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Patterns of 'leakage' in the utilisation of clinical guidelines: a systematic review
Sharon Mickan1, Amanda Burls, Paul Glasziou
1Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK. sharon.mickan@phc.ox.ac.uk
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.
Insights
Physicians often fail to fully implement clinical guidelines, a process called "leakage." This study found significant gaps from awareness to adherence, indicating a need for tailored strategies to improve guideline utilization and patient care.
Area of Science:
- Medical Education
- Health Services Research
- Evidence-Based Practice
Background:
- Physician behavior change is challenging, with existing research evidence often insufficient for adoption.
- Pathman's 1996 model outlines four key steps for guideline implementation: awareness, agreement, adoption, and adherence.
Purpose of the Study:
- To systematically review evidence on 'leakage' in clinical guideline utilization.
- To analyze guideline implementation patterns using Pathman's awareness-to-adherence model across diverse settings.
Main Methods:
- A systematic review of primary studies was conducted in June 2010.
- Studies reporting on awareness, agreement, adoption, and/or adherence rates for clinical guidelines were included.
Main Results:
- Eleven primary studies covering 29 recommendations were analyzed, revealing progressive 'leakage' across all four implementation steps.
- Median adherence was 34%, with significant variations by guideline type; drug, vaccination, and health promotion guidelines showed higher awareness, while adherence gaps were notable for drug and medical management recommendations.
Conclusions:
- Significant 'leakage' occurs from research publication to guideline utilization in various clinical settings and at all stages of the implementation pathway.
- Clinical guidelines alone are insufficient for research implementation, highlighting the need for tailored interventions addressing specific barriers at each step of the clinician's pathway.
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