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1.  Guidelines on uncomplicated urinary tract infections are difficult to follow: perceived barriers and suggested interventions 
BMC Family Practice  2010;11:51.
Urinary tract infections (UTI) are among the most common health problems seen in general practice. Evidence-based guidelines on UTI are available, but adherence to these guidelines varies widely among practitioners for reasons not well understood. The aim of this study was to identify the barriers to the implementation of a guideline on UTI perceived by Dutch general practitioners (GPs) and to explore interventions to overcome these barriers.
A focus group study, including 13 GPs working in general practices in the Netherlands, was conducted. Key recommendations on diagnosis and treatment of uncomplicated UTI were selected from the guideline. Barriers to guideline adherence and possible interventions to address these barriers were discussed. The focus group session was audio-taped and transcribed verbatim. Barriers were classified according to an existing framework.
Lack of agreement with the recommendations, unavailable and inconvenient materials (i.e. dipslides), and organisational constraints were perceived as barriers for the diagnostic recommendations. Barriers to implementing the treatment recommendations were lack of applicability and organisational constraints related to the availability of drugs in pharmacies. Suggested interventions were to provide small group education to GPs and practice staff members, to improve organisation and coordination of care in out of hour services, to improve the availability of preferred dosages of drugs, and to pilot-test guidelines regionally.
Despite sufficient knowledge of the recommendations on UTI, attitudinal and external barriers made it difficult to follow them in practice. The care concerning UTI could be optimized if these barriers are adequately addressed in implementation strategies. The feasibility and success of these strategies could be improved by involving the target group of the guideline in selecting useful interventions to address the barriers to implementation.
PMCID: PMC2908068  PMID: 20584276
2.  Characteristics of effective clinical guidelines for general practice. 
BACKGROUND: The use of clinical guidelines in general practice is often limited. Research on barriers to guideline adherence usually focuses on attitudinal factors. Factors linked to the guideline itself are much less studied. AIM: To identify characteristics of effective clinical guidelines for general practice, and to explore whether these differ between therapeutic and diagnostic recommendations. DESIGN OF STUDY: Analysis of performance data from an audit study of 200 general practitioners (GPs) in The Netherlands conducted in 1997. SETTING: Panel of 12 GPs in The Netherlands who were familiar with guideline methodology. METHOD: A set of 12 attributes, including six potential facilitators and six potential barriers to guideline use, was formulated. The panel assessed the presence of these attributes in 96 guideline recommendations formulated by the Dutch College of General Practitioners. The attributes of recommendations with high compliance rates (70% to 100%) were compared with those with low compliance rates (0% to 60%). RESULTS: Recommendations with high compliance rates were to a lesser extent those requiring new skills (7% compared with 22% in recommendations with low compliance rates), were less often part of a complex decision tree (12% versus 25%), were more compatible with existing norms and values in practice (87% versus 76%), and more often supported with evidence (47% versus 31%). For diagnostic recommendations, the ease of applying them and the potential (negative) reactions of patients were more relevant than for therapeutic recommendations. CONCLUSION: To bridge the gap between research and practice, the evidence as well as the applicability should be considered when formulating recommendations. If the recommendations are not compatible with existing norms and values, not easy to follow or require new knowledge and skills, appropriate implementation strategies should be designed to ensure change in daily practice.
PMCID: PMC1314503  PMID: 12569898
3.  “I Think It, but Don't Often Write It”: The Barriers to Charting in Private Practice 
Physiotherapy Canada  2009;61(4):252-258.
Purpose: To describe barriers to charting identified by physiotherapists working in private practice in New Brunswick.
Method: Physiotherapists were invited to focus-group interviews to discuss the results of a comprehensive chart audit. Sixty-nine physiotherapists who responded were assigned to nine focus groups. Seven of nine audiotaped interviews (49 participants) were of sufficient quality to be transcribed and imported into qualitative data analysis software for thematic analysis.
Results: Participants described the challenges of including charting in their routine client care. Barriers included the disjuncture between charting and thinking, the translation of impairment goals to functional goals, the time it takes to chart, fear of failure, and the difficulty of predicting length of treatment. Strategies to facilitate charting were suggested by participants.
Conclusion: Understanding barriers to charting in private practice is necessary to improve the quality of documentation. Barriers described are related to the fast-moving nonverbal, kinaesthetic, and cognitive process that is clinical reasoning in physiotherapy. This tacit, implicit process is mismatched with the charting task, which requires that the implicit become explicit in written form. Strategies to facilitate charting noted by participants address some of these issues; however, a broader, profession-wide discussion is necessary.
PMCID: PMC2793700  PMID: 20808487
barriers; charting; focus-group interviews; qualitative research; subacute low back pain; groupes de discussion; lombalgie subaiguë; obstacles; recherche qualitative; tenue de dossiers
4.  Perceived barriers to guideline adherence: A survey among general practitioners 
BMC Family Practice  2011;12:98.
Despite considerable efforts to promote and support guideline use, adherence is often suboptimal. Barriers to adherence vary not only across guidelines but also across recommendations within guidelines. The aim of this study was to assess the perceived barriers to guideline adherence among GPs by focusing on key recommendations within guidelines.
We conducted a cross-sectional electronic survey among 703 GPs in the Netherlands. Sixteen key recommendations were derived from four national guidelines. Six statements were included to address the attitudes towards guidelines in general. In addition, GPs were asked to rate their perceived adherence (one statement) and the perceived barriers (fourteen statements) for each of the key recommendations, based on an existing framework.
264 GPs (38%) completed the questionnaire. Although 35% of the GPs reported difficulties in changing routines and habits to follow guidelines, 89% believed that following guidelines leads to improved patient care. Perceived adherence varied between 52 and 95% across recommendations (mean: 77%). The most perceived barriers were related to external factors, in particular patient ability and behaviour (mean: 30%) and patient preferences (mean: 23%). Lack of applicability of recommendations in general (mean: 22%) and more specifically to individual patients (mean: 25%) were also frequently perceived as barriers. The scores on perceived barriers differed largely between recommendations [minimum range 14%; maximum range 67%].
Dutch GPs have a positive attitude towards the NHG guidelines, report high adherence rates and low levels of perceived barriers. However, the perceived adherence and perceived barriers varied largely across recommendations. The most perceived barriers across recommendations are patient related, suggesting that current guidelines do not always adequately incorporate patient preferences, needs and abilities. It may be useful to provide tools such as decision aids, supporting the flexible use of guidelines to individual patients in practice.
PMCID: PMC3197492  PMID: 21939542
5.  Barriers to guideline implementation and educational needs of general practitioners regarding heart failure: a qualitative study 
Objectives: A clinical practice guideline (CPG) contains specifically developed recommendations that can serve physicians as a decision aid in evidence-based practice. The implementation of heart failure (HF) CPGs represents a challenge in general practice. As part of the development of a tailored curriculum, aim of this study was to identify barriers of guideline adherence and needs for medical education (CME) in HF care.
Methods: We conducted a modified focus group with elements of a workshop of three hours duration. Thirteen GPs collected and discussed together and parallel in smaller groups barriers of guideline implementation. Afterwards they performed a needs assessment for a tailored CME curriculum for chronic HF. The content of the discussions was analysed qualitatively according to Mayring and categorised thematically.
Results: Barriers of guideline adherence were found in the following areas: doctor: procedural knowledge (knowledge gaps), communicative and organisational skills (e.g. time management) and attitude (dissatisfaction with time-money-relation). Patients: individual case-related problems (multimorbidity, psychiatric comorbidity, expectations and beliefs). Doctor and patient: Adherence and barriers of communication. Main measures for improvement of care concerned the areas of the identified barriers of guideline adherence with the focus on application-oriented training of the abovementioned procedural knowledge and skills, but also the supply of tools (like patient information leaflets) and patient education.
Conclusion: For a CME-curriculum for HF tailored to the needs of GPs, a comprehensive educational approach seems necessary. It should be broad-based and include elements of knowledge and skills to be addressed and trained case-related. Additional elements should include support in the implementation of organisational processes in the practice and patient education.
PMCID: PMC3374142  PMID: 22737201
heart failure; family practice; clinical practice guidelines; qualitative research; continuing medical education
6.  Identifying barriers and tailoring interventions to improve the management of urinary tract infections and sore throat: a pragmatic study using qualitative methods 
Theories of behaviour change indicate that an analysis of factors that facilitate or impede change is helpful when trying to influence professional practice. The aim of this study was to identify barriers to implementing evidence-based guidelines for urinary tract infection and sore throat in general practice in Norway, and to tailor interventions to address these barriers.
We used a checklist to identify barriers and possible interventions to address these in an iterative process that included a review of the literature, brainstorming, focus groups, a pilot study, small group discussions and interviews.
We identified at least one barrier for each category. Both guidelines recommended increased use of telephone consultations and reduced use of laboratory tests, and the barriers and the interventions were similar for the two guidelines. The complexity of changing routines involving patients, general practitioners and general practitioner assistants, loss of income with telephone consultations, fear of overlooking serious disease, perceived patient expectations and lack of knowledge about the evidence for the guidelines were the most prominent barriers. The interventions that were tailored to address these barriers included support for change processes in the practices, increasing the fee for telephone consultations, patient information leaflets and computer-based decision support and reminders.
A systematic approach using qualitative methods helped identify barriers and generate ideas for tailoring interventions to support the implementation of guidelines for the management of urinary tract infections and sore throat. Lack of resources limited our ability to address all of the barriers adequately.
PMCID: PMC150569  PMID: 12622873
7.  Barriers and facilitators to implement shared decision making in multidisciplinary sciatica care: a qualitative study 
The Dutch multidisciplinary sciatica guideline recommends that the team of professionals involved in sciatica care and the patient together decide on surgical or prolonged conservative treatment (shared decision making [SDM]). Despite this recommendation, SDM is not yet integrated in sciatica care. Existing literature concerning barriers and facilitators to SDM implementation mainly focuses on one discipline only, whereas multidisciplinary care may involve other barriers and facilitators, or make these more complex for both professionals and patients. Therefore, this qualitative study aims to identify barriers and facilitators perceived by patients and professionals for SDM implementation in multidisciplinary sciatica care.
We conducted 40 semi-structured interviews with professionals involved in sciatica care (general practitioners, physical therapists, neurologists, neurosurgeons, and orthopedic surgeons) and three focus groups among patients (six to eight per group). The interviews and focus groups were audiotaped and transcribed in full. Reported barriers and facilitators were classified according to the framework of Grol and Wensing. The software package Atlas.ti 7.0 was used for analysis.
Professionals reported 53 barriers and 5 facilitators, and patients 35 barriers and 18 facilitators for SDM in sciatica care. Professionals perceived most barriers at the level of the organizational context, and facilitators at the level of the individual professional. Patients reported most barriers and facilitators at the level of the individual professional. Several barriers and facilitators correspond with barriers and facilitators found in the literature (e.g., lack of time, motivation) but also new barriers and facilitators were identified. Many of these new barriers mentioned by both professionals and patients were related to the multidisciplinary setting, such as lack of visibility, lack of trust in expertise of other disciplines, and lack of communication between disciplines.
This study identified barriers and facilitators for SDM in the multidisciplinary sciatica setting, by both professionals and patients. It is clear that more barriers than facilitators are perceived for implementation of SDM in sciatica care. Newly identified barriers and facilitators are related to the multidisciplinary care setting. Therefore, an effective implementation strategy of SDM in a multidisciplinary setting such as in sciatica care should focus on these barriers and facilitators.
PMCID: PMC3765956  PMID: 23968140
Sciatica; Lumbar radicular syndrome; Implementation strategy; Shared decision making; Barriers and facilitators; Multidisciplinary; Patients; Professionals; Providers
8.  Acceptance and perceived barriers of implementing a guideline for managing low back in general practice 
Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation.
Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion.
Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP.
Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system.
Trial registration
BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 [25].
PMCID: PMC2275295  PMID: 18257923
9.  Why are some evidence-based care recommendations in chronic obstructive pulmonary disease better implemented than others? Perspectives of medical practitioners 
Clinical guidelines for management of patients with chronic obstructive pulmonary disease (COPD) include recommendations based on high levels of evidence, but gaps exist in their implementation. The aim of this study was to examine the perspectives of medical practitioners regarding implementation of six high-evidence recommendations for the management of people with COPD.
Semi-structured interviews were conducted with medical practitioners involved with care of COPD patients in hospital and general practice. Interviews sought medical practitioners’ experience regarding implementation of smoking cessation, influenza vaccination, pulmonary rehabilitation, guideline-based medications, long-term oxygen therapy for hypoxemia and plan and advice for future exacerbations. Interviews were audiotaped, transcribed verbatim and analyzed using content analysis.
Nine hospital-based medical practitioners and seven general practitioners participated. Four major categories were identified which impacted on implementation of the target recommendations in the care of patients with COPD: (1) role clarity of the medical practitioner; (2) persuasive communication with the patient; (3) complexity of behavioral change required; (4) awareness and support available at multiple levels. For some recommendations, strength in all four categories provided significant enablers supporting implementation. However, with regard to pulmonary rehabilitation and plans and advice for future exacerbations, all identified categories that presented barriers to implementation.
This study of medical practitioner perspectives has indicated areas where significant barriers to the implementation of key evidence-based recommendations in COPD management persist. Developing strategies to target the identified categories provides an opportunity to achieve greater implementation of those high-evidence recommendations in the care of people with COPD.
PMCID: PMC3257951  PMID: 22259242
chronic obstructive pulmonary disease; guideline implementation; barriers; enablers; medical practitioners; qualitative research
10.  "We don't really have cause to discuss these things, they don't affect us": a collaborative model for developing culturally appropriate sexual health services with the Bangladeshi community of Tower Hamlets 
Sexually Transmitted Infections  2005;81(2):158-162.
Objective: To identify barriers to accessing sexual health care among the Bangladeshi community of east London and to develop a model of community participation in service development.
Methods: Qualitative study using one to one interviews with sexual health service users plus focus groups in community settings.
Results: 58 people participated in the study, 12 in individual interviews and the remainder in six focus groups. All were of Bangladeshi origin. Four main themes were reported as impacting on access to services; confidentiality concerns, relevance of services to the community, problems with discussing sexual issues, and problems with previous experiences of health promotion. Community values regarding sex outside of marriage were an important underlying factor in participants' responses. Existing sexual health services were seen as culturally insensitive by patients and community groups.
Conclusions: Community based health initiatives among hard to reach ethnic minority groups should use existing networks of statutory and non-statutory groups to benefit from local expertise and relationships. Steering groups composed of members of the local communities served by the clinic can usefully inform service development.
PMCID: PMC1764666  PMID: 15800096
11.  Why don't some women attend antenatal and postnatal care services?: a qualitative study of community members' perspectives in Garut, Sukabumi and Ciamis districts of West Java Province, Indonesia 
Antenatal, delivery and postnatal care services are amongst the recommended interventions aimed at preventing maternal and newborn deaths worldwide. West Java is one of the provinces of Java Island in Indonesia with a high proportion of home deliveries, a low attendance of four antenatal services and a low postnatal care uptake. This paper aims to explore community members' perspectives on antenatal and postnatal care services, including reasons for using or not using these services, the services received during antenatal and postnatal care, and cultural practices during antenatal and postnatal periods in Garut, Sukabumi and Ciamis districts of West Java province.
A qualitative study was conducted from March to July 2009 in six villages in three districts of West Java province. Twenty focus group discussions (FGDs) and 165 in-depth interviews were carried out involving a total of 295 respondents. The guidelines for FGDs and in-depth interviews included the topics of community experiences with antenatal and postnatal care services, reasons for not attending the services, and cultural practices during antenatal and postnatal periods.
Our study found that the main reason women attended antenatal and postnatal care services was to ensure the safe health of both mother and infant. Financial difficulty emerged as the major issue among women who did not fulfil the minimum requirements of four antenatal care services or two postnatal care services within the first month after delivery. This was related to the cost of health services, transportation costs, or both. In remote areas, the limited availability of health services was also a problem, especially if the village midwife frequently travelled out of the village. The distances from health facilities, in addition to poor road conditions were major concerns, particularly for those living in remote areas. Lack of community awareness about the importance of these services was also found, as some community members perceived health services to be necessary only if obstetric complications occurred. The services of traditional birth attendants for antenatal, delivery, and postnatal care were widely used, and their roles in maternal and child care were considered vital by some community members.
It is important that public health strategies take into account the availability, affordability and accessibility of health services. Poverty alleviation strategies will help financially deprived communities to use antenatal and postnatal health services. This study also demonstrated the importance of health promotion programs for increasing community awareness about the necessity of antenatal and postnatal services.
PMCID: PMC2964562  PMID: 20937146
The Journal of Sexual Medicine  2012;9(5):1285-1294.
Sexuality is a key aspect of women’s physical and psychological health. Research shows both patients and physicians face barriers to communication about sexuality. Given their expertise and training in addressing conditions of the female genital tract across the female life course, obstetrician/gynecologists (ob/gyns) are well-positioned among all physicians to address sexuality issues with female patients. New practice guidelines for management of female sexual dysfunction and the importance of female sexual behavior and function to virtually all aspects of ob/gyn care, and to women’s health more broadly, warrant up-to-date information regarding ob/gyns’ sexual history-taking routine.
To determine obstetrician/gynecologists’ practices of communication with patients about sexuality, and to examine the individual and practice-level correlates of such communication.
A population-based sample of 1154 practicing U.S. obstetrician/gynecologists (53% male; mean age 48 years) was surveyed regarding their practices of communication with patients about sex.
Main Outcome Measures
Self-reported frequency measures of ob/gyns’ communication practices with patients including whether or not ob/gyns discuss patients’ sexual activities, sexual orientation, satisfaction with sexual life, pleasure with sexual activity, and sexual problems or dysfunction, as well as whether or not one ever expresses disapproval of or disagreement with patients’ sexual practices. Multivariable analysis was used to correlate physicians’ personal and practice characteristics with these communication practices.
Survey response rate was 65.6%. Sixty-three percent of ob/gyns reported routinely assessing patients’ sexual activities; 40% routinely asked about sexual problems. Fewer asked about sexual satisfaction (28.5%), sexual orientation/identity (27.7%), or pleasure with sexual activity (13.8%). A quarter of ob/gyns reported they had expressed disapproval of patients’ sexual practices. Ob/gyns practicing predominately gynecology were significantly more likely than other ob/gyns to routinely ask about each of the five outcomes investigated.
The majority of U.S. ob/gyns report routinely asking patients about their sexual activities, but most other areas of patients’ sexuality are not routinely discussed.
PMCID: PMC3387502  PMID: 22443146
Female Sexuality; Patient-Physician Communication; Sexual History-Taking; Female Sexual Health
13.  "What lies beneath it all?" – an interview study of GPs' attitudes to the use of guidelines 
General practitioners (GPs) adopt clinical practice guidelines to varying degrees. Several factors have been found to influence application of guidelines in practice and the GP is apparently the key actor. Studies are needed to increase our understanding of how GPs' attitudes influence their use of guidelines. In this study we explored GPs' attitudes to guidelines.
In 2007 we conducted six semi-structured group interviews with a purposive sample of 27 Norwegian GPs. The participants were encouraged to discuss guidelines they were familiar with, the evidence base of guidelines, professional autonomy and doctor-patient relations. We used thematic content analysis to extract central themes and arguments.
When deciding whether tfollow guideline recommendations, GPs consider whether guidelines are trustworthy, whether they suit patients and whether the recommended action is feasible. There were two important findings. First, the GP's were concerned that guidelines may be more heavily influenced by economic considerations than clinical ones. Second, in contrast to earlier findings, changes in recommendations and disagreement between experts were mostly viewed positively.
This study underscores the need for transparency in the process of development and implementation of guidelines. To enhance the use of guidelines, primary care physicians should be involved in the process of developing guidelines and the process should be transparent and explicit regarding the evidence base and economic considerations.
PMCID: PMC2577651  PMID: 18945360
14.  Analysis of the Practice Guidelines of the Dutch College of General Practitioners with Respect to the Use of Blood Tests 
Objective: To determine the consistency among the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests.
Methods: The authors evaluated 64 practice guidelines of the Dutch College of General Practitioners. For each guideline, they analyzed each sentence that contained a reference to a blood test to determine the clinical situation in which the test should be performed (the indication) and to determine the tests that should be performed in that situation (the recommended test). An incomplete recommendation refers to a guideline that mentioned a blood test but did not identify the indication for that test. An inconsistency refers to the situation in which one guideline recommended a certain test for a given indication whereas another guideline mentioned the same indication but did not recommend the same test.
Results: Twenty-seven practice guidelines mentioned blood tests. Of these, three explicitly recommended not to request blood tests. Five guidelines contained incomplete recommendations, and the authors encountered two inconsistencies among the guidelines. Twenty-three guidelines mentioned blood tests and allowed the authors to identify indications and recommended tests.
Conclusion: The identification of indications and recommended tests allows evaluation of consistency among practice guidelines. Although some incomplete recommendations and inconsistencies were discovered, the majority of the guidelines provide clear and unambiguous recommendations for blood-test ordering in primary care.
PMCID: PMC61373  PMID: 10428005
15.  Don't ask, don't tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle 
Sexually Transmitted Infections  2004;80(6):512-517.
Objectives: A high incidence of HIV continues among men who have sex with men (MSM) in industrialised nations and research indicates many MSM do not disclose their HIV status to sex partners. Themes as to why MSM attending sexually transmitted infection (STI) clinics in Los Angeles and Seattle do and do not disclose their HIV status are identified.
Methods: 55 HIV positive MSM (24 in Seattle, 31 in Los Angeles) reporting recent STI or unprotected anal intercourse with a serostatus negative or unknown partner from STI clinics underwent in-depth interviews about their disclosure practices that were tape recorded, transcribed verbatim, coded, and content analysed.
Results: HIV disclosure themes fell into a continuum from unlikely to likely. Themes for "unlikely to disclose" were HIV is "nobody's business," being in denial, having a low viral load, fear of rejection, "it's just sex," using drugs, and sex in public places. Themes for "possible disclosure" were type of sex practised and partners asking/disclosing first. Themes for "likely to disclose" were feelings for partner, feeling responsible for partner's health, and fearing arrest. Many reported non-verbal disclosure methods. Some thought partners should ask for HIV status; many assumed if not asked then their partner must be positive.
Conclusions: HIV positive MSM's decision to disclose their HIV status to sex partners is complex, and is influenced by a sense of responsibility to partners, acceptance of being HIV positive, the perceived transmission risk, and the context and meaning of sex. Efforts to promote disclosure will need to address these complex issues.
PMCID: PMC1744943  PMID: 15572626
16.  Barriers to optimal antibiotic use for community‐acquired pneumonia at hospitals: a qualitative study 
Quality & Safety in Health Care  2007;16(2):143-149.
Physician adherence to key recommendations of guidelines for community‐acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change.
The authors used semistructured interviews with care providers in three Dutch medium‐sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP. They discussed recommendations about the prescription of empirical antibiotic therapy that adheres to the guidelines, timely administration of antibiotics, adjusting antibiotic dosage to accommodate decreased renal function, switching and streamlining therapy, and blood and sputum culturing. The authors then classified the barriers each recommendation faced into categories using a conceptual framework (Cabana).
Eighteen interviews were performed with residents and specialists in pulmonology and internal medicine, with medical microbiologists and a clinical pharmacist. Two additional multidisciplinary small group interviews which included nurses were performed. Each guideline recommendation elicited a different type of barrier. Regarding the choice of guideline‐adherent empirical therapy, treating physicians said that they worried about patient outcome when prescribing narrow‐spectrum antibiotic therapy. Regarding the timeliness of antibiotic administration, barriers such as conflicting guidelines and organisational factors (for example, delayed laboratory results, antibiotics not directly available, lack of time) were reported. Not streamlining therapy after culture results became available was thought to be due to the physicians' attitude of “never change a winning team”.
Efforts to improve the use of antibiotics for patients with CAP should consider the range of barriers that care providers face. Each recommendation meets its own barriers. Interventions to improve adherence should be tailored to these factors.
PMCID: PMC2653154  PMID: 17403764
17.  Sudden unexpected death in epilepsy (SUDEP): don't ask, don't tell? 
The National Institute for Clinical Excellence in the UK has issued guidelines stating all individuals with epilepsy be given information about sudden unexpected death in epilepsy (SUDEP).
We conducted a survey of current practice among UK neurologists, using a questionnaire sent to all practising neurologists in the UK listed on the Association of British Neurologists database, asking under what circumstances they told patients about SUDEP.
Of the validated respondents, 5% discussed SUDEP with all patients, 26% with a majority, 61% with a few, and 7.5% with none. The commonest reasons for SUDEP to be discussed were the patient asking about it and the neurologist counselling people with known risk factors for SUDEP.
The variation we found, although not necessarily in tune with the guidelines, reflects the variation in patients' need for knowledge about their condition.
PMCID: PMC2077594  PMID: 16421121
epilepsy; SUDEP
18.  Improving stroke prevention in patients with atrial fibrillation 
Trials  2013;14:193.
Patients with atrial fibrillation (AF) are at increased risk for stroke. Antithrombotic treatment reduces this risk. Antithrombotic treatment consists of either administration of oral anticoagulants (OAC) or the provision of an antiplatelet drug. International guidelines provide advice on the preferred treatment, thereby balancing the risks and benefits of OAC. However, adherence to these guidelines is reported to be as low as 50%. There is paucity in research on why adherence rates are low. Recent studies have shown decision support systems can improve guideline adherence. We investigate the use of a clinical decision support system to improve guideline adherence among general practitioners (GPs) treating patients with AF and study reasons for guideline non-adherence.
The study is a randomized controlled trial, which is performed among Dutch general practitioners. Initially, GPs in the vicinity of the Academic Medical Center (AMC) in Amsterdam will be included, after which other practices will be recruited. We have developed a novel decision support system that displays a list with pending messages for the on-screen medical record in real time. Messages are generated on a server that evaluates a decision rule based on the atrial fibrillation guideline of the Dutch College of General Practitioners. By interacting with the list, messages can be opened for a description and explanation, or be ignored. GPs are allocated into three groups: 1) control group; 2) intervention group A, in which messages can be ignored without justification; and 3) intervention group B, in which messages can only be ignored with justification.
Our main outcome measure is the between-group difference in the proportion of patients receiving antithrombotic prescriptions in adherence to the Dutch GP guideline for atrial fibrillation. Secondary outcomes are reasons GPs state for deviating from the guideline and the effect on guideline adherence of requiring justification when ignoring a message.
This paper describes the protocol for a cluster randomized trial to study the effects of a clinical decision support system in patients with atrial fibrillation. The system is characterized by a non-interruptive presentation and real-time messages that are updated after each relevant action the GP performs.
Trial registration
This trial is registered with the Dutch Trial Register under registration number 3570.
PMCID: PMC3703259  PMID: 23815891
Atrial fibrillation; Decision support; Stroke prevention; Anti-thrombotic treatment; Clinical decision support system; General practice
19.  SIMPLE: implementation of recommendations from international evidence-based guidelines on caesarean sections in the Netherlands. Protocol for a controlled before and after study 
Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently.
Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives).
An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs.
This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child.
Trial registration NCT01261676
PMCID: PMC3547819  PMID: 23281646
20.  Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage 
Quality in Health Care : QHC  2000;9(2):106-110.
Madelaine van der Meulen, social scientist
Dirk Wijkel, social scientist
Objective—To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers.
Design—Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage.
Setting—General practices and midwifery practices in the Netherlands.
Subjects—73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months.
Main measures—Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place.
Results—In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level.
Conclusions—The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.
(Quality in Health Care 2000;9:106–110)
Key Words: guidelines; miscarriage; implementation
PMCID: PMC1743515  PMID: 11067248
21.  Respiratory medicine 
The General Medical Services (GMS) contract has focused the attention of United Kingdom (UK) general practitioners (GPs) on the provision of high quality routine care for patients with chronic disease.1 The quality markers defined by the contract endorse the need for objective diagnosis and structured care recommended by the British Thoracic Society/Scottish Intercollegiate Guideline Network (BTS–SIGN) guideline for the management of asthma and the National Institute for Clinical Excellence (NICE) guideline on the management of chronic obstructive pulmonary disease (COPD).2,3 In this paper the key recommendations of these guidelines and their implementation in the pragmatic world of general practice are discussed, with specific focus on diagnosis, monitoring, management, self-management and delivery of care.
PMCID: PMC1324808  PMID: 15239918
22.  Physicians Report Barriers to Deliver Best Practice Care for Asplenic Patients: A Cross-Sectional Survey 
PLoS ONE  2011;6(3):e17302.
Current management of asplenic patients is not in compliance with best practice standards, such as defined by the British Committee for Standards in Haematology. To improve quality of care, factors inhibiting best practice care delivery need to be identified first. With this study, we aimed to identify and quantify physicians' barriers to adhere to best practice management of asplenic patients in the Netherlands.
Methods and Principal Findings
A cross-sectional survey, preceded by multiple focus group discussions, was performed among Dutch physicians responsible for prevention of infections in asplenic patients, including specialists (of Internal medicine and Surgery) and general practitioners (GPs). Forty seven GPs and seventy three hospital specialists returned the questionnaire, yielding response rates of 47% and 36,5% respectively. Physicians reported several barriers to deliver best practice. For both GPs and specialists, the most frequently listed barriers were: poor patient knowledge (>80% of hospital specialists and GPs) and lack of clarity about which physician is responsible for the management of asplenic patients (50% of Internists, 46% of Surgeons, 55% of GPs). Both GPs and hospital specialists expressed to experience a lack of mutual trust: specialists were uncertain whether the GP would follow their advice given on patient discharge (33–59%), whereas half of GPs was not convinced that specialists' discharge letters contained the correct recommendations. Almost all physicians (>90%) indicated that availability of a national guideline would improve adherence to best practice, especially if accessible online.
This study showed that, in accordance with reports on international performance, care delivery for asplenic patients in the Netherlands is suboptimal. We identified and quantified perceived barriers by physicians that prevent adherence to post-splenectomy guidelines for the first time. Better transmural collaboration and better informed patients are likely to improve the quality of care of the asplenic patient population. A national, online-available guideline is urgently required.
PMCID: PMC3053367  PMID: 21423748
23.  Do general practitioners adhere to the guideline on infectious conjunctivitis? Results of the Second Dutch National Survey of General Practice 
BMC Family Practice  2007;8:54.
In 1996 the guideline 'The Red Eye' was first published by the Dutch College of General Practitioners. The extent to which general practitioners adhere to this guideline is unclear. Recently, data on the management of infectious conjunctivitis by general practitioners became available from the Second Dutch National Survey of General Practice. We measured the age-specific incidence of infectious conjunctivitis, described its management by Dutch general practitioners, and then compared these findings with the recommendations made in the guideline.
In 2001, over a 12-month period, data from all patient contacts with 195 general practitioners were taken from electronic medical records. Registration was episode-oriented; all consultations dealing with the same health problem were grouped into disease episodes. Data concerning all episodes of infectious conjunctivitis (ICPC-code F70 and sub codes) were analysed.
Over one year, 5,213 new and recurrent episodes of infectious conjunctivitis were presented to general practitioners from a population of N = 375,899, resulting in an overall incidence rate of 13.9 per 1000 person-years, varying from more than 80/1000 py in children up to one-year old, to less than 12/1000 py in children over the age of 4. Topical ophthalmic ointments were prescribed in 87% of the episodes, of which 80% was antibiotic treatment. Fusidic acid gel was most frequently prescribed (69%). In most episodes general practitioners did not adhere to the guideline.
In 2001, the management of infectious conjunctivitis by Dutch general practitioners was not in accordance with the recommendations of the consensus-based guideline published five years previously, despite its wide distribution. In 2006 this guideline was revised. Its successful implementation requires more than distribution alone. Probably the most effective way to achieve this is by following a model for systemic implementation.
PMCID: PMC2034564  PMID: 17868475
24.  Labour intensity of guidelines may have a greater effect on adherence than GPs' workload 
BMC Family Practice  2009;10:74.
Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time.
Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.
A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines.
On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.
84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR = 0.46), while those that can save time have much higher adherence levels: OR = 1.55). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR = 3.13).
No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to.
PMCID: PMC2791751  PMID: 19943953
25.  A qualitative study of barriers to the use of statins and the implementation of coronary heart disease prevention in primary care. 
BACKGROUND: Statin prescribing to prevent coronary heart disease is well below recommended levels. Studies suggest that the prescribing behaviour of doctors may be the biggest factor in the wide variation in statin prescribing in general practice. Understanding doctors' perceptions offers some insight into why variation occurs. AIM: To understand general practitioners' (GPs') views about barriers to statin prescribing, statin prescribing guidelines, and the successes and barriers to coronary prevention in primary care. DESIGN OF STUDY: Qualitative analysis of semi-structured interviews. SETTING: General practices in mid and south Bedfordshire. METHOD: Interviews with 26 GPs. RESULTS: GPs spoke of a variety of barriers to initiating statin treatment specifically, and coronary heart disease prevention generally. Barriers to statin prescribing included: concerns about cost; increased workload and adherence to treatment; variation in treatment targets for lowering cholesterol; and concerns about medicalisation, lifestyle, and health behaviour. GPs found it difficult to prioritize patients for statin treatment, their statin treatment targets varied, and many found primary prevention risk assessment tools difficult to interpret. Coronary prevention was limited by practice space and organisational issues, by problems with recording and retrieval of electronic data, and by limited doctor and nurse time. GPs suggested that funded nurse time, nurse-led heart disease clinics, and better use of electronic data would improve primary care coronary prevention. CONCLUSION: There are complex barriers to statin prescribing and coronary prevention in general practice, which may explain some of the variation that exists. Further studies of patients' views of statins may provide more information. More resources, improved guidance, and better dissemination of guidance may only address some of the issues.
PMCID: PMC1314690  PMID: 15103875

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