Family Practice Advance Access published July 16, 2015 Family Practice, 2015, 1–5 doi:10.1093/fampra/cmv061
Qualitative Research
How GPs implement clinical guidelines in everyday clinical practice—a qualitative interview study
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Jette V Lea,*, Helle P Hansena, Helle Riisgaarda, Jesper Lykkegaarda, Jørgen Nexøea, Flemming Brob and Jens Søndergaarda Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense and Research Unit of General Practice, Department of Public Health Aarhus University, Aarhus, Denmark.
*Correspondence to Jette V Le, Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark; E-mail: [email protected]
Abstract Background. Clinical guidelines are considered to be essential for improving quality and safety of health care. However, interventions to promote implementation of guidelines have demonstrated only partial effectiveness and the reasons for this apparent failure are not yet fully understood. Objective. To investigate how GPs implement clinical guidelines in everyday clinical practice and how implementation approaches differ between practices. Methods. Individual semi-structured open-ended interviews with seven GPs who were purposefully sampled with regard to gender, age and practice form. Interviews were recorded, transcribed verbatim and then analysed using systematic text condensation. Results. Analysis of the interviews revealed three different approaches to the implementation of guidelines in clinical practice. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GP’s decision on whether and how to manage implementation. Conclusion. Approaches to implementation of clinical guidelines vary substantially between practices. Supporting activities should take this into account. Key words. Clinical guidelines, general practice, general practitioners, implementation, qualitative research, quality of health care.
Introduction General practices around the world face significant challenges in continuously improving quality of health care. Many efforts have been made and numerous quality improvement programmes attempted to meet these challenges, including development of clinical practice guidelines. However, it has proven difficult to translate clinical guidelines into action and in general even well-developed intervention strategies have not been able to demonstrate more than partial effectiveness (1,2).
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
Grol (3) has, among others, described the steps involved in the process of changing behaviour. The steps include (i) attention to and interest in, for instance, a new clinical guideline, (ii) insight into the clinical guideline and own performance, (iii) acceptance of the clinical guideline and intention to change and finally (iv) implementation in practice followed by maintenance of change. Several qualitative studies regarding GPs’ attitudes and barriers towards clinical guidelines have been conducted (4) and different intervention strategies aiming to promote adherence to clinical guidelines have been tried out in randomized clinical trials. The effects of single interventions
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Methods Setting Practice units in Denmark are on average fairly small: usually two GPs per unit plus nurses and secretaries. The units all have computer-based patient records, electronic communication with hospitals and submission of prescriptions digitally to pharmacies etc. All GPs are self-employed, working on contract for the public funder. The payment is a mixture of per capita payment and fees for services, and there is no requirement for recertification (9). Also, the Danish continuous professional development (CPD) programme is voluntary but based on accredited activities remunerated up to approximately EUR 1800 per year (10). The Danish College of General Practitioners continuously develops clinical practice guidelines and each guideline is accompanied by a range of CPD activities arranged by the Organisation of General Practitioners in Denmark and the Danish Quality Unit of General Practice in collaboration with the regions (9).
Sampling
Data collection Individual semi-structured open-ended interviews with the GPs took place in their surgeries and were digitally recorded with the consent of the participants. Interviews were carried out by JVL, a medical doctor who had participated in courses on interview technique and analysis, and who was supervised by the other authors. The interview guide was developed on the basis of a literature search in PubMed and a snowball search aiming to assess what was already known about how guidelines are implemented in general practice including barriers and facilitators as well as the research group’s own experience from general practice. The interviews lasted ~40 minutes each and comprised questions regarding GPs’ reactions to the latest clinical guideline, what had been done with clinical guidelines in general and what specific changes clinical guidelines had brought about (for interview guide see Table 2). Thus, the interviews focused on the GPs’ own experiences and attitudes and were based on concrete examples from everyday clinical practice.
Data analysis Each interview was transcribed verbatim by JVL and analysed using systematic text condensation (12,13). This procedure involves four steps. First, the transcripts were read thoroughly to get a total impression of the material and preliminary themes associated with the research questions were generated, discussed and written down by three of the authors: JVL, JS (GP, experienced in qualitative research) and HPH (anthropologist). Next, text fragments (meaning units (12)) representing aspects of the preliminary themes were identified and sorted into code groups. Through discussion, the code groups were adjusted and refined, and to clarify different aspects within the code groups, each code group was further split into 2–4 subgroups. Meaning units of each individual subgroup were then compiled into one artificial quotation, a condensate. Meaning units that did not fit were either left out or placed in another subgroup. Finally, based on the quotations, an analytic text for each code group was developed and the essence expressed in separate category headings. All transcripts were then reread in search for data that might challenge the final conclusions. Decisions on each step in the process of analysis Table 1. GP characteristics Gender Age
We applied a purposeful sampling strategy aiming to obtain maximum variation (11) with regard to practice form, age and gender of the GPs. Seven GPs from different practices in the Region of Southern Denmark were included (for GP characteristics see Table 1). The GPs were approached by letter invitations followed by a phone call. Sampling ceased when we found to have covered a broad range of approaches towards implementation of clinical guidelines in general practice.
Practice type
Practice size
Female Male 45 Single-handed practice Partnership practice Collaborative practice 1 GP 2 GPs 3 GPs 4 GPs
2 5 3 4 2 4 1 2 2 1 2
Table 2. Interview guide Research questions
Main topics
Probing questions
How do GPs deal with new knowledge as provided by clinical guidelines? What is done in the practices to implement clinical guidelines?
Reaction to clinical guidelines
What did you do the last time you received a new clinical guideline? Could you give an example of a clinical guideline that has led to changes in your everyday clinical practice? What was done to make these changes happen? What do you think is most important to do to accomplish change?
Specific changes in practice Actions to bring about changes
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have been sparse and non-consistent (5) and targeted implementation initiatives in the form of complex interventions are now regarded the best way to promote change (6) even though this approach still has not been able overall to demonstrate more than partial effectiveness (7). In spite of this extensive research there is still a lack of knowledge regarding the actual implementation process in general practice defined as ‘translation and application of innovations, recommended practices or policies. A process of interaction between the setting of goals and actions geared to achieving them’ (8). To be able to facilitate change in clinical practice, we need insight into how GPs deal with new knowledge as provided in clinical guidelines, and specifically what is done in the practices to implement clinical guidelines. This will provide knowledge on which elements are particularly important to target for future quality improvement programmes and intervention strategies. Additionally, we know from previous research that adherence to clinical guidelines varies considerably between practices on a number of different topics. Therefore, the aim of this study was to investigate how GPs implement clinical practice guidelines in their everyday clinical practice and how implementation approaches differ between practices.
How GPs implement clinical guidelines were based on discussions between the three main authors, and the final results were discussed with the rest of the research group comprising GPs and experienced qualitative researchers.
Results Analysis of the interviews revealed the following three main themes: (i) establishing interest, (ii) the receiving of guidelines and (iii) concretization of implementation.
Establishing interest The GPs’ inclination to read a clinical guideline was very much determined by the topic. Most GPs had areas of special interests and one of the GPs explained how they exerted an informal kind of subspecialization in her practice:
Two other participants explained how they had formalized their areas of interest by collectively delegating responsibilities to different GPs and nurses in the practice. This meant that in relation to some of the chronic diseases, such as chronic obstructive pulmonary disorder, diabetes or hypertension, one doctor and one nurse were responsible for the implementation of new guidelines in the area. We have formed some small teams, where some are in charge of anything to do with the heart, some of lungs, some of diabetes, some of hypertension … one doctor has the primary responsibility for heart, and that’s me, and then someone is responsible for lung, so they have the ultimate responsibility for them (the guidelines) being implemented. (Male, 39 years, partnership practice)
The receiving of guidelines In the two practices where they exerted formal delegation of medical areas, the participants explained that the responsible doctor and nurse studied new guidelines when they arrived and identified discrepancies between the new recommendations and existing clinical practice. One of the GPs explained how he viewed it as his responsibility to transfer the new guidelines into patient care. One of the single-handed GPs elicited a similar statement. He regarded guidelines as a direct guidance on how to treat his patients: First of all, I consider whether I do it the way it says it should be done because otherwise I ought to change something, and I find that very useful. It is after all a guideline. (Male, 38, singlehanded GP)
Other GPs opposed these views. They considered clinical guidelines as inspiration and something to have an opinion about, but not as something to strictly adhere to. These GPs explained how they browsed through the clinical guidelines to see if there were any good ideas compared to what they already knew about the topic or to evaluate on what they did compared to the new recommendations, but without necessarily feeling the need to change anything in their existing practice, if they discovered any differences. I try to just browse through it, and then maybe I get some ideas… but otherwise they usually sit on the shelf over there. (Female, 61, single-handed GP)
‘The shelf’ was mentioned by another GP, who explained how he rarely read the clinical guidelines when they arrived but rather
waited until a need might arise. It could for instance be if the GP was to communicate its content to other people, patients, colleagues or students or if a situation occurred that made him doubt his current quality of care. One of the GPs pointed out how his use of a guideline depended on whom it involved: GPs or practice staff. If it involved practice staff or could involve them, he was more inclined to read it thoroughly and to adhere to its recommendations. You could say that if it’s a clinical guideline primarily targeting the doctor, so to speak, then I read it, and then I make a note of what it is, and I may agree or disagree, but I have an opinion about it … If it’s a clinical guideline, which is—what shall I say— different, where it also involves the staff, then I often involve them and use them to very high degree. (Male, 49 years, collaborative practice)
Concretization of implementation Implementation too was characterized by very different approaches. One of the GPs described how they very informally discussed it when a new clinical guideline was disseminated—not necessarily its content but rather the mere fact of its arrival. Thus, if new clinical guidelines were to be implemented in this practice, the GPs needed to individually apply it to their own clinical practice and then more tacitly than explicitly compel the others to do the same. As this quote demonstrates: Well, I think that I would pass it on, that it is a bit through diffusion that they will notice it. They will notice it the same way I did and maybe just think: oh, that’s the way it is done, so I’m going to do the same, maybe look into it, maybe come and ask me: what on earth is this? (Male, 36 years, partnership practice)
Other GPs discussed the clinical guidelines in formalized meetings and made informal oral agreements to make a change based on guideline recommendations: Then we just talk about it: oh yes, we must remember to do this and that and then we do it. (Female, 48 years, partnership practice)
Thus, an informal agreement was established, but no further collective actions were taken to support the decision. The actual actions to apply and sustain it were left up to the individual GP. One of the singlehanded GPs explained how he prepared practice protocols for the practice nurse to follow and used the clinical guidelines to do it. If the nurse then had any questions they would discuss it afterwards. Similarly, two of the other GPs described how they prepared practice protocols although they did it in formalized meetings together with practice staff. One of the GPs explained part of their procedure like this: What we spend time doing is actually the logistics, making it fit into our clinic, our staff and our equipment … the guideline has to be adjusted so that it is practically implementable … We sit down together and say: what should be the content of the consultation? Who should do what and when and how? And describe the patient flow in it and then add some notes to the laboratory request chart and phrases to the patient records and other places so that we will remember that this is how we do it every time. (Male, 49 years, partnership practice)
Hence, in this practice, the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. The GPs spending most time on collective guideline implementation activities were also the ones who valued consistency and agreement on patient care the most. As one of the GPs expressed:
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There is one who is definitely better at reading ECGs and stuff like that than the rest of us. I am probably better at things like gynaecology and skin diseases, so yes like that… (Female, 48, partnership practice)
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4 It is vitally important to come to an agreement. Of course there is room for disagreement, but when it comes to the kind of care we deliver, regarding the patients, we have to agree. We have to agree on what it is that we do, where we are heading and how we want to treat our patients. We also have to agree on what kind of drugs we use for specific conditions. (Male, 49 years, partnership practice)
The GPs who did not exert collective implementation activities expressed less need for agreement. One stated that this was not an ideal in his clinic.
Nevertheless, one GP made a clear distinction and explained that with respect to tasks delegated to practice staff, some protocols had to be collectively developed for the staff to follow, but when it came to tasks only performed by doctors he saw no need to interfere in decisions made by colleagues. Another GP described how they discussed new clinical guidelines both internally in the practice and externally with network and at courses, but valued a very individual patient approach and expected the practice staff to do the same. Hence, they saw no need to collectively decide what guideline recommendations were to be followed, such as by developing practice protocols, as far as GPs or practice staff were concerned: People are just different, and they don’t fit into those boxes, and they will come whenever they see fit (laughs), so it’s also a bit like they (practice staff, ed.) have to learn the general practice approach to things and accept people for who they are, and when they are here. (Female, 48 years, partnership practice)
Discussion Summary of main findings Analysis of the interviews revealed three different approaches to the implementation of clinical guidelines. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed clinical guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GP’s decision on whether and how to manage implementation.
Strengths and limitations The study was designed as a qualitative interview study based on GPs’ own experiences with implementation of guidelines in clinical practice. The strength of this method is that we got a deep insight into how the GPs received guidelines, and how implementation was managed in the practices. By using a semi-structured approach we ensured that the topics were relevant to our research question while leaving enough space to elaborate on other relevant experiences, values and attitudes regarding implementation of guidelines. We aimed to obtain maximum variation in our sampling to get a broad insight into the subject (14). Sampling was based on practice form as well as age and gender of the participating GPs because we hypothesized that these characteristics affect how implementation is handled and
Findings in relation to other studies The main themes of our study represent areas in which practices differ with regard to guideline implementation. The essential difference between the three approaches identified in our study lies in the extent to which implementation of guidelines is handled through collective or individual activities. Our results mostly correspond with the findings of Grant et al. (15) who described two different ways of making prescribing decisions depending on whether prescribing was based on collective policies or individual processes (macro- or micro-prescribing). However, in addition we identified a ‘middle group’, a group of GPs who prioritized collective knowledge-sharing activities in the practice but who did not value consistency or develop practice protocols. Important parts of this reluctance towards consistency of care could lie in barriers towards performing ‘cookbook medicine’ and not treating patients individually, as well as a wish to maintain clinical autonomy and to safeguard one’s own and colleague’s professional pride (16,17), although our study indicates that task delegation to practice staff in some instances cancels out these barriers. Nevertheless, discussing clinical guidelines and reaching consensus on practice protocols have previously been associated with high quality of care in general practice (15,18). Findings by Gabbay and le May (19) support this although they underline the fact that it is mainly through discussion and social interaction that clinical guidelines are internalized and that the actual practice protocols are of less importance in that respect. Social interaction is a recurring theme in Normalization Process Theory (NPT) as well (20). NPT characterizes implementation as a social process of collective actions based on four components: coherence, cognitive participation, collective action and reflexive monitoring. Thus, according to NPT both discussions of clinical guidelines as well as definition of which recommendations should be implemented and by whom are essential. These factors could pose important pitfalls for the GPs identified in our study who relied on individual or partly individual implementation activities, because most changes in clinical activity involve more than one person. Thus, individuals’ attempt to implement guideline recommendations could easily go wrong if, for instance, a collective agreement is not established or if participants are not aware of their particular responsibilities.
Interpretation Traditionally, GPs have worked very individually in general practice, but organizational restructuring of health care and the evidencebased practice movement have, among others, led to larger practices with more task delegation to practice staff and a higher focus on guidelines, equity and quality of care. This tendency is not only seen in Denmark but also in other developed countries such as the Netherlands, UK, Canada and Australia (21). This means that implementation of guidelines is not necessarily only an individual decision anymore but could require a structural and organizational change in the practices. What makes general practice interesting in this perspective, though, is that the organization of practice units still differs in many aspects, for instance regarding size, distribution of tasks to practice staff and status as training practice. All this could affect how clinical guidelines are received, discussed and used and thereby represent important prerequisites for implementation of guidelines in
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We don’t reach agreement, and there is no requirement about us agreeing. The patients probably experience that they receive the same treatment, or have an expectation of the ideal being that they receive the same treatment, but I don’t think it is quite the ideal we have in the clinic. It’s not something that upsets or annoys us like mad that one doctor chooses differently from others. (Male, 36 years, partnership practice)
perceived. However, our small sample size proposes a risk of not having covered the entire range of approaches towards implementation. Nevertheless, we are quite confident that we have covered a broad range of approaches.
How GPs implement clinical guidelines general practice. Thus, future research should address the influence of organizational characteristics on implementation activities as well as investigate if any particular implementation activities are associated with quality of care in different practice settings.
Implications of this research for clinical practice
Conclusion When developing and disseminating clinical guidelines it is important to recognize that approaches to implementation of clinical guidelines vary substantially between practices. Knowledge on which approaches are used in specific practice settings could prove essential when deciding where to put the focus and support in future quality improvement programmes. Further research is needed to investigate if different approaches to guideline implementation are associated with quality of care in different organizational settings.
Acknowledgements The authors wish to thank all the GPs for their participation in the interviews and also administrator Lise Stark for proofreading the manuscript.
Declaration Funding: Danish Health Foundation (2013B070). Ethical approval: none. Conflict of interest: JL has received a research consultancy fee from Boehringer Ingelheim, and he has twice received a research grant from the Governmental Region of Southern Denmark and once from Danish General Practitioners’ Education and Development Foundation. JS has been involved in research partly sponsored by AstraZeneca, Boehringer Ingelheim, GSK and MSD.
References 1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003; 362: 1225–30. 2. Grimshaw JM, Thomas RE, MacLennan G et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004; 8: iii–iv, 1–72.
3. Grol R. Implementing guidelines in general practice care. Qual Health Care 1992; 1: 184–91. 4. Carlsen B, Glenton C, Pope C. Thou shalt versus thou shalt not: a metasynthesis of GPs’ attitudes to clinical practice guidelines. Br J Gen Pract 2007; 57: 971–8. 5. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci 2012; 7: 50. 6. Grol R, Wensing M, Eccles M, Davis D. Improving Patient Care: The Implementation of Change in Health Care. Chichester, UK: Wiley, 2013. 7. Baker R, Camosso-Stefinovic J, Gillies C et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010; 3: CD005470. 8. Green LW, Ottoson JM, García C, Hiatt RA. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health 2009; 30: 151–74. 9. Pedersen KM, Andersen JS, Sondergaard J. General practice and primary health care in Denmark. J Am Board Fam Med 2012; 25 (suppl 1): S34–8. 10. Kjaer NK, Steenstrup AP, Pedersen LB, Halling A. Continuous professional development for GPs: experience from Denmark. Postgrad Med J 2014; 90: 383–7. 11. Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995; 18: 179–83. 12. Malterud K. Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health 2012; 40: 795–805. 13. Malterud K. Qualitative Methods [Kvalitative metoder i medisinsk forskning: en innføring]. Oslo, Norway: Universitetsforlaget, 2011. 14. Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description—the poor cousin of health research? BMC Med Res Methodol 2009; 9: 52. 15. Grant A, Sullivan F, Dowell J. An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practices? Implement Sci 2013; 8: 72. 16. Søndergaard J, Andersen M, Kragstrup J, Hansen P, Freng Gram L. Why has postal prescriber feedback no substantial impact on general practitioners’ prescribing practice? A qualitative study. Eur J Clin Pharmacol 2002; 58: 133–6. 17. Watkins C, Timm A, Gooberman-Hill R et al. Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study. Fam Pract 2004; 21: 661–9. 18. Hedin K, Strandberg EL, Gröndal H et al. Management of patients with sore throats in relation to guidelines: an interview study in Sweden. Scand J Prim Health Care 2014; 32: 193–9. 19. Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ 2004; 329: 1013. 20. May CR, Mair F, Finch T et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009; 4: 29. 21. Phillips RL Jr. International learning on increasing the value and effectiveness of primary care (I LIVE PC). J Am Board Fam Med 2012; 25 (suppl 1): S2–5. 22. Lugtenberg M, Burgers JS, Han D, Westert GP. General practitioners’ preferences for interventions to improve guideline adherence. J Eval Clin Pract 2014; 20: 820–6.
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Recent research has shown how it is important to take into account the preferences of GPs when developing interventions related to distribution of clinical guidelines (22). According to our findings, GPs work very differently with implementation of guidelines in their practices. This means that the mere dissemination of clinical guidelines could lead to quality improvements in some practices, whilst not having any effect in others. If implementation strategies in relation to dissemination of guidelines are to provide adequate guidance and support, the already established implementation activities of the individual practices should be taken into consideration as well as GPs’ preferences for the type of intervention.
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Qualitative Research
How GPs implement clinical guidelines in everyday clinical practice—a qualitative interview study
a b
Downloaded from http://fampra.oxfordjournals.org/ at University of Manitoba on November 16, 2015
Jette V Lea,*, Helle P Hansena, Helle Riisgaarda, Jesper Lykkegaarda, Jørgen Nexøea, Flemming Brob and Jens Søndergaarda Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense and Research Unit of General Practice, Department of Public Health Aarhus University, Aarhus, Denmark.
*Correspondence to Jette V Le, Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark; E-mail: [email protected]
Abstract Background. Clinical guidelines are considered to be essential for improving quality and safety of health care. However, interventions to promote implementation of guidelines have demonstrated only partial effectiveness and the reasons for this apparent failure are not yet fully understood. Objective. To investigate how GPs implement clinical guidelines in everyday clinical practice and how implementation approaches differ between practices. Methods. Individual semi-structured open-ended interviews with seven GPs who were purposefully sampled with regard to gender, age and practice form. Interviews were recorded, transcribed verbatim and then analysed using systematic text condensation. Results. Analysis of the interviews revealed three different approaches to the implementation of guidelines in clinical practice. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GP’s decision on whether and how to manage implementation. Conclusion. Approaches to implementation of clinical guidelines vary substantially between practices. Supporting activities should take this into account. Key words. Clinical guidelines, general practice, general practitioners, implementation, qualitative research, quality of health care.
Introduction General practices around the world face significant challenges in continuously improving quality of health care. Many efforts have been made and numerous quality improvement programmes attempted to meet these challenges, including development of clinical practice guidelines. However, it has proven difficult to translate clinical guidelines into action and in general even well-developed intervention strategies have not been able to demonstrate more than partial effectiveness (1,2).
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
Grol (3) has, among others, described the steps involved in the process of changing behaviour. The steps include (i) attention to and interest in, for instance, a new clinical guideline, (ii) insight into the clinical guideline and own performance, (iii) acceptance of the clinical guideline and intention to change and finally (iv) implementation in practice followed by maintenance of change. Several qualitative studies regarding GPs’ attitudes and barriers towards clinical guidelines have been conducted (4) and different intervention strategies aiming to promote adherence to clinical guidelines have been tried out in randomized clinical trials. The effects of single interventions
1
Family Practice, 2015, Vol. 00, No. 00
2
Methods Setting Practice units in Denmark are on average fairly small: usually two GPs per unit plus nurses and secretaries. The units all have computer-based patient records, electronic communication with hospitals and submission of prescriptions digitally to pharmacies etc. All GPs are self-employed, working on contract for the public funder. The payment is a mixture of per capita payment and fees for services, and there is no requirement for recertification (9). Also, the Danish continuous professional development (CPD) programme is voluntary but based on accredited activities remunerated up to approximately EUR 1800 per year (10). The Danish College of General Practitioners continuously develops clinical practice guidelines and each guideline is accompanied by a range of CPD activities arranged by the Organisation of General Practitioners in Denmark and the Danish Quality Unit of General Practice in collaboration with the regions (9).
Sampling
Data collection Individual semi-structured open-ended interviews with the GPs took place in their surgeries and were digitally recorded with the consent of the participants. Interviews were carried out by JVL, a medical doctor who had participated in courses on interview technique and analysis, and who was supervised by the other authors. The interview guide was developed on the basis of a literature search in PubMed and a snowball search aiming to assess what was already known about how guidelines are implemented in general practice including barriers and facilitators as well as the research group’s own experience from general practice. The interviews lasted ~40 minutes each and comprised questions regarding GPs’ reactions to the latest clinical guideline, what had been done with clinical guidelines in general and what specific changes clinical guidelines had brought about (for interview guide see Table 2). Thus, the interviews focused on the GPs’ own experiences and attitudes and were based on concrete examples from everyday clinical practice.
Data analysis Each interview was transcribed verbatim by JVL and analysed using systematic text condensation (12,13). This procedure involves four steps. First, the transcripts were read thoroughly to get a total impression of the material and preliminary themes associated with the research questions were generated, discussed and written down by three of the authors: JVL, JS (GP, experienced in qualitative research) and HPH (anthropologist). Next, text fragments (meaning units (12)) representing aspects of the preliminary themes were identified and sorted into code groups. Through discussion, the code groups were adjusted and refined, and to clarify different aspects within the code groups, each code group was further split into 2–4 subgroups. Meaning units of each individual subgroup were then compiled into one artificial quotation, a condensate. Meaning units that did not fit were either left out or placed in another subgroup. Finally, based on the quotations, an analytic text for each code group was developed and the essence expressed in separate category headings. All transcripts were then reread in search for data that might challenge the final conclusions. Decisions on each step in the process of analysis Table 1. GP characteristics Gender Age
We applied a purposeful sampling strategy aiming to obtain maximum variation (11) with regard to practice form, age and gender of the GPs. Seven GPs from different practices in the Region of Southern Denmark were included (for GP characteristics see Table 1). The GPs were approached by letter invitations followed by a phone call. Sampling ceased when we found to have covered a broad range of approaches towards implementation of clinical guidelines in general practice.
Practice type
Practice size
Female Male 45 Single-handed practice Partnership practice Collaborative practice 1 GP 2 GPs 3 GPs 4 GPs
2 5 3 4 2 4 1 2 2 1 2
Table 2. Interview guide Research questions
Main topics
Probing questions
How do GPs deal with new knowledge as provided by clinical guidelines? What is done in the practices to implement clinical guidelines?
Reaction to clinical guidelines
What did you do the last time you received a new clinical guideline? Could you give an example of a clinical guideline that has led to changes in your everyday clinical practice? What was done to make these changes happen? What do you think is most important to do to accomplish change?
Specific changes in practice Actions to bring about changes
Downloaded from http://fampra.oxfordjournals.org/ at University of Manitoba on November 16, 2015
have been sparse and non-consistent (5) and targeted implementation initiatives in the form of complex interventions are now regarded the best way to promote change (6) even though this approach still has not been able overall to demonstrate more than partial effectiveness (7). In spite of this extensive research there is still a lack of knowledge regarding the actual implementation process in general practice defined as ‘translation and application of innovations, recommended practices or policies. A process of interaction between the setting of goals and actions geared to achieving them’ (8). To be able to facilitate change in clinical practice, we need insight into how GPs deal with new knowledge as provided in clinical guidelines, and specifically what is done in the practices to implement clinical guidelines. This will provide knowledge on which elements are particularly important to target for future quality improvement programmes and intervention strategies. Additionally, we know from previous research that adherence to clinical guidelines varies considerably between practices on a number of different topics. Therefore, the aim of this study was to investigate how GPs implement clinical practice guidelines in their everyday clinical practice and how implementation approaches differ between practices.
How GPs implement clinical guidelines were based on discussions between the three main authors, and the final results were discussed with the rest of the research group comprising GPs and experienced qualitative researchers.
Results Analysis of the interviews revealed the following three main themes: (i) establishing interest, (ii) the receiving of guidelines and (iii) concretization of implementation.
Establishing interest The GPs’ inclination to read a clinical guideline was very much determined by the topic. Most GPs had areas of special interests and one of the GPs explained how they exerted an informal kind of subspecialization in her practice:
Two other participants explained how they had formalized their areas of interest by collectively delegating responsibilities to different GPs and nurses in the practice. This meant that in relation to some of the chronic diseases, such as chronic obstructive pulmonary disorder, diabetes or hypertension, one doctor and one nurse were responsible for the implementation of new guidelines in the area. We have formed some small teams, where some are in charge of anything to do with the heart, some of lungs, some of diabetes, some of hypertension … one doctor has the primary responsibility for heart, and that’s me, and then someone is responsible for lung, so they have the ultimate responsibility for them (the guidelines) being implemented. (Male, 39 years, partnership practice)
The receiving of guidelines In the two practices where they exerted formal delegation of medical areas, the participants explained that the responsible doctor and nurse studied new guidelines when they arrived and identified discrepancies between the new recommendations and existing clinical practice. One of the GPs explained how he viewed it as his responsibility to transfer the new guidelines into patient care. One of the single-handed GPs elicited a similar statement. He regarded guidelines as a direct guidance on how to treat his patients: First of all, I consider whether I do it the way it says it should be done because otherwise I ought to change something, and I find that very useful. It is after all a guideline. (Male, 38, singlehanded GP)
Other GPs opposed these views. They considered clinical guidelines as inspiration and something to have an opinion about, but not as something to strictly adhere to. These GPs explained how they browsed through the clinical guidelines to see if there were any good ideas compared to what they already knew about the topic or to evaluate on what they did compared to the new recommendations, but without necessarily feeling the need to change anything in their existing practice, if they discovered any differences. I try to just browse through it, and then maybe I get some ideas… but otherwise they usually sit on the shelf over there. (Female, 61, single-handed GP)
‘The shelf’ was mentioned by another GP, who explained how he rarely read the clinical guidelines when they arrived but rather
waited until a need might arise. It could for instance be if the GP was to communicate its content to other people, patients, colleagues or students or if a situation occurred that made him doubt his current quality of care. One of the GPs pointed out how his use of a guideline depended on whom it involved: GPs or practice staff. If it involved practice staff or could involve them, he was more inclined to read it thoroughly and to adhere to its recommendations. You could say that if it’s a clinical guideline primarily targeting the doctor, so to speak, then I read it, and then I make a note of what it is, and I may agree or disagree, but I have an opinion about it … If it’s a clinical guideline, which is—what shall I say— different, where it also involves the staff, then I often involve them and use them to very high degree. (Male, 49 years, collaborative practice)
Concretization of implementation Implementation too was characterized by very different approaches. One of the GPs described how they very informally discussed it when a new clinical guideline was disseminated—not necessarily its content but rather the mere fact of its arrival. Thus, if new clinical guidelines were to be implemented in this practice, the GPs needed to individually apply it to their own clinical practice and then more tacitly than explicitly compel the others to do the same. As this quote demonstrates: Well, I think that I would pass it on, that it is a bit through diffusion that they will notice it. They will notice it the same way I did and maybe just think: oh, that’s the way it is done, so I’m going to do the same, maybe look into it, maybe come and ask me: what on earth is this? (Male, 36 years, partnership practice)
Other GPs discussed the clinical guidelines in formalized meetings and made informal oral agreements to make a change based on guideline recommendations: Then we just talk about it: oh yes, we must remember to do this and that and then we do it. (Female, 48 years, partnership practice)
Thus, an informal agreement was established, but no further collective actions were taken to support the decision. The actual actions to apply and sustain it were left up to the individual GP. One of the singlehanded GPs explained how he prepared practice protocols for the practice nurse to follow and used the clinical guidelines to do it. If the nurse then had any questions they would discuss it afterwards. Similarly, two of the other GPs described how they prepared practice protocols although they did it in formalized meetings together with practice staff. One of the GPs explained part of their procedure like this: What we spend time doing is actually the logistics, making it fit into our clinic, our staff and our equipment … the guideline has to be adjusted so that it is practically implementable … We sit down together and say: what should be the content of the consultation? Who should do what and when and how? And describe the patient flow in it and then add some notes to the laboratory request chart and phrases to the patient records and other places so that we will remember that this is how we do it every time. (Male, 49 years, partnership practice)
Hence, in this practice, the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. The GPs spending most time on collective guideline implementation activities were also the ones who valued consistency and agreement on patient care the most. As one of the GPs expressed:
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There is one who is definitely better at reading ECGs and stuff like that than the rest of us. I am probably better at things like gynaecology and skin diseases, so yes like that… (Female, 48, partnership practice)
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4 It is vitally important to come to an agreement. Of course there is room for disagreement, but when it comes to the kind of care we deliver, regarding the patients, we have to agree. We have to agree on what it is that we do, where we are heading and how we want to treat our patients. We also have to agree on what kind of drugs we use for specific conditions. (Male, 49 years, partnership practice)
The GPs who did not exert collective implementation activities expressed less need for agreement. One stated that this was not an ideal in his clinic.
Nevertheless, one GP made a clear distinction and explained that with respect to tasks delegated to practice staff, some protocols had to be collectively developed for the staff to follow, but when it came to tasks only performed by doctors he saw no need to interfere in decisions made by colleagues. Another GP described how they discussed new clinical guidelines both internally in the practice and externally with network and at courses, but valued a very individual patient approach and expected the practice staff to do the same. Hence, they saw no need to collectively decide what guideline recommendations were to be followed, such as by developing practice protocols, as far as GPs or practice staff were concerned: People are just different, and they don’t fit into those boxes, and they will come whenever they see fit (laughs), so it’s also a bit like they (practice staff, ed.) have to learn the general practice approach to things and accept people for who they are, and when they are here. (Female, 48 years, partnership practice)
Discussion Summary of main findings Analysis of the interviews revealed three different approaches to the implementation of clinical guidelines. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed clinical guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GP’s decision on whether and how to manage implementation.
Strengths and limitations The study was designed as a qualitative interview study based on GPs’ own experiences with implementation of guidelines in clinical practice. The strength of this method is that we got a deep insight into how the GPs received guidelines, and how implementation was managed in the practices. By using a semi-structured approach we ensured that the topics were relevant to our research question while leaving enough space to elaborate on other relevant experiences, values and attitudes regarding implementation of guidelines. We aimed to obtain maximum variation in our sampling to get a broad insight into the subject (14). Sampling was based on practice form as well as age and gender of the participating GPs because we hypothesized that these characteristics affect how implementation is handled and
Findings in relation to other studies The main themes of our study represent areas in which practices differ with regard to guideline implementation. The essential difference between the three approaches identified in our study lies in the extent to which implementation of guidelines is handled through collective or individual activities. Our results mostly correspond with the findings of Grant et al. (15) who described two different ways of making prescribing decisions depending on whether prescribing was based on collective policies or individual processes (macro- or micro-prescribing). However, in addition we identified a ‘middle group’, a group of GPs who prioritized collective knowledge-sharing activities in the practice but who did not value consistency or develop practice protocols. Important parts of this reluctance towards consistency of care could lie in barriers towards performing ‘cookbook medicine’ and not treating patients individually, as well as a wish to maintain clinical autonomy and to safeguard one’s own and colleague’s professional pride (16,17), although our study indicates that task delegation to practice staff in some instances cancels out these barriers. Nevertheless, discussing clinical guidelines and reaching consensus on practice protocols have previously been associated with high quality of care in general practice (15,18). Findings by Gabbay and le May (19) support this although they underline the fact that it is mainly through discussion and social interaction that clinical guidelines are internalized and that the actual practice protocols are of less importance in that respect. Social interaction is a recurring theme in Normalization Process Theory (NPT) as well (20). NPT characterizes implementation as a social process of collective actions based on four components: coherence, cognitive participation, collective action and reflexive monitoring. Thus, according to NPT both discussions of clinical guidelines as well as definition of which recommendations should be implemented and by whom are essential. These factors could pose important pitfalls for the GPs identified in our study who relied on individual or partly individual implementation activities, because most changes in clinical activity involve more than one person. Thus, individuals’ attempt to implement guideline recommendations could easily go wrong if, for instance, a collective agreement is not established or if participants are not aware of their particular responsibilities.
Interpretation Traditionally, GPs have worked very individually in general practice, but organizational restructuring of health care and the evidencebased practice movement have, among others, led to larger practices with more task delegation to practice staff and a higher focus on guidelines, equity and quality of care. This tendency is not only seen in Denmark but also in other developed countries such as the Netherlands, UK, Canada and Australia (21). This means that implementation of guidelines is not necessarily only an individual decision anymore but could require a structural and organizational change in the practices. What makes general practice interesting in this perspective, though, is that the organization of practice units still differs in many aspects, for instance regarding size, distribution of tasks to practice staff and status as training practice. All this could affect how clinical guidelines are received, discussed and used and thereby represent important prerequisites for implementation of guidelines in
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We don’t reach agreement, and there is no requirement about us agreeing. The patients probably experience that they receive the same treatment, or have an expectation of the ideal being that they receive the same treatment, but I don’t think it is quite the ideal we have in the clinic. It’s not something that upsets or annoys us like mad that one doctor chooses differently from others. (Male, 36 years, partnership practice)
perceived. However, our small sample size proposes a risk of not having covered the entire range of approaches towards implementation. Nevertheless, we are quite confident that we have covered a broad range of approaches.
How GPs implement clinical guidelines general practice. Thus, future research should address the influence of organizational characteristics on implementation activities as well as investigate if any particular implementation activities are associated with quality of care in different practice settings.
Implications of this research for clinical practice
Conclusion When developing and disseminating clinical guidelines it is important to recognize that approaches to implementation of clinical guidelines vary substantially between practices. Knowledge on which approaches are used in specific practice settings could prove essential when deciding where to put the focus and support in future quality improvement programmes. Further research is needed to investigate if different approaches to guideline implementation are associated with quality of care in different organizational settings.
Acknowledgements The authors wish to thank all the GPs for their participation in the interviews and also administrator Lise Stark for proofreading the manuscript.
Declaration Funding: Danish Health Foundation (2013B070). Ethical approval: none. Conflict of interest: JL has received a research consultancy fee from Boehringer Ingelheim, and he has twice received a research grant from the Governmental Region of Southern Denmark and once from Danish General Practitioners’ Education and Development Foundation. JS has been involved in research partly sponsored by AstraZeneca, Boehringer Ingelheim, GSK and MSD.
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Recent research has shown how it is important to take into account the preferences of GPs when developing interventions related to distribution of clinical guidelines (22). According to our findings, GPs work very differently with implementation of guidelines in their practices. This means that the mere dissemination of clinical guidelines could lead to quality improvements in some practices, whilst not having any effect in others. If implementation strategies in relation to dissemination of guidelines are to provide adequate guidance and support, the already established implementation activities of the individual practices should be taken into consideration as well as GPs’ preferences for the type of intervention.
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