BMJ 1998;317:858-861 ( 26 September )

General Practice

Attributes of clinical guidelines that influence use of guidelines in general practice: observational study

Richard Grol, professor, ^a Johannes Dalhuijsen, general practitioner, ^b Siep Thomas, director of guidelines development, ^b Cees in 't Veld, general practitioner, ^b Guy Rutten, associate professor, ^c Henk Mokkink, senior researcher. ^a

^a Centre for Quality of Care Research, Universities of Nijmegen-Maastricht, PO Box 9101, 6500 HB Nijmegen, Netherlands, ^b Dutch College of General Practitioners, PO Box 3231, 3502 GE Utrecht, Netherlands, ^c Department of General Practice, Utrecht University, PO Box 80045, 3508 TA Utrecht

Correspondence to: Professor Grol rgrol{at}hsu.kun.nl

Objective: To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice.
Design: Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelinesfor example, evidence based, controversial, concrete.
Setting: General practice in the Netherlands.
Subjects: 61 general practitioners who made 12 880 decisions in their contacts with patients.
Main outcome measures: Compliance of decisions with clinical guidelines according to the attribute of the guideline.
Results: Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)).
Conclusions: People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.

Key messages Specific attributes of clinical practice guidelines determine whether they are used in practice Evidence based recommendations are better followed in practice than recommendations not based on scientific evidence Precise definitions of recommended performance improve the use of guidelines Testing the feasibility and acceptance of clinical guidelines among the target group is important for effective implementation People setting evidence based guidelines need to understand the attributes of effective guidelines

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© BMJ 1998

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