Table 3 A revised version of Cabana et al.'s framework for classifying barriers to physicians' guideline adherence
Knowledge-related | |
|---|---|
Type of barriers | Physicians typically diverge from a guideline because they: |
Lack of knowledge of the guideline | Don't know (and don't already use) its decision criteria |
Attitude/feeling-related | |
Lack of agreement with the guideline | Disagree with the guideline, thinking that it |
-lack of agreement with its decision criteria | -has faulty decision criteria |
-lack of outcome expectancy* | -worsens (or doesn't improve) patient outcomes |
-lack of process expectancy* | -worsens (or doesn't improve) health care process |
Lack of feelings expectancy* | Think it provokes difficult feelings |
Lack of self-efficacy† | Don't think they have competence to follow it |
Lack of motivation/inertia of previous practice | Aren't motivated to follow it or to change habits |
External | |
Guideline-related | Consider the guideline unclear or impractical to use |
Patient-related | Perceive pressure from patients to diverge |
Setting-related | Think their practice setting makes them diverge due to: |
-lack of time | -insufficient time to inform or negotiate with patients |
-lack of other practice resources | -insufficient materials, staff or reimbursement |
-increased costs | -increased costs if the guideline is followed |
-increased malpractice liability | -risk of legal actions |
-pressures in the health care system | -pressure from other health care providers/organisations |
-improper access to health care services | -too easy/difficult access to actual or alternative services |