongly between GPs or practices after controlling for age and self-rated health. Second, our data contain only cases that could be measured by an indicator. The content of the guidelines encompasses many more recommendations that were not measured, due to the simple fact that not all GPs actions are recorded in a file. Third, in our analyses, workload was considered a stable characteristic at individual GP level, i.e. some GPs are consistently busier than others. At the same time, workload can also vary between days. Consequently, it seems plausible that the same GP might make other decisions on busy days than on less busy days. To determine how busy a GP was on a specific day, one needs the number of contacts on that day as a numerator and the number of working hours as a denominator. The latter was, however, not known. Fourth, the data used in this study are relatively old. It was, however the most recent database available with this specific information. When more recent data are available, it should be investigated whether the relations that we found have been changing over time. Fifth, there are possibly factors that were not included in our analyses but do influence adherence. These might be individual preferences of patients or specific conditions in the situation of patients that can not be derived from electronic records.
The finding that the required time investment incurred by a recommendation was strongly correlated with adherence, in combination with the fact that an overwhelming proportion of the variance was located on the GAI level, leads to two important conclusions. First, in the Netherlands, adherence to guidelines seems to depend on the content of the guidelines to a far greater extent than on the GPs. As described in the introduction, a great effort has already been made in the Netherlands to promote and disseminate the guidelines. It is therefore likely that in countries where guidelines have a less firm position, more variation between GPs will be found and that thus, there is more to gain by encouraging GPs to adhere to and to adopt guidelines. Second, when developing guidelines, it seems sensible to take the required time investment of recommendations into account, since this may affect the likelihood that recommendations are followed.