Attitudes and Perceptions about Clinical Guidelines: A Qualitative Study with Spanish Physicians

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. 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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