A i udes and Pe cep ions abou Clinical Guidelines: A
Quali a i e S udy wi h Spanish Physicians
I an Sola
`
1,4
, Jose
´Miguel Ca asco
2
, Pe a Dı
´az del Campo
5
, Ja ie G acia
5
, Ca ola O ego
10,13,14
,
Flo a Ma ı
´nez
9
, Anna Ko ze a
3
, Imma Guillamo
´n
3
, En ique Calde o
´n
6
, Idoia de Gaminde
5,7
,
A u o Lou o
8
, Ra ael Ro aeche
5,11
, Fla ia Salcedo
5,12
, Paola Vela
´zquez
1
, Pablo Alonso-Coello
1,4,5
*
1Ibe oame ican Coch ane Cen e - Clinical Epidemiology and Public Heal h Depa men , Biomedical Resea ch Ins i u e San Pau (IIB San Pau), Ba celona, Spain,
2Uni e si y o Na a a, Ins i u e o Cul u e and Socie y, Pamplona, Spain, 3Agency o Heal h Quali y and Assessmen o Ca alonia (AQuAS), Ba celona, Spain, 4CIBER de
Epidemiologı
´a y Salud Pu
´blica (CIBERESP), Ba celona, Spain, 5Scien i ic Commi ee o Guı
´asalud - Na ional Clinical P ac ice Guideline P og amme o he NHS, Mad id,
Spain, 6Ins i u o de Biomedicina de Se illa, Hospi al Uni e si a io Vi gen del Rocı
´o/CSIC/Uni e sidad de Se illa, Se ille, Spain, 7Se icio de Docencia y Desa ollo
Sani a ios, Depa amen o de Salud Gobie no de Na a a, Spain, 8Cen o de Sau
´de de Camb e. Xe encia de A encio
´n P ima ia A Co un
˜a – SERGAS –, A Co un
˜a, Spain,
9Gene al Sec e a ia o Public Heal h, Social Inclusion and Quali y o Li e, Andalusian Regional Minis y o Heal h and Social Well-being, Se ille, Spain, 10 A edis
Donabedian Resea ch Ins i u e (FAD), Ba celona, Spain, 11 G upo K onikgune sob e ges io
´n del conocimien o, Cen o de Salud de Alza, Donos ia-San Sebas ia
´n, Spain,
12 Ins i u o A agone
´s de Ciencias de la Salud, Za agoza, Spain, 13 Uni e si a Au o
`noma de Ba celona, Ba celona, Spain, 14 Red de in es igacio
´n en se icios de salud en
en e medades c o
´nicas (REDISSEC), Ba celona, Spain
Abs ac
Backg ound:
Clinical guidelines (CGs) a e popula o heal hca e decision making bu hei accep abili y and use by
heal hca e p o ide s is in luenced by nume ous ac o s. Some o hese ac o s a e p o essional- ela ed, such as knowledge
and pe cep ions o and a i udes owa d CGs in gene al. The aim o ou s udy was o e alua e a i udes and pe cep ions o
Spanish physicians owa ds CGs.
Me hods:
We coo dina ed six discussion g oups wi h a o al o 46 physicians. The pa icipan s we e d awn om 12 medical
special ies om bo h specialized and p ima y ca e. We eco ded he sessions and ansc ibed he con en e ba im. We
analyzed he da a using an app oach based on he g ounded heo y.
Resul s:
We iden i ied wo main cons uc s ha de ined he physicians’ pe cep ions owa ds guidelines: knowledge and
use ulness. ‘‘Knowledge’’ de ined he heo e ical meanings o guidelines, while ‘‘Use ulness’’ e e ed o he p agma ic
app oach o guidelines. These cons uc s we e in e ela ed h ough a se ies o ca ego ies such as con idence, usabili y,
accessibili y, dissemina ion and o ma s.
Conclusions:
In ou s udy, he cons uc s ha impac ed mos on physician’s a i udes o clinical guidelines we e knowledge
and use ulness. The ension be ween he heo e ical and he p agma ic cons uc s de e mined he a i udes and how
physicians use guidelines. G oups de eloping guidelines should ask ele an clinical ques ions and de elop implemen able
and con ex speci ic ecommenda ions. De elope s should be explici and consis en in he de elopmen and p esen a ion
o ecommenda ions.
Ci a ion: Sola
`I, Ca asco JM, Dı
´az del Campo P, G acia J, O ego C, e al. (2014) A i udes and Pe cep ions abou Clinical Guidelines: A Quali a i e S udy wi h
Spanish Physicians. PLoS ONE 9(2): e86065. doi:10.1371/jou nal.pone.0086065
Edi o : Laxmaiah Manchikan i, Uni e si y o Louis ille, Uni ed S a es o Ame ica
Recei ed Sep embe 20, 2013; Accep ed Decembe 9, 2013; Published Feb ua y 5, 2014
Copy igh : ß2014 Sola e al. This is an open-access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s
un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal au ho and sou ce a e c edi ed.
Funding: This p ojec has been unded by he Ins i u o de Salud Ca los III, co- inanced by he Eu opean Regional De elopmen Fund (PI08/90647). The unde s
had no ole in s udy design, da a collec ion and analysis, decision o publish, o p epa a ion o he manusc ip .
Compe ing In e es s: The o he au ho s ha e decla ed ha no compe ing in e es s exis . Pablo Alonso-Coello and I an Sola
`a e membe s o he GRADE
wo king g oup. This does no al e he au ho s’ adhe ence o all he PLOS ONE policies on sha ing da a and ma e ials.
* E-mail: [email p o ec ed]a
Backg ound
E idence-based medicine (EBM) has d i en he use o ools o
he c i ical syn hesis o he li e a u e, including sys ema ic e iews
and, mo e signi ican ly, clinical guidelines (CGs). The o me we e
ecen ly de ined as ‘‘s a emen s ha include ecommenda ions
in ended o op imize pa ien ca e ha a e in o med by a
sys ema ic e iew o e idence and an assessmen o he bene i s
and ha ms o al e na i e ca e op ions’’ [1]. No iceably, he
de ini ion highligh s he necessi y o suppo ecommenda ions
based on he esul s o igo ous sys ema ic e iews o add ess
speci ic esea ch ques ions ha minimize bias by using explici
me hods [1,2]. The las ew yea s ha e seen some signi ican
changes in he me hods conce ning he de elopmen o CGs, and
me hodological wo king g oups such as GRADE ha e concen-
a ed on p o iding anspa en , sys ema ic, me hodologically-
sophis ica ed guidance o each s ep in he o mula ion o
ecommenda ions [3].
Al hough conce n has been aised o e he us wo hiness o
guidelines, se e al in e na ional ini ia i es ha e been pu o wa d
in o de o de elop c edible guidelines. These endea o s, amongs
o he hings, ha e a ge ed he exing p oblem o guidelines and
PLOS ONE | www.plosone.o g 1 Feb ua y 2014 | Volume 9 | Issue 2 | e86065
`
con lic s o in e es , balancing he p os o ha ing inpu om
expe s and assu ing ha con lic s o in e es do no in luence
ecommenda ions [4,5]. A he same ime, me hodologis s
con inue wo k o de elop amewo ks and ools o acili a e he
de elopmen and dynamic upda ing o us wo hy guidelines [6].
Heal h p o essionals’ a i udes and expec a ions conce ning
EBM and CGs sha e some simila i ies. These include aspec s such
as a gene ally posi i e a i ude owa d b inging igo o clinical
p ac ice, he need o imp o e hei skills and he di icul ies in he
implemen a ion o he e idence in eal li e [7,8]. In gene al,
e idence shows physicians a e highly sa is ied wi h guidelines
[9,10]. In a Canadian su ey, physicians conside ed CGs a use ul
educa ional ool o guide hei p ac ice and imp o e quali y o ca e
[11]. Ne e heless, he p ac ical impac o hese documen s was o
conce n, pa icula ly as o hei applica ion in indi idual pa ien s,
hei ole in esou ce sa ing, and hei po en ial o a possible
inc ease o lawsui s [11]. A me a-syn hesis o quali a i e s udies
ecen ly showed ha al hough GPs ha e a posi i e a i ude o CGs,
hey do no ollow hem o a numbe o easons, mos ly ela ed o
he lack o applicabili y o he pa icula pa ien ’s needs [12]. The
analysis showed ha physicians’ easons o adhe e o CGs o no
di e ed depending on whe he he guideline was p esc ip i e, ha
is, whe he i p omo ed a ce ain ype o beha io o ea men , o
p osc ip i e, ha is, i i discou aged ce ain ea men s o
beha io s [12].
In Spain, and despi e he ac ha CGs play a cen al ole in he
s a egies o imp o e decision-making, se e al s udies show ha
he implemen a ion o CGs has ce ain d awbacks, such as he
limi ed sys ema iza ion and coo dina ion o esou ces, he
p oli e a ion o guidelines ha con as wi h subop imal upda ing,
he edundancy in he subjec s add essed, and biases in hei
me hodology [13]. O he expe iences ha e also s essed he
pe cei ed need o anspa ency h ough he p ocess o de elop-
men and implemen a ion o guidelines [14].
Ano he ac o ha may imply a ba ie o he use o CGs is he
exis ence o mul iple sys ems o he o mula ion o ecommen-
da ions, which some imes ha e impo an limi a ions [15]. This
hinde s unde s anding and communica ion. The lack o anspa -
ency in he c i e ia applied in e alua ing e idence and g ading o
he ecommenda ions, he unclea es ima ion o a bene i / isk
a io, and he absence o he g ading o he ela i e impo ance o
ou comes o in e es a e aspec s ha limi he c edibili y o
ecommenda ions and, hence, may limi implemen a ion. The e is
li le esea ch e alua ing how hese sys ems may in luence he
pe cep ion among heal h p o essionals. Some au ho s ha e a gued
ha he ypical classi ica ion o he ecommenda ions using le e s,
symbols o numbe s has been sca cely e alua ed [16,17]. Finally,
empi ical e idence sugges s ha hei wo ding could imp o e hei
implemen a ion [18,19]. Fo all he abo e-men ioned a gumen s,
we unde ook his s udy o explo e knowledge, pe cep ions and
a i udes o heal h ca e p o essionals owa ds CGs, g ading
sys ems, and ac o s con ibu ing o hei unde s anding, accep-
ance, and use.
Me hods
Quali a i e esea ch based on discussion g oups. We epo ed
he comple e de ails o he s udy p o ocol elsewhe e [20]. This
quali a i e esea ch me hod allows comp ehensi e app oxima ions
o he cons i u i e p ocesses o eali y and he pe cep ions o
speci ic g oups, an in-dep h analysis o hei subjec i i y, and an
unde s anding o pa icipan ’s expe iences and belie s [21–23].
This s udy is pa o a mixed me hods esea ch p ojec which
includes a na ionwide su ey among heal h p o essionals.
Fi s , we o ganized six discussion g oups in di e en geog aph-
ical a eas o e lec he egional di e ences in he o ganiza ion o
heal hca e se ices in Spain. En olmen o he 46 pa icipa ing
physicians om wel e medical special ies was ca ied ou
conside ing a pu posi e sample [24,25]. G oup composi ion was
based on he le el o ca e in which physicians p o ided
p o essional assis ance (specialized o p ima y ca e) and by he
knowledge decla ed in e idence-based medicine. In he case o
physicians who p o ide se ices in specialized ca e, a g ea e
ep esen a i eness o clinical a he han su gical p o iles was
sough . Fu he mo e, o gua an ee basic g oup homogenei y and
in e g oup he e ogenei y, an app op ia e age and sex dis ibu ion
was conside ed. The i s con ac wi h in o man s was by le e o
by elephone. A e consen was g an ed, pa icipan s we e
eminded by SMS o he day when he discussion g oups would
ake place. Table 1 ou lines he main cha ac e is ics om
pa icipan s in he discussion g oups. The s udy has been app o ed
by he E hics Boa d o he Hospi al de la San a C eu i San Pau,
Ba celona, Spain. Pa icipan s p o ided w i en in o med consen
o pa icipa e in his s udy.
We designed a p o ocol o guide he mode a ion and he ole o
he obse e s, and o homogenize he p ocess be ween g oups.
Simila ly, we p epa ed a backg ound documen wi h gene al
opics o be add essed in he g oup in e iews, and wi h
sugges ions o bo h open and conc e e ques ions ha could be o
assis ance o guidance o mode a o s. To explo e pa icipan s’
pe cep ion ega ding he di e en sys ems o classi ica ion and
g ading o he e idence, we p epa ed illus a i e ma e ials
con aining ecommenda ions o mula ed wi h di e en a ing
sys ems.
Discussion g oups we e mode a ed by membe s o he esea ch
eam who had p e ious expe ience in ha ield, oge he wi h he
collabo a ion o an obse e , who collec ed ield no es on any hing
ha migh be o in e es o subsequen da a analysis. No g oup
in e iews las ed mo e han nine y minu es. They we e digi ally
audio- aped wi h he in o man s’ consen and ansc ibed e ba-
im o ob ain he inal se o quali a i e da a o he analysis. The
mode a o ini ia ed he discussion indi ec ly wi h an open-ended
ques ion (wha comes o you mind when we speak abou CGs?).
Du ing he session, he mode a o assumed a minimally di ec i e
ole, limi ing in e en ion o p omp ing he g oup - i necessa y -
o add ess he opics in he sc ip .
Da a we e analysed in a i s s ep om a heo e ical app oach
based on he g ounded heo y in which ca ego ies o analysis we e
de ined. This was la e complemen ed wi h a discu si e sociolog-
ical app oach ha analysed discu si e posi ions, na a i e con ig-
u a ions and seman ic spaces. All he analyses we e iangula ed
be ween se e al membe s o he esea ch eam, and discussed wi h
hose in cha ge o he mode a ion and obse a ion in each g oup
[26].
Resul s
Physicians pa icipa ing in he discussion g oups showed ha
hei pe cep ion o CGs was based on wo main cons uc s ela ed
o hei knowledge o CGs (such as hose aspec s de e mining he
a i ude o p o essionals owa d he heo e ical concep o CGs)
and he possible use ulness o CGs (p agma ic cha ac e is ics).
Bo h discu si e cons uc s we e in ol ed in he ollowing
ca ego ies ha shaped he pa icipan s’ a i udes owa d CGs
and we e also de e minan s o hei u iliza ion (implemen a ion
o he CPG in he se ing o daily p ac ice): con idence (posi ion
o us ha p o essionals con e o he heo e ical in o ma ion
ound in he CPG), access and dissemina ion (heal h
A i udes and Pe cep ions abou CPG
PLOS ONE | www.plosone.o g 2 Feb ua y 2014 | Volume 9 | Issue 2 | e86065
Table 1. Cha ac e is ics o he pa icipan s in he discussion g oups.
Loca ion
Numbe o
pa icipan s Age Sex Special ies
Yea s in clinical
p ac ice Expe ience wi h CG
Expe ience in
epidemiology
Female Male Mean Yes No Yes No
Ba celona 8 26–36 yea s: 2 6 2 - Anes hesiology 18 1 7 0 8
37–47 yea s 5 - In e nal Medicine
.65 yea s: 1 - Pneumology
- Su ge y
- Pedia ics
Ba celona 7 26–36 yea s: 3 6 1 - Communi y/Family Doc o 13 1 6 1 6
37–47 yea s 3
48–58 yea s 1
Mad id 7 37–47 yea s: 6 4 3 - Communi y/Family doc o 18 6 1 7 0
48–58 yea s 1 - Pedia ics
Se ille 9 26–36 yea s: 2 3 6 - Pedia ics 22 2 7 1 8
37–47 yea s: 2 - In e nal Medicine
48–58 yea s 4 - Communi y/Family doc o
58–65 yea s: 1 - Nu sing
Za agoza 7 37–47 yea s:3 5 2 - Psychia y 25 7 0 3 4
48–58 yea s: 2 - Radio he apy
59–65 yea s: 1 - Neph ology
.65 yea s: 1 - Pedia ics
- P e en i e Medicine and Public
Heal h
Za agoza 8 37–47 yea s:3 3 4 - Anes hesiology 23 0 7 2 5
48–58 yea s 4 - Gas oen e ology
59–65 yea s 1 - Su ge y
- Pa hology
- Eme gency Medicine
- Psychia y
doi:10.1371/jou nal.pone.0086065. 001
A i udes and Pe cep ions abou CPG
PLOS ONE | www.plosone.o g 3 Feb ua y 2014 | Volume 9 | Issue 2 | e86065
p o essionals’ modes o con ac wi h CGs and hei ecommen-
da ions), o ma (aspec s ela ed o he way in o ma ion is
p esen ed), ecommenda ions (CGs conclusions as indica ions
aimed a di ec ing clinical p ac ice and decision-making), and
le els o scien i ic e idence (concep ual c i e ia o classi ica-
ion o he ecommenda ions ob ained om s udies based on
clinical p ac ice).
Theo e ical concep ion and applicabili y o p ac ice
(Table 2)
The obse ed a i udes ha de ine he knowledge cons uc ha
physicians ha e ega ding CGs a e based on a se ies o in ellec ual
cons uc ions on he cha ac e is ics o hese documen s, o he
concep s suppo ing hem. The main poin in common when i
comes o de ining a CG, ega dless o he me hodological
knowledge possessed by pa icipan s in he discussion g oups in
his espec , was ha o he homogenizing unc ion o CGs, which
helps o s anda dize he p ac ice, o o ganize assis ance and,
ul ima ely, o assis in clinical decision-making, assigning hem an
ins umen al cha ac e ( able 2).
Pa icipan s easily iden i ied he heo e ical concep s ha de ine
CGs, showing a posi i e pe cep ion o medical p o essionals
owa d CGs as ools based ei he on scien i ic li e a u e, o on a
consensus ha should homogenize he clinical p ac ice ( able 2).
We obse ed a disag eemen be ween physicians’ posi i e pe cep-
ion ega ding CGs a a heo e ical le el and hei applicabili y in
p ac ice. This disag eemen s emmed om he iden i ica ion o a
se ies o ba ie s ha limi his posi i e pe cep ion. Such ba ie s
mainly co esponded o CGs ha did no es ablish a p ocess
o e ing a clea solu ion and CGs ha we e no indi idually
applicable o pa ien s. Howe e , hey also co esponded o he as
quan i y o in o ma ion hey ga he , which hinde s hei comp e-
hension and managemen in daily p ac ice ( able 2). Da a show he
link be ween heo e ical knowledge on CGs (which de ines i s
pe cep ion) and hei p ac ical knowledge and, ul ima ely, he
possible use ha can be made o hem. Simila ly, aining was
ega ded as a acili a o o knowledge and use o CGs.
Use ulness, u iliza ion and implemen a ion o he
ecommenda ions (Table 3)
As o he a i udes owa ds CGs use, wo di e en ia ed
beha iou al pa e ns o demands we e obse ed. Fi s , he e was
he mo i a ion o p o essionals o ca y ou an ac i e sea ch o
documen s ha could acili a e hei clinical p ac ice. Second,
p o essionals appea ed o ha e a passi e a i ude, expec ing he
wo kplace o ganiza ion (planne s, manage s, e c) o acili a e
access ( able 3).
Table 2. Knowledge o CGs (quo es).
P ac ice S anda diza ion
‘‘(…) ha ’s p ecisely wha hey a e, some guidelines on how o p oceed wi h ou job’’
‘‘I ’s abou homogenizing pa ien ca e o a oid unce ain ies as o he s eps o ollow. I also includes pa ien in ol emen and he in o ma ion we p o ide hem’’
Guidelines as Tools
‘‘A ool wi h a summa y o he exis ing e idence abou how o manage pa icula condi ions, in pa icula clinical si ua ions, and also condi ions abou which he e is a lack o
e idence’’
"I s ongly belie e i is abou consensus and help in pa icula momen s’’
‘‘Posi i e (…) I o ally ag ee wi h you’’
‘‘(…) I’m pleased when I hea o clinical p ac ice guidelines, I hink hey help a i s wi h my decision-making’’
‘‘I belie e we all ag ee ha hey a e use ul and also con incing’’
‘‘O cou se, guides a e use ul bu wha people hink o hem is… hey p e e p o ocols’’
‘‘I hink hey’ e impo an . I ’s impo an ha he e a e people behind hem, who ha e wo ked on hem, who ha e de eloped hem. And hen i ’s impo an ou wo k can be
based on hem’’.
‘‘The e m ‘clinical p ac ice guidelines’ seems o me mo e a ques ion o aid in decision-making’’
‘‘(…) I belie e we all ag ee ha hey a e use ul and also con incing. The e has o be a change o mindse , knowledge, dissemina ion, wo king habi s. Then we’ll ha e a
ema kable ask be o e us i we a e o wo k wi h guidelines.’’
Ba ie s
‘‘Bu no all pa ien s may be included in he guidelines om he e. Pe haps each case is di e en ,…’’
"They’ e cumbe some. They’ e so comple e ha you ge los in he a emp . The (…) guidelines we e, li e ally, a weigh y ome. (…) Wha can I say? Which a e he posi i e
aspec s? You’ e go all hese o choose om. All igh , bu which is he bes one? Tha ’s no clea ei he …’’
‘‘(…) applicabili y is no su icien ly conside ed… Tha ’s why he implemen a ion o he guidelines is o en low. And I hink his is so because no enough a en ion is paid o
he se ing whe e a gi en guideline is going o be applied’’
Passi e e sus ac i e a i ude
‘‘… p o essionals should s a accep ing hei exis ence, and ha hey should be used as a e e ence, a guide o hei wo k, hei upda ing, hei … s udying o ha e upda ed
knowledge and o know how o use hem each ime’’
‘‘Wha we wan : o ha e he Minis y o Heal h come and say: ‘The hype ension guide is he one ollowed by he Spanish Socie y o Ca diology’’’
Implemen a ion
‘‘The e mus be an ins i u ion ha makes sea ching, sys ema iza ion and ga he ing o da a easie , an ins i u ion which p esen s you he da a so ha you a e en i led o say:
This is igh , his is w ong’’’
‘‘Wha ’s e y clea is ha any guide, no ma e how good hey may be, has li le chance o success i hey a e no dissemina ed, discussed locally, i adhe ence o he guides
and he esul s o hei ollow-up a e no moni o ed, …’’
doi:10.1371/jou nal.pone.0086065. 002
A i udes and Pe cep ions abou CPG
PLOS ONE | www.plosone.o g 4 Feb ua y 2014 | Volume 9 | Issue 2 | e86065
CGs use in daily p ac ice implies a p ocess o implemen a ion,
in ol ing dissemina ion and aining in hese documen s. These
wo meanings cons i u e acili a ing elemen s ha ake pa in a
posi i e eedback p ocess, gi en ha a co ec dissemina ion and
aining con ibu e o a be e knowledge and use o CGs ( able 3).
The pe cei ed use ulness o CGs was iden i ied as he main
ca ego y illing he gap be ween heo e ical knowledge and hei
use in he clinical p ac ice. Physicians who pa icipa ed in he
discussion g oups had a posi i e opinion abou CGs as hese ools
can p o ide s anda ds om which hey can make he bes possible
decision when acing si ua ions o unce ain y ( able 3), al hough
hey we e no ecognized as esolu ion ools o all he p oblems
hey ha e o ace in clinical p ac ice.
As o he CGs aim o educing he a iabili y in clinical
p ac ice, wo opposing a i udes ha e been iden i ied among
pa icipan s in he discussion g oups. On he one hand, CGs a e
pe cei ed as use ul ools o a co ec app oach o he mos
equen condi ions, and on he o he hand, hey a e also
pe cei ed as assis ance ools o add ess less common heal h issues
o a lesse complexi y ( able 3).
A ailabili y o se e al o ma s o a CG is iden i ied as ano he
possible de e minan o i s use. Implemen a ion and use o CGs
Table 3. Use o CGs (quo es).
Unce ain y
‘‘The e idence -be i a guide o in guide o ma - should be adap ed o ou con ex , and i should ease and educe any unce ain y.’’
Resolu ion o common p oblems e sus less common p oblems
‘‘Among he condi ions, we should ha e as e access o hose ha a e mo e common and discuss he less equen ones in special sessions o as special cases…’’
‘‘… ch onic diseases, hype ension, … you ead he guide mainly o ge acquain ed wi h he way hings a e going in he ield …’’
‘‘… I eel ha he clinical p ac ice guidelines a e p ecisely mos use ul in he case o hose condi ions which I’m no used o handling on a day- o-day basis’’
‘‘… I ha e consul ed hem excep ionally, o pa icula cases whe e a decision has o be made and he e’s no one he e o ell you wha you should do…’’
Ba ie s
‘‘I belie e hey should be adap ed o you own hospi al, you own eali y. Suppose he case o a li e whose only choice is a ansplan . Well, i ’s ob ious ha no all con ex s
will p o ide he necessa y acili ies o pe o m i ’’.
‘‘So hen, whose judgmen a e we o ollow? Don’ you hink so? Some imes you don’ know o which ex en hey’ e… which one is he mos eliable o which one is he mos
applicable.’’
‘‘To con ol a gi en condi ion you ha e o e ise eigh , nine -a bes - clinical p ac ice guidelines [laugh e ]. Many o hem, based on he same scien i ic e idence, mos o hem.
And wi h o en con lic ing ecommenda ions.’’
‘‘Do you ha e ime o do e idence-based medicine in you o ice? Well, hones ly, I don’ .’’
Knowledge
‘‘… we should be gi en a p e-es ablished ime om ou wo king hou s o aining’’
‘‘… ou o ganiza ion has no been much conce ned wi h in oducing hem in ou wo king hou s’’
‘‘I e e o he ins i u ion in he sense ha hey should ge in ol ed in acili a ing hei use.’’
‘‘In my case, I’ e used hem bu he e’s a limi o i since he es is o ien ed o he hospi al, o hospi al issues. I do no ha e he same access. Tha belongs o ano he le el.’’
Con idence
‘‘I hink ha he guides a e use ul only o e y well es ablished ma e s (…) hose who design he guides a e people who a e no cu en ly in ol ed in heal h ca e p ac ice.
They a e o en people who ake pa in commi ees. I know a ew commi ees and hey’ e people who ha e ne e seen a pa ien , o i ’s been long since hey las saw one. So
hey some imes bea abou he bush while he p oblems we ace in he p ac ice a e ne e esol ed.’’
‘‘Bu hey ge un eliable when he pha maceu ical indus y is behind. And his becomes a ba ie .’’
‘‘Ce ainly, and despi e all his, he pha maceu ical indus y (…) exe cises p essu e and in o ms us much mo e han he o icial ins i u ions p epa ing he clinical p ac ice
guidelines, who heo e ically, and p agma ically, a e less biased.’’ ZgzMHCon-H3
‘‘To know he con lic s and in e es s hey may ha e. To know who sponso s hem, who p omo es hem and hen ead hem c i ically and sys ema ically o igu e ou whe e he
clinical p ac ice guideline comes om (…)’’
Fo ma s
‘‘I ’s like he as hma GEMA guideline, whe e you ha e he he e is he big one and he pocke one. And you can download bo h om he socie y si e, can’ you? And you ha e
he la ge one wi h all he e idence, all you ha e o do, and a small one whe e hings a e mo e o less summa ized and a e mo e applicable. And his is wha is use ul in he
end, because i you ha e a weigh y ome ha can’ be applied in he p ac ice, hey gi e you some ecommenda ions, some guidelines which ha e been ag eed upon, and his
is much mo e p ac ical.’’
‘‘Yes, i is e y di icul o implemen , because o he use o he language, wha is s a ed is e y a i icial. And al hough you may wan o use a gi en wo d o ha , ou mind, a
leas in my case, will no wo k.’’
‘‘(…) he language is impo an , isn’ i ? The way i is w i en will a ec how much o i you can ac ually ge (…) I mean, he language has o be s aigh o wa d, including a
ecommenda ion which is in ac a ecommenda ion.’’
‘‘I belie e ha hey should ea his mo e se iously, use scien i ic language which is in elligible o e e yone’’
‘‘O whe e p oblems we e s anda dized wi h algo i hms ha a e easy o g asp, wi h hei g ade o ecommenda ion and use ul e idence, and his can be p esen ed in
elec onic o ma o be used daily’’.
‘‘To implemen i you ha e o know i i s , and some imes knowing i is o be up- o-da e (…).’’
‘‘A clinical p ac ice guideline (…) has o ha e implemen ed in i s own upda ing mechanism.’’
‘‘(…) in ac , he clinical p ac ice guidelines a e a emendously use ul ins umen o be up- o-da e and in ag eemen wi h e idence-based medicine.’’
doi:10.1371/jou nal.pone.0086065. 003
A i udes and Pe cep ions abou CPG
PLOS ONE | www.plosone.o g 5 Feb ua y 2014 | Volume 9 | Issue 2 | e86065

could be acili a ed by ha ing a summa ized e sion wi h concise
in o ma ion on he mos impo an ecommenda ions o clinical
p ac ice, submi ing w i en ecommenda ions in plain language
wi h no ambigui ies, and gaining access o an elec onic o ma
ha allows o equen upda ing ( able 3).
Ano he de e minan in he use o CGs was con idence.
Al hough he de elopmen and o mula ion p ocess o ecom-
menda ions is pe cei ed as an impo an ac o , pa icipan s in he
discussion g oups asc ibed much mo e impo ance o hose who
de elop and endo se he CGs. The ac ha CGs de elope s can
be expe me hodologis s o p o essionals no in ol ed in clinical
p ac ice gene a es some ejec ion and limi s hei implemen a ion.
A ac o ha con ibu ed mos o he con idence pe cei ed by
heal h ca e p o essionals was au ho ship o ecommenda ions,
which could lead o a posi i e o nega i e a i ude owa d he use
o a gi en CG. The in ol emen o he pha maceu ical indus y in
he de elopmen o CGs gene a es a ce ain a i ude o suspicion,
and e en ejec ion o he ecommenda ions included in CGs
de eloped o inanced by he same company ( able 3).
Ce ain aspec s ela ed o he use ulness o CGs c ea e ba ie s
o hei use. One ba ie is he inabili y o CGs o adap o ake
in o accoun he cha ac e is ics o he pa icula se ing in which
hei ecommenda ions a e in ended o be used, hus limi ing i s
applicabili y. Thei use is also limi ed by he a ailabili y o se e al
CGs o add ess a single heal h p oblem; his makes i di icul o
assimila e hei con en s, and ecommenda ions may e en di e ge.
Ano he poin o conside is ha upda ing o CGs may no keep up
wi h scien i ic ad ances in ce ain pa hologies, possibly igge ing
scep icism owa d some o hese documen s ( able 3).
Le els o e idence and ecommenda ions (Table 4)
The collec ed da a show ha he le els o scien i ic e idence and
he ecommenda ions a e a common elemen be ween he wo
main ca ego ies buil upon discou se analysis (knowledge and use
o CGs), being loca ed in a mac o-discou se le el. They appea in
he heo e ical plane (as one o he basic componen s in he
de elopmen o CGs), bu also as a ca ego y ha could gua an ee
c edibili y and con idence in CGs, hus acili a ing hei use,
dissemina ion, and access.
CGs me hodological sec ions, wi h in o ma ion such as ables
syn hesizing he e idence ha back up he ecommenda ions, we e
highly ega ded by pa icipan s, since hey a e pe cei ed as
indica o s o s ic ness, esponsibili y and anspa ency. Howe e ,
al hough he inclusion o hese sec ions in CGs adds alue, i does
no necessa ily mean ha use s know how o handle hem, since
some knowledge o esea ch me hodology is needed o his end
( able 4).
Al hough he mode a o s o he g oups ied o explo e
pa icipan s’ pe cep ion o he di e en ways in which le els o
e idence and he s eng h o he ecommenda ions we e g aded,
pa icipan s showed li le in e es in he g ading models used. In
gene al, pa icipan s showed a p e e ence o sys ems based on
numbe s and le e s o classi y he e idence and g ade he s eng h
o he ecommenda ions ( able 4). The lack o s anda dized
classi ica ion sys ems uni ying he many sugges ions o da e is
esponsible o conside able con usion among use s who mus
mo e om one CG o he o he , and is ega ded as an impo an
ba ie ha may condi ion CGs use.
Discussion
Ou s udy iden i ied wo main cons uc s explaining how
physicians pe cei e CGs, and how his pe cep ion impac s on he
a i ude owa ds hem. On one hand, he e is a concep ion a he
le el o knowledge o CGs ( om a heo e ical cons uc ion) and,
on he o he hand, he e a e a se ies o ca ego ies ela ed o hei
use ulness ( om a p agma ic cons uc ion). The ca ego ies
iden i ied in he ex s om he discussion g oups shape aspec s
ha enable us o ela e hese wo main cons uc s, ac ing bo h as
acili a o s in he implemen a ion o his concep ual pe cep ion o
CGs, and as ba ie s o hei use.
O e all, heal h ca e p o essionals show a posi i e a i ude
owa d CGs, ega ding hem as use ul ools o s anda dize clinical
p ac ice and sha ed decision-making. Howe e , a numbe o
ac o s appea o hinde hei p ac ical use. These ac o s a e
ela ed o aspec s such as a limi ed knowledge and limi ed access o
Table 4. Le els o e idence/S eng h o ecommenda ion (quo es).
Me hods
‘‘Pe sonally, i I see a guideline showing which le el o e idence co esponds o each ecommenda ion I conside i mo e eliable han ano he which does no men ion his.’’
To my mind, his gi es s eng h o he ecommenda ion, o he sugges ion, which some imes says ‘We ecommend o we sugges based on he e idence s eng h o he
s udies’. Indeed, his gi es me mo e con idence.’’
‘‘I belie e ha he non-specialis should ge he in o ma ion p ediges ed, no e e yone should be diges ing hings a ound, bu a he same ime you jus can’ p esen i as i
hey we e dummies…’’
‘‘In any case, I hink p o essionals do no look a he me hodology.’’
P oposals symbols numbe s sys ems
‘‘Yes, i is e y di icul o implemen , because o he use o he language, wha is s a ed is e y a i icial. And al hough you may wan o use a gi en wo d o ha , ou mind, a
leas in my case, will no wo k. On he o he hand, wha she says is igh , I see A, 1A o A. And ha ge s in o my head.’’
‘‘On he o he hand, i you say ‘I is ecommended’ and hen you decide o A, you know ha ’s he bes hing o do. Then you go o i . On he o he hand, i hey say ‘I is
ecommended…’, hey gi e you he choice o be open o o he choices. A is ha ins ead.’’
‘‘Because i ’s only na u al ha you don’ know abou A, o B, o ha 1B is be e han C, o ha 1 is he same as 4, o ha 4 is he bes he e is because i ’s he highes , and ha
you a e no su e abou i … I unde s and ha many people may ind 1 easie o g asp.’’
Need o homogenei y
‘‘No, I’d p e e he same sys em is used e e y ime. O he one ha is as homogeneous as possible, because hen you can compa e op ions. Because i I look a a guide (…) I
need all he same o be old wha i is, igh ? Tha ’s wha I wan . Bu i ’d be a easie o me i hey always used he same classi ica ion sys em.’’
’’They’ e emendously cumbe some o me. I o ge abou hem e e y ime I look a hem, and i I don’ ha e he able a my side, and all he a ious sys ems, well, hen, I jus
can’ do i .’’
doi:10.1371/jou nal.pone.0086065. 004
A i udes and Pe cep ions abou CPG
PLOS ONE | www.plosone.o g 6 Feb ua y 2014 | Volume 9 | Issue 2 | e86065
CGs, lack o con idence in de elope s, lack o manageable o ma s
in daily clinical p ac ice, and he absence o s anda dized
classi ica ion sys ems o he le els o e idence and ecommenda-
ions.
Some ba ie s o he use o CGs ha e also been iden i ied
a ound hese wo cons uc s. The main scep ical a i udes owa d
CGs a e ela ed, on one hand, o he o en di icul applicabili y o
he scien i ic li e a u e ha suppo s ecommenda ions a he
indi idual le el [27]. On he o he hand, ou s udy shows ha he
ques ioning o CGs and hei use ulness is also oo ed in he
dis ance ha sepa a es he heo e ical con en collec ed by CGs
om hei ealiza ion in he clinical p ac ice. This is mainly due o
a limi ed adap a ion o CGs o hei con ex s o applica ion.
Ou s udy sugges s ha an impo an ba ie o he use o CGs,
and a ac o o physicians’ pe cep ion o hei use ulness, is he
disag eemen be ween he heo e ical con en o CGs and he daily
p ac ice. The ole played by heal h p o essionals as p ima y ac o s
in decision-making in clinical p ac ice can di e om he
objec i es o CGs [28]. This ep esen s a ba ie o he in e es
ha p o essionals show owa ds hem, since he e is a con lic
be ween he ecommenda ions p esen ed by a CG and physicians’
needs and expe iences. We also ound in he li e a u e he need o
inco po a e on -line clinicians in he de elopmen o ecommen-
da ions o imp o e he ep esen a i eness o CGs [12,14].
As in o he s udies [12,27,28], pa icipan s in ou discussion
g oups exp essed he need o commi men in he dissemina ion
and implemen a ion o CGs on he pa o hei o ganiza ional
s uc u es. Pa icipan s highligh ed he need o in ol e heal hca e
p o essionals wi h expe ise in he a ea co e ed by he guideline
scope o a oid me hodologically igo ous documen s bu wi h
limi ed applicabili y. In ou con ex , he in luence o he
ins i u ions o companies p omo ing CGs, unding sou ce, and
i s au ho s a e i al o he con idence ha heal h p o essionals
place in a CG. In his ega d, he ac ha a CG can be backed up
o inanced by he pha maceu ical indus y is pe cei ed wi h ea
gi en he isk ha hei con en migh be condi ioned by p o i able
in en ions [27]. These aspec s a e e en mo e ele an o
pa icipan s in he s udy han he igo o me hods ha sus ain
ecommenda ions.
Some o he ba ie s o he use o CGs ha e been associa ed
wi h p ac ical aspec s in ou s udy, as o he au ho s ha e also
poin ed ou [12]. They a e ealized as aspec s such as he lack o
ime o ead o e alua e hese ools, and his usually implies a
se back o an adequa e knowledge o CGs.
Some pa icipan s in ou s udy exp essed he need o
dissemina e CGs be e be o e hei implemen a ion [27]. This
includes ecei ing adequa e aining abou he CGs con en and
hei implica ions o hei p ac ice. Howe e , his need o
aining is in con lic wi h se ings ha ing a high wo kload p essu e
and he limi ed ime a ailable o his end.
Dissemina ion, o m o access o CGs, and CGs o ma a e he
main de e minan s o hei knowledge and use. O e all, he
li e a u e also iden i ies o ma as a acili a o o hei use [14].
Ou s udy has iden i ied he b ie and simple o ma s as he aspec s
mos app ecia ed by p o essionals. Accessibili y s ands ou as a new
componen ha adds alue o he o ma o a CG. In his ega d, i
is o no e ha ou s udy ein o ces he posi i e pe cep ions
ecei ed by he elec onic o ma s men ioned in p e ious s udies
[27].
Con a y o ou expec a ions, he pa icipan s in he discussion
g oups did no de o e much ime discussing g ading sys ems. This
is due o he na u al complexi y o quali a i e designs and
speci ically in g oup discussions. A esea che who mode a es
g oup discussions has less con ol o e he da a p oduced han in
in-dep h in e iews o quan i a i e s udies. Pa icipan s exp essed
ha he lack o s anda dized classi ica ion sys ems could be
esponsible o conside able con usion among use s and a po en ial
ba ie o he use o CGs. This opic clea ly dese es u he
esea ch. O he au ho s highligh he impo ance o s anda dizing
hese sys ems o ind a balance be ween igou and simplici y [29].
Ou s udy highligh s he in ol emen ha CGs de elope
g oups should ha e when de eloping CGs aimed a answe ing
speci ic and ele an ques ions. They should coun on all he ac o s
implica ed, and hey should be explici , consis en and s ic in he
p ocess o de elopmen . Finally, i is impo an ha CGs a e
accompanied by wo king ools ha s eng hen hei u ili y, ying
o acili a e hei dissemina ion and applicabili y, and aking in o
accoun he need o adap CG o ma s o he speci ic cha ac e -
is ics o he di e en use p o iles.
Acknowledgmen s
To all he p o essionals who pa icipa ed in he discussion g oups. We a e
also g a e ul o Ca olyn Newey (Language Suppo Se ice, Hospi al de la
San a C eu i San Pau, Ba celona, Spain) o he help edi ing he
manusc ip .
Au ho Con ibu ions
Concei ed and designed he expe imen s: IS PAC. Pe o med he
expe imen s: IS JMC PDC JC CO FM AK IG EC IdG AL RR FS PV
PAC. Analyzed he da a: IS JMC. W o e he pape : IS JMC. Designed he
s udy and o ganized he g oups: IS JMC PDC JC CO FM AK IG EC IdG
AL RR FS PV PAC. O ganized and an he g oups: IS JMC PAC PDC JG
FM EC CO. P o ided subs an ial eed-back and accep ed he inal e sion
o he manusc ip : IS JMC PDC JC CO FM AK IG EC IdG AL RR FS
PV PAC.
Re e ences
1. Ins i u e o Medicine (IOM) (2011) Clinical P ac ice Guidelines We Can T us .
Washing on, DC: The Na ional Academies P ess. 290 p.
2. The Coch ane Collabo a ion (2011) Coch ane Handbook o Sys ema ic
Re iews o In e en ions Ve sion 5.1.0 A ailable: www.coch ane-handbook.
o g.Accessed 2013 Dec 23.
3. Guya GH, Oxman AD, Schu¨nemann HJ, Tugwell P, Kno ne us A (2011)
GRADE guidelines: a new se ies o a icles in he Jou nal o Clinical
Epidemiology. J Clin Epidemiol 64: 380–382.
4. Hi sh J, Guya G (2009) Clinical expe s o me hodologis s o w i e clinical
guidelines? Lance 374: 273–275.
5. Guya G, Akl EA, Hi sh J, Kea on C, C ow he M, e al. (2010) The exing
p oblem o guidelines and con lic o in e es : a po en ial solu ion. Ann In e n
Med 152: 738–741.
6. Vand ik PO, B and L, Alonso-Coello P, T eweek S, Akl EA, e al. (2013)
C ea ing clinical p ac ice guidelines we can us , use, and sha e: a new e a is
imminen . Ches 144: 381–389.
7. F eeman AC, Sweeney K (2001) Why gene al p ac i ione s do no implemen
e idence: quali a i e s udy. B i ish Medical Jou nal 323: 1100–2A.
8. Heselmans A, Donceel P, Ae gee s B, Van de Velde S, Ramaeke s D (2009)
The a i ude o Belgian social insu ance physicians owa ds e idence-based
p ac ice and clinical p ac ice guidelines. BMC Fam P ac 10: 64.
9. Fa quha CM, Ko a EW, Slu sky JR (2002) Clinicians’ a i udes o clinical
p ac ice guidelines: a sys ema ic e iew. Med J Aus 177: 502–506.
10. Heselmans A, Donceel P, Ae gee s B, Van de Velde S, Ramaeke s D (2009)
The a i ude o Belgian social insu ance physicians owa ds e idence-based
p ac ice and clinical p ac ice guidelines. BMC Fam P ac 10: 64.
11. Haywa d RS, Guya GH, Moo e KA, McKibbon KA, Ca e AO (1997)
Canadian physicians’ a i udes abou and p e e ences ega ding clinical p ac ice
guidelines. CMAJ 156: 1715–1723.
12. Ca lsen B, Glen on C, Pope C (2007) Thou shal e sus hou shal no : a me a-
syn hesis o GPs’ a i udes o clinical p ac ice guidelines. B J Gen P ac 57: 971–
978.
13. Mo illo Ga cı
´aA,Pe´ ez Lozano MJ, Calde o´n E, Gue a JA, San os JM, e al.
(2005) Fac o es asociados al uso de guı
´as de p a´c ica clı
´nica en el manejo del
ic us. Pe spec i as del p o esional. In XXI Cong eso de la SADEMI, Je ez.
Lib o de comunicaciones; 131.
A i udes and Pe cep ions abou CPG
PLOS ONE | www.plosone.o g 7 Feb ua y 2014 | Volume 9 | Issue 2 | e86065
14. Ca lsen B, No heim OF (2008) ‘‘Wha lies benea h i all?’’–an in e iew s udy o
GPs’ a i udes o he use o guidelines. BMC Heal h Se Res 8: 218.
15. A kins D, Eccles M, Flo o p S, Guya GH, Hen y D, e al. (2004) Sys ems o
g ading he quali y o e idence and he s eng h o ecommenda ions I: C i ical
app aisal o exis ing app oaches. BMC Heal h Se ices Resea ch 4: 38.
16. Schunemann HJ, Bes D, Vis G, Oxman AD, GRADE Wo king G oup (2003)
Le e s, numbe s, symbols and wo ds: how o communica e g ades o e idence
and ecommenda ions. CMAJ 169: 677–680.
17. Akl EA, Ma oun N, Guya G, Oxman AD, Alonso-Coello P, e al. (2007)
Symbols we e supe io o numbe s o p esen ing s eng h o ecommenda ions
o heal hca e consume s: a andomized ial. J Clin Epidemiol 60: 1298–1305.
18. Michie S, Les e K (2005) Wo ds ma e : inc easing he implemen a ion o
clinical guidelines. Qual Sa Heal h Ca e 14: 367–370.
19. Michie S, Johns on M (2004) Changing clinical beha iou by making guidelines
speci ic. BMJ 328: 343–345.
20. Ko ze a A, Sola` I, Ca asco JM, Dı
´az del Campo P, G acia FJ, e al. (2010)
Pe cep ions and a i udes o clinicians in Spain owa d clinical p ac ice
guidelines and g ading sys ems: a p o ocol o a quali a i e s udy and a na ional
su ey. BMC Heal h Se Res 10: 328.
21. Mo gan DL, K uege RA edi o s (1998) The Focus G oup Ki . Thousand Oaks
(CA): Sage Publica ions. 103 p.
22. G een J, Tho ogood N, edi o s(2009) Quali a i e Me hods o Heal h Resea ch,
2nd Edi ion. London: SAGE Publica ions. 320 p.
23. Pope C, Mays N, edi o s: Quali a i e Resea ch in Heal h Ca e (2000). London:
BMJ books. 168 p.
24. Cu is S, Gesle W, Smi h G, Washbu n S (2000) App oaches o sampling and
case selec ion in quali a i e esea ch: examples in he geog aphy o heal h. Soc
Sci Med 50: 1001–1014.
25. Tucke AG (2004) Quali a i e esea ch sampling: he e y eal complexi ies.
Nu se Res 12: 47–61.
26. Phillips N, Ha dy Cedi o s (2002) Discou se Analysis. In es iga ing P ocesses o
Social Cons uc ion. Thousand Oaks (CA): Sage Publica ions. 104 p.
27. Ca lsen B, No heim OF (2008) ‘‘Wha lies benea h i all?’’–an in e iew s udy o
GPs’ a i udes o he use o guidelines. BMC Heal h Se Res 8: 218.
28. Van de Weijden T, Le´ga e´ F, Boi in A, Bu ge s JS, an Veenendaal H, e al.
(2010) How o in eg a e indi idual pa ien alues and p e e ences in clinical
p ac ice guidelines? A esea ch p o ocol. Implemen Sci 5: 10.
29. Dahm P, Djulbego ic B (2011) The Aus alian ‘FORM’ app oach o guideline
de elopmen : he ques o he pe ec sys em. BMC Med Res Me hodol 11: 17.
A i udes and Pe cep ions abou CPG
PLOS ONE | www.plosone.o g 8 Feb ua y 2014 | Volume 9 | Issue 2 | e86065