The attitudes and beliefs of general practitioners towards clinical practice guidelines: a qualitative study in Al Ain, United Arab Emirates

The attitudes and beliefs of general practitioners towards clinical practice guidelines: a... Background: The efficacy of implementing practices based on the best evidence is determined by the limitations and preparedness of the structure and processes of the healthcare system as well as healthcare professionals’ (HCP) levels of knowledge and acceptance. Facilitating implementation of such practices also partly depends on HCPs’ attitudes. Method: We investigate the attitudes and beliefs of four groups of physicians in the United Arab Emirates on clini- cal practice guidelines (CPGs), with a focus on applying revisions to these CPGs in a different setting than the one in which they were developed, and where no locally developed guidelines exist. Results: CPGs were the main source of information for revisions. We identified a rising concern in the applicabil- ity of the recommendations, which persists due to a lack of locally developed revisions. Other concerns include the pressures of practice management changes and of coping with the rapid development in resources and the growing demand on its use. Some international and government-endorsed CPGs were still accepted as being the best candi- dates for adoption. Conclusions: This group welcomes evidence-based practice and is supported by electronic medical records, struc- tured care programmes, and ongoing quality monitoring. Barriers and facilitators of clinical practice guidelines are discussed and thoughts on effective implementation strategies are considered. Keywords: Attitude, Clinical practice guidelines, General practice, Healthcare practitioners, Healthcare systems physicians can help guide and support the implementa Background - In recent years, using clinical practice guidelines (CPGs) tion of CPGs in healthcare systems [5]. has become a common method of ensuring quality care In Ambulatory Healthcare Services AHS centres within healthcare systems. Well-developed guidelines in Abu Dhabi, United Arab Emirates, comprehensive and a commitment of the organization to implement healthcare is offered with heavy emphasis on preven - guidelines form a crucial preliminary base to ensure the tative care. As such, the Department of Health of Abu provision of the best care to consumers. Importantly, the Dhabi issued preventive care guidelines to facilitate the key to success in implementing CPGs is in the hands of implementation of numerous national prevention pro- the doctors. Their resistance to new interventions is the grams such as the Well-Child Program, Cancer Preven- main obstacle to achieving the intended effectiveness of tion Program, and Cardiovascular Prevention Program the interventions [1–4]. Exploring the perspectives of [6, 7]. Given the high prevalence of chronic illness and the fact that more than 50% of the ambulatory health- care encounters were for patients less than 18 years old *Correspondence: latifa.mohammad@gmail.com [8], the other practice improvement guidelines focused Ambulatory Health Care Services, Abu Dhabi Health Services, SEHA, PO Box 81815, Al Ain, United Arab Emirates on chronic disease and child and maternal health. © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 2 of 9 To facilitate the adoption of the best practices in eight participants, except the western-trained doctors, who healthcare, and to implement these practices, medical were a group of six because very few (25 in total) practice in services in the Emirate of Abu Dhabi received strong sup- the city. Furthermore, we selected these three populations port in the form of technology and medical expertise. In to achieve some degree of representation of the actual pop- guideline implementation, knowledge is transferred and ulation of practicing doctors and to obtain results reflecting blended with a healthcare system’s various structures a variety of experiences and perspectives. The focus group and processes. Particularly, the adaptation and adoption approach was used to facilitate generation of opinions and of guidelines are greatly affected by the limitations and ideas through participants’ interactions and reflections. availability of certain resources (i.e., technology and med- The study was approved by Al Ain Human Research ical expertise). Therefore, effectively utilizing advances ethics committee. in the Abu Dhabi healthcare system mandates the explo- ration of healthcare professionals’ beliefs and concerns about how to implement CPGs, which are regarded as Participant and focus group procedures important tools in facilitating the use of best practice. The authors are from the AHS academic affairs depart - Because of their value in anticipating reduced variations, ment who oversees continuous professional development improving diagnostic accuracy, reducing costs, reducing and practice improvement and the authors interact with harm, and promoting effective treatments in the last two Health care centres for education and quality improve- decades, CPGs have become a part of daily practice in all ment projects. As such, we recruited physicians who healthcare disciplines and specialties. Nevertheless, for their centres believed would be vocal about their expe- effective CPG implementation to occur, guideline devel - rience with CPGs. Furthermore, we recruited physicians opment, and implementation must be rigorous and scien- who we believed were active participants in their profes- tific. Guideline implementation is emerging as a science sional development. They were invited from several AHS that requires extensive study to ensure timely and efficient centres from within Al Ain city. All participants had to transfer of scientific knowledge and best practices [9 ]. meet the inclusion criteria of being a practicing family A study was conducted in Al Ain, United Arab Emir- physician or general practitioner of Ambulatory Health ates, that included 817 subjects. It aimed to investigate Care Services of the UAE College of Medicine, with at cardiovascular risk factors [10]. The survey included 817 least 2 years of experience in their role. patients. Physicians participating in the project were asked The 25 respondents were mostly female (16 females and 9 to treat patients who had significant cardiovascular risks males). Of these participants, eight were family physicians, according to the United States’ National Cholesterol Edu- eight were board-eligible family medicine residents, and cation Program (NCEP) Adult Treatment Panel (ATP) III nine were general practitioners who had been in practice for guidelines [11]. An interesting finding was that although more than 15 years. All members of the resident group were physicians were in the research group and participated in female. The other groups accurately represented the popula - planning and conducting the study, adherence proportion tion of practicing physicians in the AHS (see Table 1). to the guidelines was as low as 45%, with adherence peak- Selected participants were invited to the focus groups, ing at 70%, across the four participating centres [10]. This which were conducted at the Ambulatory Health Services study suggests that lack of adherence to evidence-based (AHS) Academic Affairs building. The focus groups lasted recommendations is not always due to a lack of knowl- from 90 to 120 min. All focus groups were audiotaped and edge, and it suggests that other barriers need to be iden- transcribed verbatim by research assistants, who was also a tified and addressed. Therefore, we sought to investigate nurse, immediately following the meeting. Data collection physicians’ use of CPGs, and their attitudes toward CPGs. proceeded until saturation was reached (Additional file 1 ). More specifically, the focus of this action-oriented qualita - The first author (LMBK), who holds an advanced tive research study is to determine the barriers and facili- degree, conducted all of the focus groups. This author tators of CPG implementation and to determine ways to led the focus group and used a guide to run the focus improve the implementation of CPG recommendations. groups. Evidence-based medicine and barriers to the implementation of the key recommendations of two Methods CPGs were discussed. More specifically, the following We employed a qualitative design using six focus groups. topics were explored: using CPGs, trust in CPGs and Specifically, two groups of family physicians trained in the evidence-based medicine, how the guidelines influenced UAE, western-trained family physicians, and family medi- the professionals or clinical practice, what factors facili- cine residents were recruited. These three physician spe - tated implementation, and barriers to using CPGs. Four cialty types make up the majority of doctors in the UAE CPG recommendation talking points were offered as primary healthcare system. Each group comprised four to examples to elicit participants’ opinions and attitudes Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 3 of 9 Table 1 Characteristics of participants Table 2 Attitude towards clinical practice guidelines Theme Statements Gender Male 9 Positive attitude towards guidelines Female 16 Provide evidence- ‘Most known guidelines contain summary of all Age based recommen- studies and analyses; so I do not have to go dation through information in parts’ < 30 7 ‘Because it is supported by evidence from many 30–40 12 trials and medications’. ‘Recommendations are > 40 6 based on trials that prove its effectiveness; this is more beneficial than the non-trial ones. It is Clinical qualifications a logical approach’ Board certified 10 Cost-effective ‘It’s cost-effective because it is the best care Non-board certified 8 given’ Under residency training 7 Save time ‘I think we need less time if we know the investi- Type of practices gations to be done. It will not take time’ ‘Save time, more comfortable, more convenient. General practice 8 If the physician is aware of the guidelines, it General practice and faculty in residency program (post-graduate) 4 will not take time’ General practice and faculty in College of medicine (under-graduate) 6 Standardize care ‘It is to standardize the language we speak and health requirements. Like any other business, it General practice and under-training in residency program 7 is measurable’ Years in practice ‘More suited to patient’ < 5 7 ‘Trackable care’ ‘Measurable care’ 5–10 8 10–15 4 Negative attitude towards guidelines > 15 6 Changing evidence ‘The CPG will be behind new studies by six months to 1 year; so we can’t think that it represents the latest evidence’ Contradicting rec- ‘There are some differences from American asso - ommendations ciations and others. Some say that HBA1c is a towards CPG use. Focus group questions targeted the diagnostic test; others say it is a follow-up test’ depth of participants’ perceptions and experience. To Lack of ability of the ‘You cannot be sure unless you learn how to induce a greater depth of information from subsequent doctors to read access the paper and decide whether it is EBM weak or strong. At the same time, there should focus groups, questions were redirected based on the be guidance from the organizing body on information that emerged after each focus group, and how to work around gaps; there should be this information was used to update the guide. some reference for people to go to. As an academic, this what I say but as a physician it The data were analysed using grounded theory analy - is not practical; even the ones who know how sis [12], which focuses on deriving conceptual categories to analyse an article, do they actually do it? I from studying and critically reviewing all collected data. don’t think so’ All transcribed lines were read and coded, and then they Not applicable to ‘Individualized treatment. Guidelines don’t fit each individual each individual’ were organized and grouped into categories based on patient ‘We can take the basic things and the rest can be concepts. Using supporting quotes from the transcripts, tailored for each patient. Not every patient has themes were then developed from these categories. Both the same case and same treatment’ manifest and latent content analyses were performed. In Multiple sources ‘Which guideline should you follow? Take this one or that? The British, American, or European’ the manifest content analysis, the written words directly Transferability of ‘All adapted’ expressed in the extracted text were used. In the latent guidelines to local ‘Because we don’t have another option’ content analysis, the aim was to find the underlying setting ‘We think it is true for particular circumstances, meaning in the text [13]. for that culture’ Results medicine (EBM). Table  2 provides a description of how A summary of the overarching themes is presented in EBM recommendations are valued by the participants. Table 2. We present the details and select quotes from the Reasons for the favourable opinions included the fact focus groups in the following passages to help shed light that the sources of evidence were clinical trials, and on this important topic. that using EBM reduced costs and improved efficiency, particularly in terms of time. Providers also tend to use Attitude towards EBM and CPGs CPGs because they allow for measurable outcomes and Participants referred to CPGs in their daily work, and tracking of progress over time. expressed an intention to practice evidence-based Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 4 of 9 Although many opinions of CPGs were favourable, Table 3 Opinions about  the  sources of  CPGs and  the  use of locally adapted ones some participants expressed a negative attitude toward CPGs, citing conflicting recommendations in different Theme Quotes from participants guidelines, the presence of an unwieldy number of guide- Sources of CPG ‘Most famous, trustable, acceptable by the commu- lines, and changing evidence. This group of individuals used nity or you as a reader’ mentioned taking caution when implementing CPGs, ‘Mostly updated’ and they also noted the importance of tailoring treat- ‘Applicable to patient’ ‘Should be from recognized body; not from just ments to the individual. Finally, those in opposition to anywhere’ CPGs stated that they were concerned that none of the ‘No drug company involvement’ guidelines were developed locally, and this led to con- ‘Be government-funded’ ‘Should answer queries’ cerns about the validity across cultures. ‘Origin of guideline’ ‘Supported by organization’ Adapting CPGs ‘It depends on how the guidelines present the information’ One of the family physicians in our study expressed con- Different culture ‘I will take the guidelines because it is updated but cerns regarding adapted CPGs, CPG developed in other and patients’ in my opinion, patients differ here from the UK and country and modified for their new setting, (see Table  3), population USA’ calling it a “risk” since it was developed for other setting. ‘Adapted guidelines are trustworthy and I will not hesitate to choose [them]’ However, other participants found that using CPGs from ‘We think it is true for particular circumstances, cul- multiple sources offered an expanded knowledge base. ture, and politics. We have to modify and produce There was a consensus among participants that adapta - our own practice [guidelines] and we have to conduct research’ tion of CPGs should be performed by the institution or a ‘We are using it because we don’t have another government organization. option’ ‘It is successful [but] we cannot copy and paste all the time. We need information from our commu- Sources of CPG nity and the problems we are facing’ The CPGs referenced by participants were all interna - ‘You can take what you need, and you can be selec- tional CPGs, or they had been adapted from interna- tive according to the community and patients’ beliefs’ tional CPGs. Examples that were provided to participants The ability to be ‘[You can] combine more than one guideline to find for review were the Scottish Intercollegiate Guidelines selective and all information needed’ Network (SIGN) asthma guidelines [14], the National use the best ‘The volume of information is more in the original Institute for Health and Care Excellence [15] diabetes knowledge [guidelines]; local guidelines include only the use- from different ful information and applicable ones’ mellitus guideline, and the Institute for Clinical System CPGs ‘It is easier, as the American Diabetic Association Improvement [16]. All of the guidelines were accessed contains all the details and as a family physician I through the local institution’s e-library or they were dis- don’t need all that information; it is useful to know but it is too detailed’ seminated by the Health Authority Abu Dhabi. The CPGs Being endorsed ‘Our guidelines adopt the most recent guidelines’ were mainly communicated through Continuous Medical by the institu- ‘Adapted guidelines have the power of authority of Education (CME) workshops and email. tion the local organization’ Perceived risk ‘Risk, there should be standards or rule to follow any miss- phrasing can lead to wrong information’, CPGs’ barriers and facilitators ‘Should be ethical and mention the source’, To assess attitudes towards implementation of CPGs, “Not biased to any area, experience or need, we participants were given CPG recommendations and then should mention all drugs and institution should follow recommendation”, they were asked about their agreement with each, as well “Self breast exam is harm but it is still in the national as their intentions for implementation. Tables  4 and 5 program and I am not following”, provide detailed information about attitudes, barriers, “We have to raise it up, they have something in their mind”, and intentions with CPGs. “We don’t know who is putting it, the things that Table  4 details the perceived barriers to implement- supposed to be removed should be referred by ing CPGs for well known accepted care recommenda- special person whom we don’t know”, “We don’t know the methodology, partially we are tions reported by family medicine practitioners. The not relying on the organization guidelines and in cited barriers were related to the patients’ condition, other parts where we are sure they are true we are patient preferences, medication or test characteris- relying on them” tics, practice settings, physician knowledge, payment Guideline repre- ‘Customize the international guidelines to become sentation national guidelines’ systems, related recommendations, feasibility or ‘Easier ’, ‘Shorter ’, ‘Relevant parts only ’, ‘Simple’, ‘Easy physician-perceived feasibility, and time factors. All language’, ‘Practical effective parts’ of these barriers must be considered in the planning Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 5 of 9 Table 4 Barriers identified for known recommendations Condition- Patient Medication Test or test Lack Doctors Insurance Lack CPG Doctors’ Time factors related preferences or prescribing ordering of continuity knowledge related of structured recommendation perceived related related of care or experience care feasibility OGTT as screen- • • • • ing test for pregnancy Prescribing • • • • • • • • lipid lowering agents Action plan for • • • • • • asthma Osteoporosis • • • • • screening Self breast exam • • Nephropathy • • • • screening in diabetes Aspirin use in • • • diabetes Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 6 of 9 Table 5 Barriers and facilitators of CPG use Table 5 (continued) Themes Quotes on perceived effective Themes Quotes on perceived effective implementation strategies implementation strategies Quality monitoring ‘Auditing’ Barriers ‘Institutional KPI’ Insurance coverage of ‘Insurance does not cover the drug’ ‘Patient satisfaction KPI’ services ‘Guidelines improve their KPI; it should support Competition of ‘Continuity of care, the private clinics does not the KPI or targets’, ‘They are seeking the KPI private sector have guidelines’ level four times per year’ ‘Other types of auditing, which we don’t know Patient-related ‘Patients’ acceptance’ about in hospitals, like how our care affects ‘They don’t like to break their fast on Ramadan admissions, complicated patients, and days’ compliance’ ‘The taste of the oral solution’ ‘Yes, now they are trying their best to better ‘A lot reject the test’/‘They vomit’ achieve the KPI’ ‘1 in 4 will accept’ ‘To reach the KPI and help patients’ Doctor-related ‘Patients are not coming’ Endorsement from ‘They formulated guidelines but didn’t work to ‘Asthma action plan is devised by the chest the institution improve implementation of guidelines…it is physician’ individual work’ ‘It (asthma action plan) will take time from ‘If the guidelines are available in the institu- doctors’ tion, it is the responsibility of all to follow it ‘Doctors believe and practice’ because we all care for the same patients and ‘Doctors are interested; we are checking the we should speak the same language with the KPI and commenting on how to improve the patient’ practice’ ‘About breast cancer screening; it is a national Communication ‘It is followed in the hospital’ programme. They didn’t give the option to between hospitals do it or not. So, we are applying it and until and AHS they change it I have to follow it as it is sup- Lack of structured ‘You have to choose the ones who are inter- ported by the organization’ care for some condi- ested. You should not choose all. Doctors ‘We cannot follow the institution always; this tions (e.g., asthma who don’t care shouldn’t be in the institution’ depends on the situation because if what is and osteoporosis) ‘Most have their spirometer but some clinics recommended by the institution is wrong compared to widely don’t’ we might miss-practice and put the patient implemented ‘Accessing the whole organization and not at risk’ structured care for individuals’ ‘As long as the guidelines are issued by the diabetes and hyper- ‘It differs if you have a chronic disease care organization it is more likely to be followed tension in the AHS clinic. Doctors will be under pressure by and more likely that they have something in other patients and will not give good care, their mind; we are not aware of all statistics and some doctors don’t have a sense of they have. They have all statistics and infor- responsibility’ mation, and as long as it is not harmful we ‘There are no guidelines for osteoporosis’ follow them’ ‘No, it is not like diabetes mellitus (DM); there ‘The HAAD and SEHA are looking for quality are no guidelines and no special clinics’ now’ ‘We are not following our target patients Electronic medical ‘It is difficult with paper medical records and (osteoporosis patients)’ records needs staff ’ ‘It is a mistake of the institutions to not recom- ‘Introduction to m-pages (health maintenance mended screening for adults’ reminder page) is one way of helping people ‘Having well women clinics is better than hav- to follow the guidelines’ ing GP clinics’ ‘If it used, it is effective’, ‘guidelines link to medi- Condition-related ‘There is a higher prevalence of DM, complica- cal records’ tions, and diagnosis’, ‘easier to diagnose DM’, Structured care ‘It differs if you have a Chronic Diseases Clinic ‘all age groups have DM’ from if you don’t, and doctor will be pushed Facilitators by other patients and will not provide good care. Some doctors don’t have a sense of Accessibility of knowl- ‘Makes things easier; so, if you have any ques- responsibility’ edge in the office tions you have the answer easily’ ‘If not, Chronic Diseases Clinic performance will ‘It reduces the anxiety of feeling alone, espe- be the same? I don’t think [so] at all’ cially during out-of-hours clinics’ ‘If I was a GP and a chronic disease patient ‘Calculators are available in computers and visited me, I will not be able to attend to him programmes’ well, because many more patients will be waiting outside’ Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 7 of 9 Adapting CPGs implementation steps. The perceived barriers may Participants generated a number of factors which vary based on the demands of the clinical situation. they perceived as limiting implementation of CPGs. A For example, the barriers in guideline recommenda- strongly stressed and unique concern (to the point where tion may be very low when a provider is ordered a it was considered a risk) was the notion that practition- mammogram to screen for breast cancer versus when ers were implementing CPGs designed based on external the provider is managing a complex patient with research done in different, possibly incompatible, popula - dyslipidaemia. tions. Endorsement or adaptation of the CPGs by a gov- In addition to barriers to CPG implementation. Par- ernmental body was effective in reassuring providers that ticipants also identified a number of important facili - it was acceptable to use these recommendations. Some tating factors. First, participants noted that electronic participants commented that there is freedom in imple- medical records (EMRs), and having easy access to mentation of guidelines; however, other have argued that computers within offices, help with facilitating CPG combining guidelines, or following them in a piecemeal implementation. Overall, while participants noted some manner can result in confusion or deficient implemen - barriers to using EMRs, including perceived burden tation. As such, adapting CPGs remains a challenging due to documentation requirements, they felt that this task, especially for organizations in countries with lim- practice would facilitate CPG implementation. Second, ited research data and scarce locally-developed CPGs. organizational endorsement and quality monitoring Consequently, this requires practitioners to make careful were also noted as strong facilitators of implementing decisions either to use caution when implementing and the CPGs. Third, structured care programmes, in par - adapting CPGs across cultures. ticular those led by a central committee who supervise The Institute of Medicine defines CPGs as “statements and conduct ongoing training of teamlets (a tightly knit that include recommendations intended to optimize group with one clinician and one or two assisting pro- patient care that are informed by a systematic review of fessionals working together closely) in all AHS centers, evidence and an assessment of the benefits and harms are perceived as being effective facilitators. of alternative care options” [20]. When guidelines are revised and adapted in order to fit different cultures, it is Discussion important for adaptation to be conducted by individuals Attitude towards CPGs with credentials and experience similar to the developers All participants in the present study had existing knowl- of the guidelines. Undoubtedly, cross-cultural research edge of CPGs, and they considered CPGs fundamental area has started to attract greater interest [21]. for their practice. Participants’ concerns about CPGs were similar to those reported in previous studies, and Common facilitators and barriers include conflicting recommendations from different The other barriers to implementation we found share guidelines, changing evidence, and the lack of gener- some similarities with those identified in a review of alizability of most recommendations. There were also barriers to guideline implementation by general practi- concerns about the need to individualize implementa- tioners (GPs). Six categories of barriers were identified: tion. In contrast with the views of the participants in the the content of the guidelines, the format of the guide- present study, Carlsen et al. reported that the changes in lines, GPs individual experiences, preserving the doc- recommendations and disagreement between experts are tor–patient relationship, professional responsibility, and mainly viewed as positives because of changing knowl- practical issues [17]. Similar barriers were found by other edge and different interpretation and implementation researchers as well [18, 22, 23]. prospective [17, 18]. The fact that disease-specific facilitators and barriers Although participants in our study viewed CPGs as in CPG implementation exist suggests that physicians being fundamental for practice, participants did report implementing CPGs should be mindful of the disease a number of barriers. This is consistent with previous to be managed as well as the clinical setting. Unfortu- research which found that among Belgian social insur- nately, there is no single solution for all to be successful ance physicians, knowledge of EBM and CPGs was rather in implementing and adhering to best practices. When poor, and perceived barriers for applying evidence to suggesting example recommendations and challenging practice were mainly time and lack of EBM skills [19]. participants with different barriers and facilitators for Taken together, this information suggests that adopting each recommendation, we noticed that not all recom- and implementing CPGs involves multiple variables, and mendations followed a similar path for implementation. physicians who are supposed to implement these guide- A unique implementation plan should be tailored with lines may have variability in their training which further frequent review of all possible barriers and facilitators affects their ability to implement and evaluate CPGs. Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 8 of 9 as a means of reaching the optimum outcome, especially model are seen by the group as facilitators. Facilitators when implementing these guidelines with diverse popu- included daily structured clinics, reminders, outcomes, lations. Barriers identified by our groups highlight the self-management programmes, educational activi- challenge in reconciling findings from well-controlled ties for the Health Care Professionals (HCP), facilitated studies with realistic clinical environments. The com - team communication, and continuous dissemination of plexity of patients and their beliefs, economic burden, new updates in email communications. Others included medication efficiency, and side effects contribute to this meeting with chronic disease champions and coordina- challenge. For example, recommending ordering diag- tors and allowing for feedback from providers [26]. nostic test as mammogram or prescription of Aspirin The present study is not without limitations. The par - have far less time and cost implications than on working ticipants did not indicate the means by which they on asthma action plan with chronic asthmatic patient. learned of CPGs. In future research, participants’ sources Probably the later needing more time, counselling skills of knowledge need to be explored in greater depth. One and knowledge but more importantly as highlighted by limitation could be participants’ tendency to agree with the group needing supportive health care system design the group norms. Although we took multiple steps to through continuity and structured care. facilitate expression of different opinions by asking ques - This calls for changes in implementing the best evi - tions in different formats, and by using props to ensure dence. Indeed, developing and disseminating guidelines understanding and depth, it is possible that group nor- is only part of the process of ensuring that these CPGs mative pressures interfered with the ability to fully are implemented appropriately. Careful implementation, express opinions. with subsequent quality checks are needed. Those who Another limitation of this study is the fact that we used choose to implement the guidelines also need to be par- self-report measurements of CPG use and knowledge, ticularly aware of the cultural environment in which they which are best assessed using other methods, including practice. In particular, ongoing monitoring using perfor- knowledge assessment and practice measurements. mance indicators that include patient satisfaction and outcomes are encouraged. Conclusions Dissemination methods described by the participants The insight of the groups on effective strategies for imple - in the present study are similar to those in other stud- menting best evidence through CPGs reflects the strong ies. In particular, we found that institutions seem to be institutional environment provided by an implanted EMR essential in disseminating evidence. Institutions can be structured care programme and ongoing quality moni- seen as powerful agents to improve care. Participants toring. Our results highlight areas of importance in deliv- reported that they would prefer their institution be the ering the best evidence in this setting through greater source of the CPG dissemination. Furthermore, all par- structure and governance of adapting CPGs. In addition, ticipants were committed to using any available tools to the results showed that participants valued the encour- help improve their outcomes. agement of local clinical research, which can improve Our results supported a need and desire for a multifac- these processes, as well as health service research, which eted approach to implementation of CPGs. In particular, can help them utilize the resource-welcoming environ- participants noted the importance of patient education ment of evidence-based medicine. and empowerment, healthcare professional education, practice change, and resource provision. All of these Additional file were highlighted as perceived challenges of this group of participants. Additional file 1. Focus group discussion moderator’s guide including questions and probing statements used. The attitude towards EMRs was positive. EMRs were perceived as a strength and opportunity to facilitate EBM. A growing number of studies have reported the Abbreviations role of EMR in facilitating evidence-based practice [24, EMR: electronic medical records; CPGs: clinical practice guidelines; NCEP: National Cholesterol Education Program; ATP: Adult Treatment Panel; UAE: 25]. United Arab Emirates; AHS: Ambulatory Healthcare Services; EBM: evidence- The structured care programme for chronic diseases, based medicine; SIGN: Scottish Intercollegiate Guidelines Network; CME: which was used in all participants’ workplaces, was highly Continuous Medical Education. valued by participants as a means of helping them to Authors’ contributions employ best practices. This is not a surprise, as the com - LBK conceptualized and conducted the study, and wrote the manuscript. ponents of the Ambulatory Healthcare Services (AHS) SZ transcribed the focus group interviews verbatim. Both authors read and approved the final manuscript. chronic disease programme are based on the chronic disease model, and interventions and tools used in the Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 9 of 9 Acknowledgements 11. Grundy SM. United States Cholesterol Guidelines 2001: expanded scope None. of intensive low-density lipoprotein-lowering therapy. Am J Cardiol. 2001;88:23J–7J. Competing interests 12. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for The authors declare that they have no competing interests. qualitative research. Piscataway: Transaction Publishers; 2009. 13. Cho JY. Reducing confusion about grounded theory and qualitative con- Ethics approval and consent to participate tent analysis: similarities and differences. Qual Rep. 2014;19(32). http:// All participants voluntarily agreed to participate. The Al Ain Human Ethics nsuwo rks.nova.edu/cgi/viewc onten t.cgi?artic le=1028&conte xt=tqr. 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BMC Health Serv Res. 2010;10:47. sion Statistics. 2017. 9. Al-Ketbi LMB. The use of clinical practice guidelines in General Practice: a study to examine the effect of implementing radiological guidelines in General Practice clinic in the Al-Ain district of the United Arab Emirates. 10. Baynouna L. Adherence to ATP III guidelines in Al Ain primary health care Ready to submit your research ? Choose BMC and benefit from: centers. Unpublished. 2005. fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

The attitudes and beliefs of general practitioners towards clinical practice guidelines: a qualitative study in Al Ain, United Arab Emirates

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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: The efficacy of implementing practices based on the best evidence is determined by the limitations and preparedness of the structure and processes of the healthcare system as well as healthcare professionals’ (HCP) levels of knowledge and acceptance. Facilitating implementation of such practices also partly depends on HCPs’ attitudes. Method: We investigate the attitudes and beliefs of four groups of physicians in the United Arab Emirates on clini- cal practice guidelines (CPGs), with a focus on applying revisions to these CPGs in a different setting than the one in which they were developed, and where no locally developed guidelines exist. Results: CPGs were the main source of information for revisions. We identified a rising concern in the applicabil- ity of the recommendations, which persists due to a lack of locally developed revisions. Other concerns include the pressures of practice management changes and of coping with the rapid development in resources and the growing demand on its use. Some international and government-endorsed CPGs were still accepted as being the best candi- dates for adoption. Conclusions: This group welcomes evidence-based practice and is supported by electronic medical records, struc- tured care programmes, and ongoing quality monitoring. Barriers and facilitators of clinical practice guidelines are discussed and thoughts on effective implementation strategies are considered. Keywords: Attitude, Clinical practice guidelines, General practice, Healthcare practitioners, Healthcare systems physicians can help guide and support the implementa Background - In recent years, using clinical practice guidelines (CPGs) tion of CPGs in healthcare systems [5]. has become a common method of ensuring quality care In Ambulatory Healthcare Services AHS centres within healthcare systems. Well-developed guidelines in Abu Dhabi, United Arab Emirates, comprehensive and a commitment of the organization to implement healthcare is offered with heavy emphasis on preven - guidelines form a crucial preliminary base to ensure the tative care. As such, the Department of Health of Abu provision of the best care to consumers. Importantly, the Dhabi issued preventive care guidelines to facilitate the key to success in implementing CPGs is in the hands of implementation of numerous national prevention pro- the doctors. Their resistance to new interventions is the grams such as the Well-Child Program, Cancer Preven- main obstacle to achieving the intended effectiveness of tion Program, and Cardiovascular Prevention Program the interventions [1–4]. Exploring the perspectives of [6, 7]. Given the high prevalence of chronic illness and the fact that more than 50% of the ambulatory health- care encounters were for patients less than 18 years old *Correspondence: latifa.mohammad@gmail.com [8], the other practice improvement guidelines focused Ambulatory Health Care Services, Abu Dhabi Health Services, SEHA, PO Box 81815, Al Ain, United Arab Emirates on chronic disease and child and maternal health. © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 2 of 9 To facilitate the adoption of the best practices in eight participants, except the western-trained doctors, who healthcare, and to implement these practices, medical were a group of six because very few (25 in total) practice in services in the Emirate of Abu Dhabi received strong sup- the city. Furthermore, we selected these three populations port in the form of technology and medical expertise. In to achieve some degree of representation of the actual pop- guideline implementation, knowledge is transferred and ulation of practicing doctors and to obtain results reflecting blended with a healthcare system’s various structures a variety of experiences and perspectives. The focus group and processes. Particularly, the adaptation and adoption approach was used to facilitate generation of opinions and of guidelines are greatly affected by the limitations and ideas through participants’ interactions and reflections. availability of certain resources (i.e., technology and med- The study was approved by Al Ain Human Research ical expertise). Therefore, effectively utilizing advances ethics committee. in the Abu Dhabi healthcare system mandates the explo- ration of healthcare professionals’ beliefs and concerns about how to implement CPGs, which are regarded as Participant and focus group procedures important tools in facilitating the use of best practice. The authors are from the AHS academic affairs depart - Because of their value in anticipating reduced variations, ment who oversees continuous professional development improving diagnostic accuracy, reducing costs, reducing and practice improvement and the authors interact with harm, and promoting effective treatments in the last two Health care centres for education and quality improve- decades, CPGs have become a part of daily practice in all ment projects. As such, we recruited physicians who healthcare disciplines and specialties. Nevertheless, for their centres believed would be vocal about their expe- effective CPG implementation to occur, guideline devel - rience with CPGs. Furthermore, we recruited physicians opment, and implementation must be rigorous and scien- who we believed were active participants in their profes- tific. Guideline implementation is emerging as a science sional development. They were invited from several AHS that requires extensive study to ensure timely and efficient centres from within Al Ain city. All participants had to transfer of scientific knowledge and best practices [9 ]. meet the inclusion criteria of being a practicing family A study was conducted in Al Ain, United Arab Emir- physician or general practitioner of Ambulatory Health ates, that included 817 subjects. It aimed to investigate Care Services of the UAE College of Medicine, with at cardiovascular risk factors [10]. The survey included 817 least 2 years of experience in their role. patients. Physicians participating in the project were asked The 25 respondents were mostly female (16 females and 9 to treat patients who had significant cardiovascular risks males). Of these participants, eight were family physicians, according to the United States’ National Cholesterol Edu- eight were board-eligible family medicine residents, and cation Program (NCEP) Adult Treatment Panel (ATP) III nine were general practitioners who had been in practice for guidelines [11]. An interesting finding was that although more than 15 years. All members of the resident group were physicians were in the research group and participated in female. The other groups accurately represented the popula - planning and conducting the study, adherence proportion tion of practicing physicians in the AHS (see Table 1). to the guidelines was as low as 45%, with adherence peak- Selected participants were invited to the focus groups, ing at 70%, across the four participating centres [10]. This which were conducted at the Ambulatory Health Services study suggests that lack of adherence to evidence-based (AHS) Academic Affairs building. The focus groups lasted recommendations is not always due to a lack of knowl- from 90 to 120 min. All focus groups were audiotaped and edge, and it suggests that other barriers need to be iden- transcribed verbatim by research assistants, who was also a tified and addressed. Therefore, we sought to investigate nurse, immediately following the meeting. Data collection physicians’ use of CPGs, and their attitudes toward CPGs. proceeded until saturation was reached (Additional file 1 ). More specifically, the focus of this action-oriented qualita - The first author (LMBK), who holds an advanced tive research study is to determine the barriers and facili- degree, conducted all of the focus groups. This author tators of CPG implementation and to determine ways to led the focus group and used a guide to run the focus improve the implementation of CPG recommendations. groups. Evidence-based medicine and barriers to the implementation of the key recommendations of two Methods CPGs were discussed. More specifically, the following We employed a qualitative design using six focus groups. topics were explored: using CPGs, trust in CPGs and Specifically, two groups of family physicians trained in the evidence-based medicine, how the guidelines influenced UAE, western-trained family physicians, and family medi- the professionals or clinical practice, what factors facili- cine residents were recruited. These three physician spe - tated implementation, and barriers to using CPGs. Four cialty types make up the majority of doctors in the UAE CPG recommendation talking points were offered as primary healthcare system. Each group comprised four to examples to elicit participants’ opinions and attitudes Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 3 of 9 Table 1 Characteristics of participants Table 2 Attitude towards clinical practice guidelines Theme Statements Gender Male 9 Positive attitude towards guidelines Female 16 Provide evidence- ‘Most known guidelines contain summary of all Age based recommen- studies and analyses; so I do not have to go dation through information in parts’ < 30 7 ‘Because it is supported by evidence from many 30–40 12 trials and medications’. ‘Recommendations are > 40 6 based on trials that prove its effectiveness; this is more beneficial than the non-trial ones. It is Clinical qualifications a logical approach’ Board certified 10 Cost-effective ‘It’s cost-effective because it is the best care Non-board certified 8 given’ Under residency training 7 Save time ‘I think we need less time if we know the investi- Type of practices gations to be done. It will not take time’ ‘Save time, more comfortable, more convenient. General practice 8 If the physician is aware of the guidelines, it General practice and faculty in residency program (post-graduate) 4 will not take time’ General practice and faculty in College of medicine (under-graduate) 6 Standardize care ‘It is to standardize the language we speak and health requirements. Like any other business, it General practice and under-training in residency program 7 is measurable’ Years in practice ‘More suited to patient’ < 5 7 ‘Trackable care’ ‘Measurable care’ 5–10 8 10–15 4 Negative attitude towards guidelines > 15 6 Changing evidence ‘The CPG will be behind new studies by six months to 1 year; so we can’t think that it represents the latest evidence’ Contradicting rec- ‘There are some differences from American asso - ommendations ciations and others. Some say that HBA1c is a towards CPG use. Focus group questions targeted the diagnostic test; others say it is a follow-up test’ depth of participants’ perceptions and experience. To Lack of ability of the ‘You cannot be sure unless you learn how to induce a greater depth of information from subsequent doctors to read access the paper and decide whether it is EBM weak or strong. At the same time, there should focus groups, questions were redirected based on the be guidance from the organizing body on information that emerged after each focus group, and how to work around gaps; there should be this information was used to update the guide. some reference for people to go to. As an academic, this what I say but as a physician it The data were analysed using grounded theory analy - is not practical; even the ones who know how sis [12], which focuses on deriving conceptual categories to analyse an article, do they actually do it? I from studying and critically reviewing all collected data. don’t think so’ All transcribed lines were read and coded, and then they Not applicable to ‘Individualized treatment. Guidelines don’t fit each individual each individual’ were organized and grouped into categories based on patient ‘We can take the basic things and the rest can be concepts. Using supporting quotes from the transcripts, tailored for each patient. Not every patient has themes were then developed from these categories. Both the same case and same treatment’ manifest and latent content analyses were performed. In Multiple sources ‘Which guideline should you follow? Take this one or that? The British, American, or European’ the manifest content analysis, the written words directly Transferability of ‘All adapted’ expressed in the extracted text were used. In the latent guidelines to local ‘Because we don’t have another option’ content analysis, the aim was to find the underlying setting ‘We think it is true for particular circumstances, meaning in the text [13]. for that culture’ Results medicine (EBM). Table  2 provides a description of how A summary of the overarching themes is presented in EBM recommendations are valued by the participants. Table 2. We present the details and select quotes from the Reasons for the favourable opinions included the fact focus groups in the following passages to help shed light that the sources of evidence were clinical trials, and on this important topic. that using EBM reduced costs and improved efficiency, particularly in terms of time. Providers also tend to use Attitude towards EBM and CPGs CPGs because they allow for measurable outcomes and Participants referred to CPGs in their daily work, and tracking of progress over time. expressed an intention to practice evidence-based Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 4 of 9 Although many opinions of CPGs were favourable, Table 3 Opinions about  the  sources of  CPGs and  the  use of locally adapted ones some participants expressed a negative attitude toward CPGs, citing conflicting recommendations in different Theme Quotes from participants guidelines, the presence of an unwieldy number of guide- Sources of CPG ‘Most famous, trustable, acceptable by the commu- lines, and changing evidence. This group of individuals used nity or you as a reader’ mentioned taking caution when implementing CPGs, ‘Mostly updated’ and they also noted the importance of tailoring treat- ‘Applicable to patient’ ‘Should be from recognized body; not from just ments to the individual. Finally, those in opposition to anywhere’ CPGs stated that they were concerned that none of the ‘No drug company involvement’ guidelines were developed locally, and this led to con- ‘Be government-funded’ ‘Should answer queries’ cerns about the validity across cultures. ‘Origin of guideline’ ‘Supported by organization’ Adapting CPGs ‘It depends on how the guidelines present the information’ One of the family physicians in our study expressed con- Different culture ‘I will take the guidelines because it is updated but cerns regarding adapted CPGs, CPG developed in other and patients’ in my opinion, patients differ here from the UK and country and modified for their new setting, (see Table  3), population USA’ calling it a “risk” since it was developed for other setting. ‘Adapted guidelines are trustworthy and I will not hesitate to choose [them]’ However, other participants found that using CPGs from ‘We think it is true for particular circumstances, cul- multiple sources offered an expanded knowledge base. ture, and politics. We have to modify and produce There was a consensus among participants that adapta - our own practice [guidelines] and we have to conduct research’ tion of CPGs should be performed by the institution or a ‘We are using it because we don’t have another government organization. option’ ‘It is successful [but] we cannot copy and paste all the time. We need information from our commu- Sources of CPG nity and the problems we are facing’ The CPGs referenced by participants were all interna - ‘You can take what you need, and you can be selec- tional CPGs, or they had been adapted from interna- tive according to the community and patients’ beliefs’ tional CPGs. Examples that were provided to participants The ability to be ‘[You can] combine more than one guideline to find for review were the Scottish Intercollegiate Guidelines selective and all information needed’ Network (SIGN) asthma guidelines [14], the National use the best ‘The volume of information is more in the original Institute for Health and Care Excellence [15] diabetes knowledge [guidelines]; local guidelines include only the use- from different ful information and applicable ones’ mellitus guideline, and the Institute for Clinical System CPGs ‘It is easier, as the American Diabetic Association Improvement [16]. All of the guidelines were accessed contains all the details and as a family physician I through the local institution’s e-library or they were dis- don’t need all that information; it is useful to know but it is too detailed’ seminated by the Health Authority Abu Dhabi. The CPGs Being endorsed ‘Our guidelines adopt the most recent guidelines’ were mainly communicated through Continuous Medical by the institu- ‘Adapted guidelines have the power of authority of Education (CME) workshops and email. tion the local organization’ Perceived risk ‘Risk, there should be standards or rule to follow any miss- phrasing can lead to wrong information’, CPGs’ barriers and facilitators ‘Should be ethical and mention the source’, To assess attitudes towards implementation of CPGs, “Not biased to any area, experience or need, we participants were given CPG recommendations and then should mention all drugs and institution should follow recommendation”, they were asked about their agreement with each, as well “Self breast exam is harm but it is still in the national as their intentions for implementation. Tables  4 and 5 program and I am not following”, provide detailed information about attitudes, barriers, “We have to raise it up, they have something in their mind”, and intentions with CPGs. “We don’t know who is putting it, the things that Table  4 details the perceived barriers to implement- supposed to be removed should be referred by ing CPGs for well known accepted care recommenda- special person whom we don’t know”, “We don’t know the methodology, partially we are tions reported by family medicine practitioners. The not relying on the organization guidelines and in cited barriers were related to the patients’ condition, other parts where we are sure they are true we are patient preferences, medication or test characteris- relying on them” tics, practice settings, physician knowledge, payment Guideline repre- ‘Customize the international guidelines to become sentation national guidelines’ systems, related recommendations, feasibility or ‘Easier ’, ‘Shorter ’, ‘Relevant parts only ’, ‘Simple’, ‘Easy physician-perceived feasibility, and time factors. All language’, ‘Practical effective parts’ of these barriers must be considered in the planning Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 5 of 9 Table 4 Barriers identified for known recommendations Condition- Patient Medication Test or test Lack Doctors Insurance Lack CPG Doctors’ Time factors related preferences or prescribing ordering of continuity knowledge related of structured recommendation perceived related related of care or experience care feasibility OGTT as screen- • • • • ing test for pregnancy Prescribing • • • • • • • • lipid lowering agents Action plan for • • • • • • asthma Osteoporosis • • • • • screening Self breast exam • • Nephropathy • • • • screening in diabetes Aspirin use in • • • diabetes Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 6 of 9 Table 5 Barriers and facilitators of CPG use Table 5 (continued) Themes Quotes on perceived effective Themes Quotes on perceived effective implementation strategies implementation strategies Quality monitoring ‘Auditing’ Barriers ‘Institutional KPI’ Insurance coverage of ‘Insurance does not cover the drug’ ‘Patient satisfaction KPI’ services ‘Guidelines improve their KPI; it should support Competition of ‘Continuity of care, the private clinics does not the KPI or targets’, ‘They are seeking the KPI private sector have guidelines’ level four times per year’ ‘Other types of auditing, which we don’t know Patient-related ‘Patients’ acceptance’ about in hospitals, like how our care affects ‘They don’t like to break their fast on Ramadan admissions, complicated patients, and days’ compliance’ ‘The taste of the oral solution’ ‘Yes, now they are trying their best to better ‘A lot reject the test’/‘They vomit’ achieve the KPI’ ‘1 in 4 will accept’ ‘To reach the KPI and help patients’ Doctor-related ‘Patients are not coming’ Endorsement from ‘They formulated guidelines but didn’t work to ‘Asthma action plan is devised by the chest the institution improve implementation of guidelines…it is physician’ individual work’ ‘It (asthma action plan) will take time from ‘If the guidelines are available in the institu- doctors’ tion, it is the responsibility of all to follow it ‘Doctors believe and practice’ because we all care for the same patients and ‘Doctors are interested; we are checking the we should speak the same language with the KPI and commenting on how to improve the patient’ practice’ ‘About breast cancer screening; it is a national Communication ‘It is followed in the hospital’ programme. They didn’t give the option to between hospitals do it or not. So, we are applying it and until and AHS they change it I have to follow it as it is sup- Lack of structured ‘You have to choose the ones who are inter- ported by the organization’ care for some condi- ested. You should not choose all. Doctors ‘We cannot follow the institution always; this tions (e.g., asthma who don’t care shouldn’t be in the institution’ depends on the situation because if what is and osteoporosis) ‘Most have their spirometer but some clinics recommended by the institution is wrong compared to widely don’t’ we might miss-practice and put the patient implemented ‘Accessing the whole organization and not at risk’ structured care for individuals’ ‘As long as the guidelines are issued by the diabetes and hyper- ‘It differs if you have a chronic disease care organization it is more likely to be followed tension in the AHS clinic. Doctors will be under pressure by and more likely that they have something in other patients and will not give good care, their mind; we are not aware of all statistics and some doctors don’t have a sense of they have. They have all statistics and infor- responsibility’ mation, and as long as it is not harmful we ‘There are no guidelines for osteoporosis’ follow them’ ‘No, it is not like diabetes mellitus (DM); there ‘The HAAD and SEHA are looking for quality are no guidelines and no special clinics’ now’ ‘We are not following our target patients Electronic medical ‘It is difficult with paper medical records and (osteoporosis patients)’ records needs staff ’ ‘It is a mistake of the institutions to not recom- ‘Introduction to m-pages (health maintenance mended screening for adults’ reminder page) is one way of helping people ‘Having well women clinics is better than hav- to follow the guidelines’ ing GP clinics’ ‘If it used, it is effective’, ‘guidelines link to medi- Condition-related ‘There is a higher prevalence of DM, complica- cal records’ tions, and diagnosis’, ‘easier to diagnose DM’, Structured care ‘It differs if you have a Chronic Diseases Clinic ‘all age groups have DM’ from if you don’t, and doctor will be pushed Facilitators by other patients and will not provide good care. Some doctors don’t have a sense of Accessibility of knowl- ‘Makes things easier; so, if you have any ques- responsibility’ edge in the office tions you have the answer easily’ ‘If not, Chronic Diseases Clinic performance will ‘It reduces the anxiety of feeling alone, espe- be the same? I don’t think [so] at all’ cially during out-of-hours clinics’ ‘If I was a GP and a chronic disease patient ‘Calculators are available in computers and visited me, I will not be able to attend to him programmes’ well, because many more patients will be waiting outside’ Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 7 of 9 Adapting CPGs implementation steps. The perceived barriers may Participants generated a number of factors which vary based on the demands of the clinical situation. they perceived as limiting implementation of CPGs. A For example, the barriers in guideline recommenda- strongly stressed and unique concern (to the point where tion may be very low when a provider is ordered a it was considered a risk) was the notion that practition- mammogram to screen for breast cancer versus when ers were implementing CPGs designed based on external the provider is managing a complex patient with research done in different, possibly incompatible, popula - dyslipidaemia. tions. Endorsement or adaptation of the CPGs by a gov- In addition to barriers to CPG implementation. Par- ernmental body was effective in reassuring providers that ticipants also identified a number of important facili - it was acceptable to use these recommendations. Some tating factors. First, participants noted that electronic participants commented that there is freedom in imple- medical records (EMRs), and having easy access to mentation of guidelines; however, other have argued that computers within offices, help with facilitating CPG combining guidelines, or following them in a piecemeal implementation. Overall, while participants noted some manner can result in confusion or deficient implemen - barriers to using EMRs, including perceived burden tation. As such, adapting CPGs remains a challenging due to documentation requirements, they felt that this task, especially for organizations in countries with lim- practice would facilitate CPG implementation. Second, ited research data and scarce locally-developed CPGs. organizational endorsement and quality monitoring Consequently, this requires practitioners to make careful were also noted as strong facilitators of implementing decisions either to use caution when implementing and the CPGs. Third, structured care programmes, in par - adapting CPGs across cultures. ticular those led by a central committee who supervise The Institute of Medicine defines CPGs as “statements and conduct ongoing training of teamlets (a tightly knit that include recommendations intended to optimize group with one clinician and one or two assisting pro- patient care that are informed by a systematic review of fessionals working together closely) in all AHS centers, evidence and an assessment of the benefits and harms are perceived as being effective facilitators. of alternative care options” [20]. When guidelines are revised and adapted in order to fit different cultures, it is Discussion important for adaptation to be conducted by individuals Attitude towards CPGs with credentials and experience similar to the developers All participants in the present study had existing knowl- of the guidelines. Undoubtedly, cross-cultural research edge of CPGs, and they considered CPGs fundamental area has started to attract greater interest [21]. for their practice. Participants’ concerns about CPGs were similar to those reported in previous studies, and Common facilitators and barriers include conflicting recommendations from different The other barriers to implementation we found share guidelines, changing evidence, and the lack of gener- some similarities with those identified in a review of alizability of most recommendations. There were also barriers to guideline implementation by general practi- concerns about the need to individualize implementa- tioners (GPs). Six categories of barriers were identified: tion. In contrast with the views of the participants in the the content of the guidelines, the format of the guide- present study, Carlsen et al. reported that the changes in lines, GPs individual experiences, preserving the doc- recommendations and disagreement between experts are tor–patient relationship, professional responsibility, and mainly viewed as positives because of changing knowl- practical issues [17]. Similar barriers were found by other edge and different interpretation and implementation researchers as well [18, 22, 23]. prospective [17, 18]. The fact that disease-specific facilitators and barriers Although participants in our study viewed CPGs as in CPG implementation exist suggests that physicians being fundamental for practice, participants did report implementing CPGs should be mindful of the disease a number of barriers. This is consistent with previous to be managed as well as the clinical setting. Unfortu- research which found that among Belgian social insur- nately, there is no single solution for all to be successful ance physicians, knowledge of EBM and CPGs was rather in implementing and adhering to best practices. When poor, and perceived barriers for applying evidence to suggesting example recommendations and challenging practice were mainly time and lack of EBM skills [19]. participants with different barriers and facilitators for Taken together, this information suggests that adopting each recommendation, we noticed that not all recom- and implementing CPGs involves multiple variables, and mendations followed a similar path for implementation. physicians who are supposed to implement these guide- A unique implementation plan should be tailored with lines may have variability in their training which further frequent review of all possible barriers and facilitators affects their ability to implement and evaluate CPGs. Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 8 of 9 as a means of reaching the optimum outcome, especially model are seen by the group as facilitators. Facilitators when implementing these guidelines with diverse popu- included daily structured clinics, reminders, outcomes, lations. Barriers identified by our groups highlight the self-management programmes, educational activi- challenge in reconciling findings from well-controlled ties for the Health Care Professionals (HCP), facilitated studies with realistic clinical environments. The com - team communication, and continuous dissemination of plexity of patients and their beliefs, economic burden, new updates in email communications. Others included medication efficiency, and side effects contribute to this meeting with chronic disease champions and coordina- challenge. For example, recommending ordering diag- tors and allowing for feedback from providers [26]. nostic test as mammogram or prescription of Aspirin The present study is not without limitations. The par - have far less time and cost implications than on working ticipants did not indicate the means by which they on asthma action plan with chronic asthmatic patient. learned of CPGs. In future research, participants’ sources Probably the later needing more time, counselling skills of knowledge need to be explored in greater depth. One and knowledge but more importantly as highlighted by limitation could be participants’ tendency to agree with the group needing supportive health care system design the group norms. Although we took multiple steps to through continuity and structured care. facilitate expression of different opinions by asking ques - This calls for changes in implementing the best evi - tions in different formats, and by using props to ensure dence. Indeed, developing and disseminating guidelines understanding and depth, it is possible that group nor- is only part of the process of ensuring that these CPGs mative pressures interfered with the ability to fully are implemented appropriately. Careful implementation, express opinions. with subsequent quality checks are needed. Those who Another limitation of this study is the fact that we used choose to implement the guidelines also need to be par- self-report measurements of CPG use and knowledge, ticularly aware of the cultural environment in which they which are best assessed using other methods, including practice. In particular, ongoing monitoring using perfor- knowledge assessment and practice measurements. mance indicators that include patient satisfaction and outcomes are encouraged. Conclusions Dissemination methods described by the participants The insight of the groups on effective strategies for imple - in the present study are similar to those in other stud- menting best evidence through CPGs reflects the strong ies. In particular, we found that institutions seem to be institutional environment provided by an implanted EMR essential in disseminating evidence. Institutions can be structured care programme and ongoing quality moni- seen as powerful agents to improve care. Participants toring. Our results highlight areas of importance in deliv- reported that they would prefer their institution be the ering the best evidence in this setting through greater source of the CPG dissemination. Furthermore, all par- structure and governance of adapting CPGs. In addition, ticipants were committed to using any available tools to the results showed that participants valued the encour- help improve their outcomes. agement of local clinical research, which can improve Our results supported a need and desire for a multifac- these processes, as well as health service research, which eted approach to implementation of CPGs. In particular, can help them utilize the resource-welcoming environ- participants noted the importance of patient education ment of evidence-based medicine. and empowerment, healthcare professional education, practice change, and resource provision. All of these Additional file were highlighted as perceived challenges of this group of participants. Additional file 1. Focus group discussion moderator’s guide including questions and probing statements used. The attitude towards EMRs was positive. EMRs were perceived as a strength and opportunity to facilitate EBM. A growing number of studies have reported the Abbreviations role of EMR in facilitating evidence-based practice [24, EMR: electronic medical records; CPGs: clinical practice guidelines; NCEP: National Cholesterol Education Program; ATP: Adult Treatment Panel; UAE: 25]. United Arab Emirates; AHS: Ambulatory Healthcare Services; EBM: evidence- The structured care programme for chronic diseases, based medicine; SIGN: Scottish Intercollegiate Guidelines Network; CME: which was used in all participants’ workplaces, was highly Continuous Medical Education. valued by participants as a means of helping them to Authors’ contributions employ best practices. This is not a surprise, as the com - LBK conceptualized and conducted the study, and wrote the manuscript. ponents of the Ambulatory Healthcare Services (AHS) SZ transcribed the focus group interviews verbatim. Both authors read and approved the final manuscript. chronic disease programme are based on the chronic disease model, and interventions and tools used in the Baynouna Al Ketbi and Zein Al Deen Asia Pac Fam Med (2018) 17:5 Page 9 of 9 Acknowledgements 11. Grundy SM. United States Cholesterol Guidelines 2001: expanded scope None. of intensive low-density lipoprotein-lowering therapy. Am J Cardiol. 2001;88:23J–7J. Competing interests 12. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for The authors declare that they have no competing interests. qualitative research. Piscataway: Transaction Publishers; 2009. 13. Cho JY. Reducing confusion about grounded theory and qualitative con- Ethics approval and consent to participate tent analysis: similarities and differences. Qual Rep. 2014;19(32). http:// All participants voluntarily agreed to participate. The Al Ain Human Ethics nsuwo rks.nova.edu/cgi/viewc onten t.cgi?artic le=1028&conte xt=tqr. 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Asia Pacific Family MedicineSpringer Journals

Published: May 30, 2018

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