Table 5.

Perspectives from Clinicians and Practice Leaders on Factors Affecting Guideline Implementation from Qualitative Interviews

Patient factors
Factors external to the clinic (ex. TV ads and experiences of friends and family) can affect patient attitudes.“Quite a few folks are leery about statins. They’ve seen ads on TV saying there are potential side effects. ‘I know my Aunt Suzi had problems and I’m not going to do that to myself.”
Some patients may be initially resistant to change and need multiple visits and promptings to adjust to new guidelines.“Some people, despite all of the evidence I show them, still don’t want to do something; like starting a statin. I respect their decision. I say that’s fine. I’ll bring it up with you again in a year.”
Patient education with concrete numbers and measurements helps with guideline implementation“I think having the risk calculators… having some numbers to discuss with people about what we think their risk is and how much the risk might be reduced if they took medicine, I think that’s helpful.”
Clinician factors
Primary care clinicians need more time to engage patients to help with reducing frequency of or ceasing testing when they are recommended.“I spent 10 minutes telling a lady who had her cholesterol checked twice this year that she didn’t need to check it a third time. You know how much more time it takes to tell somebody they don’t need a test than to tell them, oh sure, I’ll order another test. That would have taken me 5 seconds; and 10 minutes later I’m like, no you don’t need to do it a third time.”
Although clinicians are frustrated with the frequency with which guidelines change, they are committed to making changes that are based on new evidence.“There seems to be no end in sight to how you can flip these numbers and come up with another guideline about stuff. It’s nice to be up to date on that kind of thing, although I find sometimes that we do end up flipping pretty quickly on things. But that’s okay. If the original thing was founded on not enough data and they got more data, then great.”
Clinicians want to engage patients in shared decisions.“I’m a big believer in kind of the mutual decision; not just me telling them what to do, and realistically if they don’t believe what I’m saying they won’t do it anyway.”
Practice/health system factors
EHR templates are not always up to date with current guideline recommendations.“The other thing we’ll do sometimes is look at existing templates in the EMR and see if the templates are consistent with guidelines.”
EHR can help facilitate care by automatically calculating CVD risks.“For me to be able to type in CVD risk and have it calculate out then 10-year risk is amazingly helpful rather than having to go on the calculator every time and enter stuff in.”
Quality metrics that clinicians are held accountable to are not always up to date with current guideline recommendations.“I mean we have these quality guidelines now that kind of drive me insane. They’re helpful to a point. They kind of make me crazy too because I don’t feel like those are as up to date as we are maybe.”
  • EHR, electronic health record; CVD, cardiovascular disease.