Arts Derk L, Voncken Albertine G, Medlock Stephanie, Abu-Hanna Ameen, van Weert Henk C P M
Academic Medical Centre, Department of General Practice and department of Medical Informatics, Amsterdam, The Netherlands.
Academic Medical Centre, Department of General Practice, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
Int J Med Inform. 2016 May;89:55-62. doi: 10.1016/j.ijmedinf.2016.02.009. Epub 2016 Feb 23.
Reasons for intentional non-adherence to guidelines are largely unknown. The objective of this systematic review was to gain insight into and categorize reasons for intentional non-adherence and their validity. Non-adherence might be a conscious choice by either the clinician or the patient, and is not influenced by external factors (e.g. lack of knowledge or resources). We use the term intentional non-adherence to describe this class of reasons for not following guideline recommendations.
Two independent reviewers examined MEDLINE citations for studies that investigated reasons for guideline non-adherence. The obtained articles were assessed for relevance and quality. Our search yielded 2912 articles, of which 16 matched our inclusion criteria and quality requirements. We planned to determine an overall ranking of categories of non-adherence.
Seven studies investigated clinical reasons and performed adjudication, while nine studies did not perform adjudication. Non-adherence varied between 8.2% and 65.3%. Meta-analysis proved unfeasible due to heterogeneity of study methodologies. The percentage of reasons deemed valid by adjudication ranged from 6.6% to 93.6%. Guideline non-adherence was predominantly valid; contra-indications and patient preference were most often reported as reasons for intentional non-adherence.
We found a wide range of rates of non-adherence to clinical guidelines. This non-adherence is often supported by valid reasons, mainly related to contra-indications and patient preference. Therefore, we submit that many guideline deviations are intentional and these deviations do not necessarily impact quality of care.
故意不遵循指南的原因大多未知。本系统评价的目的是深入了解故意不遵循的原因并进行分类，以及评估这些原因的合理性。不遵循可能是临床医生或患者的有意识选择，且不受外部因素（如知识或资源匮乏）的影响。我们使用“故意不遵循”一词来描述这类不遵循指南建议的原因。
两名独立评审员查阅了MEDLINE数据库中调查不遵循指南原因的研究文献。对获取的文章进行相关性和质量评估。我们的检索共得到2912篇文章，其中16篇符合我们的纳入标准和质量要求。我们计划确定不遵循类别总的排名。
七项研究调查了临床原因并进行了判定，而九项研究未进行判定。不遵循率在8.2%至65.3%之间。由于研究方法的异质性，荟萃分析不可行。经判定认为合理的原因所占比例从6.6%至93.6%不等。不遵循指南大多是合理的；禁忌证和患者偏好最常被报告为故意不遵循的原因。
我们发现临床指南不遵循率范围很广。这种不遵循往往有合理原因支持，主要与禁忌证和患者偏好有关。因此，我们认为许多指南偏差是故意的，且这些偏差不一定会影响医疗质量。
