Why don't physicians adhere to evidence-based guidelines? For starters, the guidelines need to be more transparent and less ambiguous.

Implementation Science has a new article, Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. The researchers did a qualitative study: 6 focus groups including 30 physicians, reviewing 56 key recommendations derived from 12 national guidelines. Each group discussed barriers preventing implementation of key recommendations.

Findings. The most commonly perceived barriers were:

• Lack of agreement with recommendations due to lack of applicability or lack of evidence (68% of key recommendations),
• Factors such as organizational constraints (52%),
• Lack of knowledge regarding the guideline recommendations (46%), and
• Guideline-specific factors such as unclear or ambiguous recommendations (43%).

Evidently, we have a ways to go before we'll have decent evidence-based guidelines. The barriers identified by the physician participants differed depending on the particular guideline being discussed. The authors recommend "barrier-driven implementation strategies focusing on key recommendations... to improve adherence in practice. In addition, guidelines should be more transparent concerning the underlying evidence and applicability, and further efforts are needed to address complex issues such as comorbidity in guidelines."

These folks are improvers. The authors of this study -- and essentially all researchers whose work I've reviewed in Implementation Science -- fall into the improver category I described last week when writing about Nick Midgley's essay on problems with evidence-based practice: "Improvers 'support the aims and goals of the EBP movement' and want to see it influence real-world practice. For them, the primary issue is better implementation of research findings. They focus on activities such as diffusion, dissemination, knowledge transfer, translation, and spread – believing the best way forward is to identify obstacles that prevent evidence uptake, and find ways around them."

The authors are Marjolein Lugtenberg, Judith M Zegers-van Schaick, Gert P Westert, and Jako S Burgers. Implementation Science 2009 4:54 doi:10.1186/1748-5908-4-54, 12-August-2009.