Relatively few studies published over the last 15 years specifically examined guideline features desired by, or associated with use among health professionals, most of these focused on physicians, and it does not appear that studies were informed by preceding research to build a cumulative body of knowledge. Considerable research has examined other factors influencing guideline use such as physician and organizational characteristics, but these studies were not eligible for this review, nor were numerous studies that examined general attitudes to guidelines on specific clinical topics. Review of 18 eligible studies revealed several features related to format or content that may positively influence guideline use, and this was expanded by reviewing the content of high quality international guidelines on various clinical topics. Most guidelines we examined contained a large volume of graded evidence and numerous tables featuring complementary clinical information to the point of being cumbersome, despite the presence of navigational features such as tables of contents. Few contained additional features specified by users or suggested by research to improve guideline use. Guideline use could potentially be improved by developing alternate versions for different purposes, incorporating summaries of evidence and recommendations, including information to facilitate interaction with and involvement of patients, outlining resource implications, and describing how to locally plan, promote, and monitor guideline use. There were no consistent trends by guideline topic.
Our findings simply suggest that more guidelines could be modified to include implementability content, but it remains unclear how various implementability features might influence guideline use. A recent analysis recommended that the reliability, relevance, and readability of knowledge resources be improved to support evidence-based decision making [48
]. Evidence is just one of several factors that inform decisions about guideline use [49
]. In reality, clinicians must often draw upon expertise and experience to consider what is best for and desired by those receiving care, but have expressed uncertainty about how to balance evidence with professional judgment and patient preferences, and the need for guidance to support these decisions [50
]. Furthermore, clinical decisions about guideline use are influenced by the availability and mobilization of organizational or system level resources, which are governed by managers and policy makers who must reconcile the competing interests of multiple stakeholders [34
]. Further insight could be gained by drawing upon decision science to examine the cognitive processes underlying guideline use. Considerable research has established that humans are not rational decision makers who identify alternative options, compare them on the same set of evaluative dimensions, and generate probability and utility estimates for different courses of action [52
]. Instead, it appears that a combination of intuitive (based on experience) and analytic (based on mental simulation) mechanisms are employed [53
]. This is particularly true in 'naturalistic' situations where decisions are complex; the quantity of information may be large or its implications ambiguous; goals may be shifting, poorly defined, or competing; and decisions have high stakes and are made within a dynamic environment under time constraints, as is true of the healthcare sector [54
]. It has been suggested that guidelines include content that mediates decisions among different stakeholders in a manner consistent with these cognitive processes [55
]. Thus, elements in the proposed framework may have impact on two dimensions: support for different types of decision making (evidence-informed, experiential, shared, allocation/policy) by providing particular information and/or tools, and support for different types of decision-making processes (intuitive, analytic) by making explicit the options for, and implications of alternate choices. This may influence attitudes about guideline relevance and confidence in choosing a course of action, which may be associated with use [56
]. While the concept of implementability is not new, the proposed framework is unique because it includes features that may be relevant not only to individuals, but to the managers and policy makers that govern the environment within which individuals function, and because it offers a novel way to improve guideline use by considering how to support different types and processes of decision making [28
Interpretation of the findings may be limited in several ways. We studied guidelines relevant to primary and institutional care. Other guidelines relevant to specialty care may differ in their implementability characteristics. However, while we reviewed few guidelines, they were specifically selected to represent different topics, countries, and types of developer. Each element may not have been relevant to all guidelines reviewed, but this exercise serves as an exploratory, baseline effort to develop the framework according to content available in a range of guidelines. The literature on this topic is sparse, and referred to conceptually in a variety of ways and therefore not consistently indexed in literature databases; the search strategy used was purposely broad in an attempt to identify all relevant studies, but it may not have retrieved all studies describing guideline features desired by, or influencing the behavior of health professionals. We are currently in the process of conducting a systematic conceptual review of theoretical and empirical research on the mechanisms by which implementability elements influencing decision making about guideline use. Still, by assembling a rudimentary implementability framework that was expanded by review of guideline content, numerous opportunities were revealed for potentially improving guideline development and use.
Prior to testing these hypotheses, practical issues must be considered. Robust methods by which to operationalize concepts more specifically to enable accurate data capture would require further development. New governance structures may be required to accommodate the development of guidelines with these features. Future research should validate the framework by applying it to different types of guidelines, and by soliciting feedback from guideline development and implementation experts, clinicians, managers, policy makers, and patients/caregivers to further clarify and expand on its elements. Research is also required to examine precisely how the elements of implementability influence guideline use. Based on an expanded stakeholder-defined implementability framework, the cost-effectiveness of tailored guidelines or adjunct products could be established by examining short-term outcomes predictive of guideline use such as recall, attitude to, confidence in, and adoption intention, then long-term objective outcomes reflecting the adoption of processes and associated patient care outcomes.