Patterns of 'leakage' in the utilisation of clinical guidelines: a systematic review

Sharon Mickan, Amanda Burls, Paul Glasziou, Sharon Mickan, Amanda Burls, Paul Glasziou

Abstract

Background: Research evidence is insufficient to change physicians' behaviour. In 1996, Pathman developed a four step model: that physicians need to be aware of, agree with, adopt, and adhere to guidelines.

Objective: To review evidence in different settings on the patterns of 'leakage' in the utilisation of clinical guidelines using Pathman's awareness-to-adherence model.

Methods: A systematic review was conducted in June 2010. Primary studies were included if they reported on rates of awareness and agreement and adoption and/or adherence.

Results: 11 primary studies were identified, reporting on 29 recommendations. Descriptive analyses of patterns and causes of leakage were tabulated and graphed. Leakage was progressive across all four steps. Median adherence from all recommendations was 34%, suggesting that potential benefits for patients from health research may be lost. There was considerable variation across different types of guidelines. Recommendations for drug interventions, vaccination and health promotion activities showed high rates of awareness. Leakage was most pronounced between adoption and adherence for drug recommendations and between awareness and agreement for medical management recommendations. Barriers were reported differentially for all steps of the model.

Conclusion: Leakage from research publication to guideline utilisation occurs in a wide variety of clinical settings and at all steps of the awareness-to-adherence pathway. This review confirms that clinical guidelines are insufficient to implement research and suggests there may be different factors influencing clinicians at each step of this pathway. Recommendations to improve guideline adherence need to be tailored to each step.

Conflict of interest statement

Competing interests: <?release-delay 0|0 >All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) SM, AB and PG have support from the Department of Primary HealthCare, University of Oxford, and Bond University for the submitted work; (2) have no relationships with any companies that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) SM, AB and PG have no non-financial interests that may be relevant to the submitted work.

Figures

Figure 1
Figure 1
Study selection diagram.
Figure 2
Figure 2
Absolute responder rates for drug recommendations. LDL, low density lipoprotein.
Figure 3
Figure 3
Absolute responder rates for medical management recommendations.
Figure 4
Figure 4
Absolute responder rates for vaccination recommendations.
Figure 5
Figure 5
Absolute responder rates for health promotion recommendations.
Figure 6
Figure 6
Absolute responder rates for screening recommendations.
Figure 7
Figure 7
Box and whisker plot for all absolute rates.

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Source: PubMed

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