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April 5, 2000

Reasons Physicians Do Not Follow Clinical Practice Guidelines—Reply

Author Affiliations

Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Fishbein FellowIndividualAuthor

JAMA. 2000;283(13):1685-1686. doi:10.1001/jama.283.13.1685

In Reply: Dr Veatch points out that physician disagreement with the value judgments incorporated within a guideline may be another reason for physician nonadherence. In our article, we found 33 surveys investigating physician disagreement with guideline-specific recommendations as a barrier and 15 surveys investigating physician disagreement with the general concept of guidelines.1 There are many specific aspects of guidelines that physicians may find objectionable. Although guideline authors have been urged to state their value judgments explicitly,2 we found no studies that examined disagreement with value judgments as a reason for guideline nonadherence, as Veatch suggests. It is an interesting point that deserves study.

We agree with Dr Montgomery and colleagues that improved patient care depends not only on physician use of guidelines, but also on accurate and proper use of such guidelines. Using their example, our analytic framework might be used to examine the reasons for inaccurate application of hypertension guidelines by physicians, such as lack of familiarity with the guideline, lack of agreement with the recommendations, the inertia of previous practice, or external barriers such as lack of time or lack of a decision support system to help correctly apply the guideline.

With respect to Dr Dahlberg's plea for concise guidelines, we reported 23 examples of barriers citing guideline format as a barrier to adherence. In these examples, guidelines were described as difficult to use, inconvenient, cumbersome, and confusing. We did not attempt to rate the relative importance of the 293 total examples of barriers in our analysis. It may well be that other physicians agree with Dahlberg that this barrier is the most important and difficult to overcome.

Cabana  MDRand  CSPowe  NR  et al.  Why don't physicians follow clinical practice guidelines? a framework for improvement.  JAMA. 1999;282:1458-1465.Google Scholar
Hayward  RSWilson  MCTunis  SR  et al.  More informative abstracts of articles describing clinical practice guidelines.  Ann Intern Med. 1993;118:731-737.Google Scholar