Factors Influencing Uptake of Changes to Clinical Preventive Guidelines
=======================================================================

* Vivian Jiang
* E. Marshall Brooks
* Sebastian T. Tong
* John Heintzman
* Alex H. Krist

## Abstract

*Background:* Despite widespread recognition that adherence to clinical preventive guidelines improves patient outcomes, clinicians struggle to implement guideline changes in a timely manner. Multiple factors influence guideline adoption and effective implementation. However, few studies evaluate their collective and inter-related effects. This qualitative study provides a comprehensive picture of the interplay between multiple factors on uptake of new or changed preventive guidelines.

*Methods:* Semistructured interviews conducted in 2018 with a diverse sample of clinicians and practice leaders sought to understand patient, clinician, practice, health system, environment, and guideline factors of influence. An immersion-crystallization approach was used to identify emergent themes.

*Results:* Interviewees expressed motivation to adhere to guidelines but also valued sharing decisions with patients. Personal biases and fears affected both clinician and patient guideline adoption. Practices facilitated implementation through workflow optimization and encouraging a culture of evidence-based practice while a key health system function was to maintain electronic health record alerts. More traditional environmental factors, such as insurance coverage or transportation, were less of a barrier to guideline adoption and implementation than the influence of media and specialists. Various specific guideline characteristics also affected ease of adoption and implementation. Different settings expressed greater health system, practice, or clinician-centric approaches to guideline implementation.

*Conclusions:* Guideline uptake is influenced by a complex interplay of multiple levels of factors including the patient, clinician, practice, health system, environment, and guideline levels. Comprehensively understanding all levels of influence for each specific clinical setting may help to determine the optimal intervention(s) for improving uptake of evidence-based guidelines.

*   Evidence-Based Medicine
*   Implementation Science
*   Preventive Medicine
*   Qualitative Research

## Introduction

Organizations like the US Preventive Services Task Force and Advisory Committee on Immunization Practices translate complex scientific evidence into clinical preventive guidelines. These guidelines are regularly updated with the most up-to-date evidence.1,2 Despite wide recognition that adherence to evidence-based guidelines improves outcomes, clinicians struggle to implement guidelines in a timely fashion.3⇓–5 Meanwhile, overscreening of breast, cervical, and prostate cancer, underscreening of lung cancer, and suboptimal vaccination rates continue to put patients at harm.4⇓⇓–7

Many factors have been shown to influence guideline uptake, such as guideline characteristics (eg, ease of implementation, guideline clarity), clinician familiarity with guidelines and evidence, and patient comorbidities or awareness of need.8,9 Interventions targeting these barriers, such as clinician and patient education or system-level changes like alerts or team-based care, have been shown effective in increasing guideline uptake.10 However, few studies provide a comprehensive evaluation of how different levels of factors collectively affect guideline uptake.11 Examining these factors as a whole and how they interact may better inform interventions. This qualitative study details clinician and practice leader perceptions on how patient, clinician, practice, health system, environment, and guideline factors impact preventive service guideline adoption and implementation.

## Methods

Using a qualitative approach, this study examined factors influencing clinical guideline uptake. Interviews were conducted and analyzed between June and August 2018. This study was approved by the Virginia Commonwealth University Institutional Review Board. Interviewees were not compensated for participation.

### Participants

We interviewed 15 clinicians and 9 practice leaders representing 15 diverse primary care practices in 5 states (Montana, North Carolina, Ohio, Oregon, Virginia) from 2 research networks (Virginia Ambulatory Outcomes Research Network [ACORN] and Oregon Community Health Information Network [OCHIN]). We solicited interviewees by emailing and calling practices, purposely selecting practices for diverse settings (eg, urban/rural) and populations served. Practices identified clinicians and leaders for participation based on involvement with ensuring guideline adoption and implementation.

### Interviews

Using a semistructured interview guide (see online Appendix 1), interviewees were asked how they learn about guideline changes and what patient, clinician, practice, health system, environment, and guideline factors influence uptake. While the interview focused on guidelines generally, interviewees were prompted to think about prevention guidelines from the US Preventive Services Task Force and Advisory Committee on Immunization Practices.12⇓⇓⇓⇓⇓⇓–19 “Adoption” was defined as the decision to accept a guideline and “implementation” as the process to ensure delivery of the service. One interviewer (VJ) conducted all interviews by phone. Interviews were voice recorded and transcribed. Interviews were scheduled until thematic saturation was reached.

### Qualitative Analysis

Two reviewers (AK and VJ) independently coded transcripts using grounded theory and an immersion-crystallization process to identify recurring themes and subthemes.20,21 Discrepancies were resolved by discussion among AK, VJ, and MB.

## Results

Interviewees included 14 physicians, 1 nurse practitioner, 1 physician practice manager, 6 nurse managers, and 2 nonclinical office managers. Interviewees had 3 to 35 years’ experience and represented 5 suburban private practices, 5 federally qualified health centers, and 5 university clinics, including 13 family medicine and 2 internal medicine practices.

There was general agreement regarding the most prominent factors affecting guideline adoption and implementation (Table 1). Interviewees described personal biases and fears of negative outcomes as major factors affecting guideline adoption for both patients and clinicians. Interviewees reported that informed health–literate patients sometimes wanted more care than guidelines recommended. While most clinicians were familiar with the latest changes in evidence, several mentioned that personal beliefs or negative experiences led them to delay fully adopting new guidelines, especially if changes involved de-escalation of services. The main patient factor influencing uptake was patients’ relationship with and trust in their clinician. Likewise, dedication to patient-centered care was a major clinician factor affecting how clinicians implemented guideline changes; clinicians expressed an overwhelming preference for sharing decisions with patients rather than pushing new guidelines onto patients.

View this table:
[Table 1.](http://www.jabfm.org/content/33/2/271/T1)

Table 1. 
Clinician and Practice Leader Perspectives on Factors Affecting Implementation of Changes in Evidence

Discussion of practice and health system factors centered around diffusing knowledge and standardizing implementation. Practices focused on streamlining workflow and defining roles while health systems maintained electronic health record (EHR) functionalities like alerts and quality measures. Interviewees reported that the media and specialists were the greatest environmental influences, promoting both evidence-based and at times excessive care. More traditional environmental factors, such as insurance coverage or transportation, were mentioned by interviewees but were less of a barrier to guideline-based care than media and specialists.

Interviewees noted that guidelines that are easier to measure, easier to explain, and involve more tangible health benefits are easier to adopt. Interviewees shared that guidelines frequently changing or differing between guidelines groups hinders adoption.

Thematic analysis revealed 3 categories describing how clinicians and practices decide which guidelines to adopt—clinician directed, practice directed, or health system directed (Table 2). Distinguishing factors included information learning and sharing, locus of decision control, communicating decisions, and primary implementation strategies. While most practices had a dominant approach, all used elements from each approach.

View this table:
[Table 2.](http://www.jabfm.org/content/33/2/271/T2)

Table 2. 
Emerging Practice Categories for Approach to Guideline Adoption and Implementation

## Discussion

Despite widespread agreement that adherence to clinical preventive guidelines improves health outcomes, timely implementation of new or changed guidelines in primary care continues to be suboptimal. Factors influencing guideline uptake are complex and involve an interplay of patient, clinician, practice, health system, environment, and guideline factors. Improving guideline uptake requires interventions that promote synchrony of all factors.

A common barrier to guideline uptake for clinicians and patients was fears and worries. This barrier was particularly difficult because it impacted care if either the clinician or patient had fears or worries. This dynamic was further aggravated by environmental factors like media and specialists, which may have financial gains and maybe biased to promoting overuse.

By examining the interplay of patient, clinician, and environmental factors, one can consider interventions beyond those that address individual factors. For instance, enhancing the patient-clinician relationship may improve guideline adoption and diminish adverse influences of media and specialists. Further ensuring that guideline developers are not influenced by financial gain and that guidelines include cost effectiveness information would add to uptake.

The categories for how practices adopt and implement guidelines shown in Table 2 provide important insights into the unique barriers and needed interventions to overcome barriers for different settings. In some practices, clinicians have more autonomy to implement changes while in others require health system leadership approval. Practices with greater clinician autonomy are at risk for greater variation in care. Interventions focusing on clinician education may be most helpful. Practices with stronger practice or health system decision making may struggle with delays in adopting changes due to time required for leadership buy-in or for electronic health record changes. Further, financial incentives and specialist needs may make it more difficult for systems to implement the right primary care approach. Interventions may need to streamline approval and support primary care needs. In all cases, advancing the nondominant adoption and implementation style may also be beneficial.11

### Limitations

All participating practices were part of a practice-based research network and may be more proactive in keeping up to date with guidelines. In addition, no patients were interviewed and identified patient factors are limited to clinician and practice leader observations.

## Conclusion

Multiple levels of factors influence guideline uptake and need to be considered within the context of each practice setting to improve adoption and implementation of evidence-based guidelines. Categorizing practices as clinician-directed, practice-directed, or health system-directed may help identify optimal implementation strategies for different practice settings.

## Acknowledgments

The authors thank Virginia Ambulatory Care Outcomes Research Network and Oregon Community Health Information Network for their support and coordination of activities. We thank Paulette Kashiri, Nate Warren, and Erik Geissal for recruiting participants and supporting practice activities.

## Appendix

### Interview Guide

Interviewer to inform participant that interview will be recorded and not to mention identifying info.

Purpose: to understand factors that come into play when implementing clinical practice guideline changes. For purposes of the study, we focused on cervical cancer, breast cancer, lung cancer, prostate cancer, hypertension, hyperlipidemia, pneumonia vaccine and influenza vaccine. However, we will be focusing broadly on how you implement clinical practice guidelines in your practice.

Questions 

1.  Learning about new practice guidelines
    
    1.  How do you generally keep up-to-date with changes in evidence?
        
        1.  What specific tools, publications do you use?
        
        2.  How do you decide what things are relevant to your practice?
    
    2.  What is your experience with implementing new guidelines that involve:
        
        1.  New services being offered to patients? (e.g. Flu vaccines to all adults rather than just those at high risk, Prevnar vaccines to all individuals >65 yo)
        
        2.  Making a service less frequent? (e.g. Increasing interval between pap smears, mammograms)
        
        3.  Changes in thinking about when to offer a service? (e.g. Statin recommendations based on cardiovascular risk rather than specific cholesterol lab values)

2.  Patient factors
    
    1.  How do you talk to your patients about new guidelines?
        
        1.  Resources?
        
        2.  Handouts?
        
        3.  Belief systems?
        
        4.  Family members?
    
    2.  Experiences when patients ask you about new guidelines?

3.  Community/socioeconomic factors (Environmental)
    
    1.  Describe your patient population.
    
    2.  Experiences with your patients having problems accessing recommended clinical services.
        
        1.  Transportation
        
        2.  Insurance coverage/co-payments
        
        3.  Time off work
        
        4.  Ease of scheduling/wait times/available times (after hours, etc)
    
    3.  Are there community organizations or groups that help with recommended clinical services? Specialists?

4.  Clinic and system support for implementation
    
    1.  Describe your practice setting and relationship with a health system.
        
        1.  Group/solo
        
        2.  Interactions with colleagues
        
        3.  Support systems (RN, MA, SW, psych, admin?)
    
    2.  How does your clinic support your implementation of new guidelines?
        
        1.  EHR support?
        
        2.  Nursing/medical assistant support?
        
        3.  Automated reminders?
        
        4.  Letters?
        
        5.  Patient resources provided?
    
    3.  How does your health system support your implementation of new guidelines? (same prompts)

5.  Guideline specific
    
    1.  Are there guidelines that you have find easier/harder to implement than others? Why? (Review one-page handout)
        
        1.  Cultural context and beliefs?
        
        2.  Media?
        
        3.  Which guideline do you follow? Any unique issues?

Interviewer will ask if any other questions or comments. Interviewer to thank clinician for participation.

### Examples of Changes in Clinical Guideline over the past 10 years

*   Breast Cancer Screening 
    
    *   Women age 40–49 yrs: Change from routine screening to personalizing age to start mammogram screening
    
    *   Women age 50–75 yrs: Change from annual to biennial screening

*   Cervical Cancer Screening 
    
    *   Change to delay screening age from age of first sexual intercourse to 21 yo
    
    *   Change to extend screening interval from every 1 year to every 3 years
    
    *   New option for co-testing for HPV for ages 30–65

*   Prostate Cancer Screening 
    
    *   New recommendation against routine PSA screening.

*   Lung Cancer Screening 
    
    *   New recommendation to obtain annual CT chest for all individuals age 55–80 with a 30 pack-year history unless they have not smoked in the last 15 years

*   Pneumonia (Prevnar 13) Vaccination 
    
    *   New recommendation to give PCV-13 vaccine to all individuals age 65 and older

*   Flu Vaccination 
    
    *   Change to expand annual flu vaccines from only those at risk under age 65 to all patients after 6 months of age.

*   Blood Pressure Goals 
    
    *   Change in goal from 120/80 to 140/90 for everyone and 150/90 for everyone age 60 or greater.

*   Statin Recommendations 
    
    *   Change from titrating statin to specific cholesterol levels to giving statins based on cardiovascular risk calculations
    
    *   Change to only using statins
    
    *   May not need to check cholesterol levels if on appropriate statin

## Notes

*   This article was externally peer reviewed.

*   To see this article online, please go to: [http://jabfm.org/content/33/2/271.full](http://jabfm.org/content/33/2/271.full).

*   *Conflicts of interest:* AHK is the Vice Chair for the United States Preventive Services Task Force (USPSTF). This manuscript does not necessarily represent the views and policies of the USPSTF. The other authors have no conflicts of interest nor financial disclosures to declare.

*   *Funding:* This project was funded by the Agency for Healthcare Research and Quality (R03 HS25032-01), National Cancer Institute (R01 CA168795-01), and National Center for Advancing Translational Sciences (UL1TR002649). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

*   Received for publication April 21, 2019.
*   Revision received August 9, 2019.
*   Accepted for publication August 11, 2019.

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