Assessing barriers and facilitators to the use of clinical practice guidelines is the first step in the local adaptation and uptake of evidence
. We surveyed Estonian physicians about barriers and facilitators to the use of clinical practice guidelines recognized by the Estonian Health Insurance Fund. We found that the majority of physicians were aware of and used the treatment guidelines. They believe the guidelines are evidence-based and are not concerned about guidelines that may limit professional autonomy (Table
1). The main reported barrier to guideline use was lack of time to identify guidelines. Lack of clinical and patient resources to implement the guidelines were also regarded as barriers (Tables
3). An easily located online database of clinical practice guidelines was suggested as the main solution to overcoming barriers to use (Table
Family doctors that is the biggest group of specialists, were more likely to experience barriers related to a lack of resources, finding necessary information, or time to search for information (Table
3). There are a number of possible explanations for these differences. One might be related to the setting, with hospitals having better resources. Outpatient doctors might see greater number of patients, resulting in less time to search for information. The biggest difference in comparison of family doctors versus hospital based physicians, was demonstrated for the barrier related to lack of time to search for information. This confirms that limited time for one patient in outpatient clinic does not allow searching for information from treatment guidelines for making decisions.
Differences in education may affect an attitude to the use of guidelines. The medical specialists are graduated from one medical university in the country and the main differences could emerge by the graduating years. During the last decade, more emphasis is given to evidence based medicine within the curricula, but still limited.
Clinical practice guidelines have considerable potential to improve quality of health care as guidelines become integrated with information systems and electronic medical records
. A major barrier to such integration is the lack of computing infrastructure in many clinical settings. However, excellent integrated national information systems that are available to Estonian physicians suggest that clinical practice guidelines could be efficiently linked with electronic decision support systems in the country. Furthermore, Estonian physicians’ demand for an online database suggests that they are eager to take advantage of informatics solutions. However, physicians with fewer years of practice experience were more favorable towards clinical guidelines and online resources than those with more experience. As these physicians were likely younger and more comfortable using computer systems, it will be important to train older physicians to use these facilities with equal skills.
It is useful to use a well-established framework to assess local barriers and facilitators because they can vary extensively by setting and even change over time
. For example, barriers may be specific to the site of practice. In a survey of barriers to guideline use in hospitals, Simpson found that four hospitals reported the same doctor-related barrier as ‘most common’ and the remaining 10 hospitals reported three different doctor-related barriers, two nursing-related barriers and three organizational barriers as most common
. Even when barriers are consistent across sites, their influence may differ by type of health care professional
 or by type of guideline, with each key recommendation having a unique pattern of barriers
[6, 8]. In our survey, doctors practicing in hospitals had easier access to guidelines and found them to be more understandable (Tables
3), identifying a need to distribute Estonian guidelines in ways that are equally suitable and accessible for outpatient clinicians. Although there were no differences by gender, more experienced physicians had more barriers to guideline use. Thus, tailoring an intervention to address the specific problems of access raised by outpatient and more experienced physicians could increase the use of guidelines in Estonia.
Resources, both human and financial, are needed for guideline development and implementation. Estonia has transitioned from a lower middle-income country in the 1990s to a higher middle-income country early in this century. However, the availability of clinicians and researchers who are trained in methods needed for evidence-based guideline development remains a resource constraint in Estonia. Few surveys of guideline implementation have been conducted in low-resource settings. However, a written survey conducted by Guindon and colleagues assessed how research evidence was used by practitioners in 10 low- and middle-income countries
. In general, the findings suggest that locally conducted and developed research played an important role, emphasizing the need for local capacity. A few questions were specific to clinical practice guidelines. In the Guindon’s study, only 12% of respondents (150/1249) had training in incorporating research evidence into a local guideline
. Thus, developing efficient mechanisms for guideline development that rely on adaptation of existing guidelines to the Estonian setting will promote the use of guidelines by involving local physicians in the process.
The major limitation of survey methods in assessing barriers to guideline use is that they are pre-specified by the investigators collecting the data. Therefore, we structured the questions in our barrier assessment according to a comprehensive theoretical framework
 to help ensure that important factors were not excluded. Furthermore, our survey included open-ended questions to allow respondents to make additional comments. One limitation of our study was that the analyzed group was restricted to physicians who are included in the database of the Department of Continuing Medical Education as attended the educational courses. Thus, the study group represents more active part of physicians who are more open to new knowledge. Also, other health care professionals, particularly administrators and nurses, can play an important role in the successful implementation of guidelines. The response rate of the study was 41%, which is similar to other online surveys. In addition, our survey population consisted of more than 10% of the national sample of Estonian physicians.