Positive attitudes towards priority setting in clinical guidelines among Danish general practitioners: A web based survey

doi:10.4236/health.2013.52026

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Vol.5, No.2, 188-192 (2013) Health

http://dx.doi.org/10.4236/health.2013.52026

Positive attitudes towards priority setting in clinical

guidelines among Danish general practitioners: A

web based survey

Ann Nielsen1, Benedicte Carlsen2*, Pia K. Kjellberg1

1KORA—Danish Institute for Local and Regional Government Research, Copenhagen, Denmark

2Uni Rokkan Centre, Uni Research, Bergen, Norway; *Corresponding Author: [email protected]

Received 4 January 2013; revised 3 February 2013; accepted 10 February 2013

ABSTRACT

Aims: Increasing focus on improvement and

optimisation of the treatment in primary care

and reduction of healthcare costs emphasize the

need to understand which factors determines

adherence and non-adherence to clinical guide-

lines. In the present study, we examined atti-

tudes towards clinical guidelines in Danish ge-

neral practitioners (GPs). Methods: We con-

ducted a survey among Danish GPs from all five

regions of Denmark. In total, 443 GPs answered

the web-based questionnaire that contained

questions about a ttit udes and ba rrier s to clinical

guidelines. Results: More than 90% of the GPs

reported that they have good knowledge of the

guidelines and in general follows the guidelines.

A majority of the GPs (81%) found it acceptable

that economic considerations are part of the

guidelines. The most important factors for non-

adherence to guidelines were “need of adjust-

ment to clinical practice” and “lack of confi-

dence in guidelines”. The attitudes to clinical

guidelines were not significantly associated

with practice characteristics such as gender,

years of experience, practice organisation and

localisation. Conclusions: Our findings show

that clinical guidelines are an integrated or inter-

nalised part of everyday practice among GPs in

Denmark. Furthermore, the findings indicate

that Danish GPs are positive towards applying

priority setting in their practice. This is decisive

in the light of rising healthcare costs due to

development of new expensive technologies

and ageing populations that puts pressure on

the healthcare system in general and primary

healthcare in particular.

Keywords: Clinical Guidelines; General

Practitioners; Adherence; Attitudes; Barriers

1. INTRODUCTION

The definition of clinical practice guidelines is “syste-

matically developed statements to assist practitioner and

patient decisions about appropriate healthcare for spe-

cific clinical circumstances” [1].

Francke et al. conducted in 2008 a meta-review to un-

derstand which factors that affect the implementation of

guidelines [2]. Based on twelve reviews and meta-

analyses the key restraints for following clinical guide-

lines were: complexity of the guideline, accessibility,

lack of confidence in guidelines, and time constraints.

Easily understood guidelines and guidelines developed

by the target group or end users were more likely to be

implemented. Lack of awareness of guideline and lack of

agreement with guideline reduced likelihood of imple-

mentation and limited time and personnel resources as

well as work pressure also made implementation less

likely [2].

In 2010, the Danish Medical Association conducted a

survey about use of clinical guidelines among 1675 cli-

nicians within a wide range of specialties. The study

showed that format, accessibility and appropriate imple-

mentation strategies are crucial to successful implemen-

tation and use of clinical guidelines among clinicians. In

2008, we conducted a qualitative interview study among

18 Danish GPs from the capital area, which showed

similar trends [3]. The views that emerged from this

study were that GPs found it difficult to keep updated on

new treatments and research evidence and some of the

GPs expressed that they missed a single comprehensive

source of guidelines. Another key finding was that the

GPs sometimes experienced a dilemma between stan-

dardisation practice and individual treatment of the pa-

tient. But most importantly the study revealed that Dan-

ish GPs have a positive attitude towards inclusion of

economic considerations and priority setting through the

A. Nielsen et al. / Health 5 (2013) 188-192 189

guidelines [3].

In Denmark there is a fairly long history of issuing

clinical guidelines. Clinical guidelines targeting GPs has

since the 1980s been issued by The Danish College of

General Practitioners, The national Board of Health and

since 1999 the Institute for Rational Pharmacotherapy

[6,13]. Internationally there has also been an increasing

focus on optimising the treatment in primary care and

reduction of healthcare costs. In England, NICE (Na-

tional Institute for Clinical Excellence) was established

to develop, disseminate and implement guidelines on a

range of clinical activities [4,5]. Large amounts of re-

sources are used continuously to develop new guidelines

and update existing guidelines within the field of primary

care. Thus knowledge about adherence and non-adher-

ence to clinical guidelines are of interest from a clinical

and a political point of view. To gain broader under-

standing of the attitudes towards clinical guideline in a

Danish setting and to update our knowledge of barriers to

implementation of guidelines, we conducted a survey

among GPs located in all five regions of Denmark.

2. METHODS

The survey was carried out in March 2011. An invita-

tion letter with a link to the web-based questionnaire was

e-mailed to all general practitioners (GP) in Denmark (n

= 3649) in March 2011. One reminder was distributed

and the link was open for two weeks. Responding to the

invitation was possible through the received link to the

web. In all, 487 GPs responded to the invitation. Of those,

10 GPs refused to participate and 34 did not answer the

questions regarding attitudes and barriers to clinical

guidelines, leaving us with a study population of 443

Danish GPs.

The questionnaire was developed in close cooperation

with Norwegian researchers as the survey was carried

out in both countries. Details on the questionnaire have

been described previously [7]. Briefly, the questionnaire

was composed of two parts, namely the clinical guide-

lines questions and a discrete choice experiment (DCE).

The DCE is not included in the present study, but will be

reported later. In the guideline section the GPs were

asked about attitudes and barriers to guidelines. All the

questions were asked as statements to which the GP, by

use of a four-point Likert scale, could express the extent

of their agreement (completely and partly agree/disagree)

or in the case of barriers to guidelines, the importance of

the statement (not, slightly, fairly or very important). The

questions included were based on the findings from pre-

vious international reviews [8-11] and from a compara-

tive interview study carried out among 45 Danish and

Norwegian GPs [3,12]. In addition, we added questions

regarding GP and practice characteristics in the Danish

survey (e.g. practice organization, GPs age, gender and

years since graduation). The questionnaire was further

validated in a Danish context by testing the questionnaire

among a couple of GPs and among persons with know-

ledge about survey methodology.

St atistical Analyses

We estimated the proportions of GPs who agreed with

the attitudes or barriers to guidelines. Furthermore asso-

ciations between adherence and attitudes to guidelines

and practice characteristics were assessed in univariate

logistic regression models (STATA 10.1). Practice char-

acteristics were organisation of the practice (single-

handed, partnership), localisation (region of Denmark),

and characteristics of the GP (gender and years since

graduation).

The measure of association was the odds ratio (OR)

with the corresponding 95% confidence interval (CI).

3. RESULTS

The mean age of the GPs was 52 years (range 32 - 75

years) and 42% were men. We do not have comparable

data on the age of all Danish GPs. The gender distribu-

tion was, however, the same among the participating GPs

(p = 0.99) as among the invited population [17]. The

mean number of years since graduation was 24 years

(range 5 - 45 years). The female GPs had slightly fewer

years of experience compared with their male colleagues

(women; 21 years vs. men; 25 years). The proportion of

GPs from single-handed practices was 17%, whereas the

remaining GPs were part of partnerships practices or

shared single-handed practices. The GPs represented the

entire country with one third being located in the Capital.

The distribution were as follows; Capital: 33%, Zealand:

19%, North: 8%, Central: 18%, South: 22%. This distri-

bution was, however, slightly different from the invited

participants where the distribution was the following;

capital: 35%, Zealand: 17%, North 11%, Central: 10%,

South: 27% (p < 0.01).

The attitudes and adherence to clinical guidelines

among the study population are shown in Table 1. In

general the GPs are positive to clinical guidelines. The

majority of the GPs report, that they have good know-

ledge of the guidelines (93.2%) and have confidence in

guidelines from the health authorities (88.9%) and the

Danish medical societies (88.3%). A significantly lower

proportion have confidence in guidelines from the phar-

maceutical industry (13.8%). In general, the GPs claim

that they follow the guidelines (95.7%) and only a minor

proportion see guidelines as a threat to their professional

work (17.2%). A majority of the GPs find it acceptable

that economic considerations are part of the guidelines,

as long as they are informed about it (80.8%).

Table 2 display different reasons for non-adherence to

A. Nielsen et al. / Health 5 (2013) 188-192

190

Table 1. Attitudes and adherence to guidelines among Danish

GPs (n = 443).

Partly or

totally agree

n (%)

I have good knowledge of guidelines in my specialty 413(93.2)

I have confidence in guidelines from the health

authorities 394 (88.9)

I have confidence in guidelines from the Danish

Medical Societies 391 (88.3)

I have confidence in guidelines from the

pharmaceutical industry 61 (13.8)

Guidelines pose a threat to my professional

judgment/autonomy 76 (17.2)

Generally, I follow the guidelines 424(95.7)

The guidelines are integrated in my practice, I do

not need to look them up 284 (64.1)

Inclusion of economic considerations are acceptable,

if it is stated in the guideline 358 (80.8)

Table 2. Barriers to use of clinical guidelines (n = 443).

Fairly or very

important

n (%)

Economic factors

Guidelines are driven by economic incentives 154(34.8)

Guidelines are driven by the government cost-savings 174(39.3)

Economic concerns overshadow clinical concerns 25.3

Time factors

Guidelines are bothersome or time consuming to

get hold of 185 (41.8)

Cannot spend time negotiating with the patient

only to follow a guideline 109 (24.6)

Do not have the time to update on new guidelines 128(28.9)

Evidence

Sceptical about the evidence 200(45.2)

Disagree frequently with the recommendations of

the guidelines 72 (16.3)

Guidelines are only suggestions, clinical judgment

should be applied 285 (64.3)

Patient perspective

Guidelines does not fit the individual patient 219(49.4)

The recommendation is contrary to the patients

preferences 172 (38.8)

guidelines. The barriers most frequently rated as fairly or

very important for non-adherence were related to the

need for adjustment to clinical practice and to the lack of

confidence in guidelines. Thus the three most important

factors mentioned were as follows; “guidelines are only

suggestions, clinical judgment should be applied” (64.3%),

“guidelines does not fit the individual patient” (49.4%)

and “I am sceptical about the evidence” (45.2%). How-

ever, the statements do not provide us with information

about how often non-adherence to guidelines occurs.

In Ta b l e 3 , we examine the associations between dif-

ferent GP and practice characteristics and adherence and

attitudes towards guidelines. We examined whether ad-

herence and attitudes to clinical guidelines were associ-

ated with the following GP and practice characteristics:

gender of the GP, years since graduation, practice or-

ganisation and localisation. The most experienced GPs

tended to be more likely to follow guidelines compared

with less experienced colleagues. Furthermore, GPs out-

side the capital area was not as likely to follow the

guidelines as GPs from the capital area. However, none

of these tendencies were statistically significant. GPs

outside the capital area were less likely to find economic

considerations acceptable in guidelines. Particularly, GPs

from Region South were less likely to accept economic

considerations.

Table 3. Associations between GP and practice characteristics

and adherence and attitudes towards guidelines.

Generally. follow the

guidelines

Economic

considerations are

acceptable. if stated

in the guideline

OR* 95% CI

OR*95% CI

Gender

Women 1.00 ref.

1.00 ref.

Men 0.67 0.25 - 1.82 1.450.88 - 2.39

Years since graduation

<10 1.00 ref.

1.00 ref.

11 - 15 1.11 0.20 - 6.07 0.810.24 - 2.73

16 - 20 1.98 0.31 - 12.46 0.700.21 - 2.33

21 - 25 2.15 0.29 - 16.07 0.630.18 - 2.15

≥26 2.27 0.44 - 11.83 0.770.25 - 2.36

Practice organisation

Single-handed 1.00 ref.

1.00 ref.

Partnership 1.50 0.46 - 4.83 0.820.40 - 1.66

Shared/group of single-

handed 0.62 0.13 - 2.93 0.530.20 - 1.43

Combination -

1.420.36 - 5.53

Region

The capital 1.00 ref.

1.00 ref.

Zealand 0.23 0.04 - 1.20 0.630.30 - 1.31

North 0.47 0.04 - 5.32 0.680.25 - 1.86

Central 0.28 0.05 - 1.54 0.670.32 - 1.44

South 0.22 0.04 - 1.10 0.480.24 - 0.94

*Crude odds ratio.

A. Nielsen et al. / Health 5 (2013) 188-192 191

Finally, we examined, whether barriers to guidelines

were associated with the above mentioned practice char-

acteristics, but no associations were found between prac-

tice characteristics and barriers to use of guidelines (data

not shown).

4. DISCUSSION

In our study, we find generally positive attitudes to-

wards guidelines. The vast majority of the GPs report

that they use guidelines is well aware of the guidelines,

and have confidence in guidelines from the government

and the medical societies. These findings indicate that

clinical guidelines are an integrated or internalised part

of the everyday practice among GPs in Denmark.

Also a previous study finds that the majority of Danish

GPs use clinical guidelines [14]. In an international per-

spective, a review by Farquhar et al. concluded, that GPs

and other healthcare professionals are very satisfied with

guidelines [10]. However, in studies where use of spe-

cific guidelines have been examined guideline adherence

has not necessarily corresponded with the revealed gene-

ral attitudes towards guidelines [2]. In a Norwegian study,

GPs were asked about their knowledge of specific guide-

lines and their use of the same guidelines [15]. The study

revealed that in most situations the knowledge of the

guideline was substantially greater than the actual use of

the guideline.

Maybe more surprisingly, we found that the majority

of Danish GPs agree with the statement that economic

considerations or incentives may be incorporated in the

guidelines as long as it is stated in the guideline. This

view is more positive than what earlier studies generally

show; a qualitative meta-study of international studies on

GPs’ attitudes to guidelines found that doctors often ex-

press scepticism to elements of cost containment in

clinical guidelines [20]. On the other hand, our finding

supports previous findings from the interview study

conducted in 2008 among eighteen GPs in the Copenha-

gen area [3]. In the interviews the GPs described that

they accepted economic considerations as long as they

were transparent to the healthcare professional. Findings

from Norwegian GPs in the same study showed a mark-

edly more sceptical view on economic considerations

and priority setting in Norwegian GPs [3].

Another key factor that supports Danish GPs integra-

tion of clinical guidelines in practice is the high propor-

tion of GPs that see clinical guidelines as suggestions to

which clinical judgment should be applied. In the late

1990’s Woolf et al. described clinical guidelines as only

one option for improving the quality of care [16]. They

described guidelines as useful in situations where clini-

cians are uncertain about the treatment, or as a tool to

reassure clinicians about the appropriateness of their

treatment and to improve the consistency of care [16]. In

this perspective clinical judgment of the individual pa-

tient is important to take into account in the daily use of

clinical guidelines and our findings indicate that this

practice is implemented among the majority of GPs in

Denmark.

Finally, we revealed no significant associations be-

tween GP and practice characteristics and adherence and

attitudes to guidelines. Beforehand, we tended to expect

that more experienced GPs and GPs in single-handed

practices may be less likely to adhere to guidelines and

may be more sceptical about economic considerations.

Our results, however, did not support these hypotheses.

Some strengths and limitations of the study merit dis-

cussion. We decided to conduct a web-based survey as

opposed to a postal survey because of the easy and low

cost distribution and attainment of responses. In addition,

methodological studies indicate that web based surveys

yield better quality data in terms of less missing and

nonsense responses [18]. However, web-surveys are fre-

quently limited by low response rates, and so also in our

study, which had a response rate of 13%. Still, this is

within the range of published studies based on Internet-

surveys with health professionals [19], and the results

show that the study group profile is quite similar to the

whole population of GPs in Denmark according to the

observable characteristics.

The GPs participating must be considered as being

highly motivated as they received no compensation for

participation in the study. Being highly motivated or in-

terested in the on-going debate about clinical guidelines

may, have facilitated GPs with strong opinions about

clinical guidelines to participate. On the other hands, our

findings are largely in line with previous findings in

Denmark as well as in settings outside Denmark, indi-

cating that the participating GPs largely represent the

attitudes in GPs in general.

A potential strength of our study is the inclusion of

questions about several aspects of barriers for imple-

mentation of guidelines. According to the review by Ca-

bana et al. only a few studies have considered the variety

of barriers that influence the implementation of clinical

guidelines. Most studies have rather focused on a few

specific barriers [8]. Cabana divides barriers into differ-

ent categories related to knowledge, attitudes and be-

haviour. In our study aspects from all three groups of

barriers have been considered, which may have ensured a

more profound examination of perceived barriers to

guidelines among Danish GPs.

In summary, we observed that Danish GPs perceive

clinical guideline as an integrated part of their everyday

practice and have great confidence in guidelines from the

Danish health authorities. Danish GPs also find that as

long as there is transparency, it is acceptable to incorpo-

rate economic incentives in the guidelines. This under-

A. Nielsen et al. / Health 5 (2013) 188-192

192

lines that Danish GPs are accustomed to apply priority

setting in their everyday practice and see clinical guide-

lines as a part of this paradigm, a paradigm, that recently

has been debated extensively, as there in the future will

be rising health care costs due to development of more

expensive technologies and ageing populations. More

elderly and more chronically ill patients with an in-

creased need of treatment, put pressure on the health-

care system in general and on primary healthcare in par-

ticular.

OPEN ACCESS

5. FUNDING ACKNOWLEDGE MENTS

The study has received funding from DSI, Danish Institute for

Health Services Research, Copenhagen and The Research Council of

Norway (Grant number 196311).

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