NPC Archive Item: Awareness, agreement, adoption and adherence to hypertension guideline recommendations

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Heneghan C, et al. Hypertension guideline recommendations in general practice: awareness, agreement, adoption, and adherence. BJGP 2007;57:948–52

What is the background to this?

This study aimed to understand GPs’ reasons for not implementing specific recommendations within the National Institute for Health and Clinical Excellence (NICE) and British Hypertension Society (BHS) hypertension guidelines and to assess whether the behaviour of GPs is consistent with an awareness-to-adherence model of steps to clinical guideline uptake.

The awareness-to-adherence model suggests that there are several steps that are made as clinicians change behaviour. They must initially become aware of the guideline (awareness), then agree with it in principle (agreement), then decide it is appropriate and feasible to use in their own practice (adoption), and finally succeed in following it at appropriate times (adherence). The latter element should also include a system to check that this has been done, for example an audit.

The study suggests that there is ‘leakage’ at every stage of this process. GPs may often not adopt or adhere to guideline recommendations, despite being aware of them. This may be because they have concerns regarding the evidence, applicability, or practicalities of implementation. The awareness-to-adoption model may help to identify GPs’ specific concerns about recommendations for which the uptake is low.

So what?
There are perhaps two groups for whom this study is essential reading. It identifies the importance of guideline developers needing to take into account the views of stakeholders when making specific recommendations in order to ensure that the evidence is clearly stated and practical clinical issues have been considered. This may also provide a useful tool for those who are looking at why evidence does not get into practice at a local level (e.g. prescribing advisers and medicines managers). If uptake of a particular recommendation is low, an analysis of the concerns and barriers may help identify the reasons behind this which can then be targeted for improvement.

Study details:-

Design: questionnaire survey of 800 GPs via the internet (50% response rate)

Aim: to explore GPs’ awareness of current hypertension guidelines and their self-reported implementation of them in clinical practice, based on the awareness-to-adherence model of behavioural change

Results: while awareness of recommendations was high, agreement and adoption were often much lower. Almost all GPs (99%) were aware of guidance on statin therapy but less than half (43%) adhered to the recommendation in practice. 77% were aware that BP should initially be measured in both arms but only 30% agreed with the recommendation and 13% adhered to it. Although the adoption of a recommendation usually depended on agreement with it, 19% of GPs reported adherence to guidance on statin therapy without either being aware or of or in agreement with it. This may be due to financial incentives.

Sponsorship: Office of Health Economics

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