Why Do Treatment Guidelines Take So Long to Be Incorporated Into Daily Practice?

Clinical practice guidelines represent the pinnacle of evidence-based medicine. The process of creating a treatment guideline includes rigorous analysis of literature, expert discussion and debate, and formalization by a reputable organization. Treatment guidelines across tumor types are published by many professional organizations, such as the European Society for Medical Oncology (ESMO), the National Comprehensive Cancer Network (NCCN), and the World Health Organization (WHO). Unfortunately, while treatment guidelines reflect the best and most up-to-date patient care, they are not always incorporated into practice quickly, and in some cases, may take several years. So why does it take so long for treatment guidelines to be incorporated into clinical practice?

One major reason guidelines take so long to be incorporated into clinical practice is because they are just that—guidelines. While guidelines and consensus papers reflect the opinions of noted experts, that does not mean everyone will agree with their recommendations. Physicians may disagree with the treatment guidelines, may prefer alternate treatment strategies, or may simply dislike the idea of treatment algorithms. Research from the New England Health Institute shows that physician culture and beliefs are major barriers to guideline adoption. This is supported by a review of physician-identified barriers to guideline uptake, where lack of agreement with recommendations and the perception that recommendations are not sufficiently evidence-based were both cited as major barriers.

A second reason that guidelines take so long to reach clinical practice is that guidelines are not always reflective of the regulatory environment within an individual area. Guidelines frequently recommend treatments that are backed by science but have not been approved. This is particularly an  issue for international guidelines, as these may not reflect the regulatory environment of different countries across the world. Indeed, a recent survey of breast cancer specialists in the United Kingdom found that these physicians had not adopted treatments recommended by the most recent NICE guidelines because the treatment was not approved in the United Kingdom.

A final reason that guidelines take so long to be incorporated into clinical practice is that clinicians are not always aware of what the most recent guidelines say, or how to interpret guideline recommendations. Guidelines are released on a regular basis, with some being updated multiple times a year, making it difficult to keep up with them. Additionally, there are sometimes several different guidelines for the same treatment area, with each professional society publishing their own guideline. While these guidelines are often very similar, there may be minor differences that lead to confusion. Finally, guidelines say what to do, but they do not say how to do it. Physicians may find it difficult to interpret guidelines, or may prefer to receive perspectives from a trusted expert.

All of these challenges highlight an unmet need for continuing education surrounding treatment guidelines. It has been shown that guideline adoption follows a Knowledge-Attitude-Behavior framework, with knowledge as the main barrier preventing guideline adoption. Once physicians are aware of the guideline, understand its recommendations, and receive answers for their questions and concerns, they are much more likely to incorporate guideline recommendations into daily practice.  As new medical evidence emerges and guidelines are updated to represent the most recent changes, physicians require education to make them aware of the new practice recommendations. This education can speed the process for adoption and help overcome the barriers to implementation of clinical practice guidelines.

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