Correspondence (letter to the editor): Barriers to Guideline Implementation

In order to investigate the high prevalence of cardiovascular risk factors in the Münster area that is still observed in spite of existing guidelines for secondary prevention of coronary heart disease (1) we conducted the COSIMA study from 2002–2004 at the Institute of Epidemiology and Social Medicine at the University of Münster (2). We asked 1023 practicing physicians organized in the administrative district of Münster of the Westphalia-Lippe Medical Association about the most important cardiovascular risk factors and about their knowledge and acceptance of guidelines in secondary coronary prevention. Our results confirm the findings described in the article (3)—namely, a higher acceptance of guideline-based medicine and a better knowledge and acceptance of guidelines among younger colleagues, internists, and doctors who take part in quality circles.

However, our results also indicate important barriers to guideline implementation. The majority of physicians primarily named organizational factors, such as a lack of reimbursement (84% agreement) and lack of time (51% agreed). Furthermore, poor patient compliance (70%) and contradictory recommendations in guidelines published by different medical societies (54%) were stated. The main criticisms of guidelines as an instrument of evidence-based medicine again focused on cost reduction and a perceived lack of flexibility in the treatment of patients.

In order to successfully implement guidelines in medical practice, a multi-level approach seems to be crucial. Local settings and circumstances, private physicians’ values, and perceived barriers could be discussed by audits in the context of local quality circles in order to develop strategies for a better guideline implementation. The acceptance of guideline recommendations by treating physicians is of critical importance, and may be achieved by publishing guidelines of high scientific quality and transparency.