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General Practice

Attributes of clinical guidelines that influence use of guidelines in general practice: observational study

BMJ 1998; 317 doi: (Published 26 September 1998) Cite this as: BMJ 1998;317:858
  1. Richard Grol, professora,
  2. Johannes Dalhuijsen, general practitionerb,
  3. Siep Thomas, director of guidelines developmentb,
  4. Cees in ‘t Veld, general practitionerb,
  5. Guy Rutten, associate professorc,
  6. Henk Mokkink, senior researchera
  1. aCentre for Quality of Care Research, Universities of Nijmegen-Maastricht, PO Box 9101, 6500 HB Nijmegen, Netherlands
  2. bDutch College of General Practitioners, PO Box 3231, 3502 GE Utrecht, Netherlands
  3. cDepartment of General Practice, Utrecht University, PO Box 80045, 3508 TA Utrecht
  1. Correspondence to: Professor Grol
  • Accepted 27 August 1998


Objective: To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice..

Design: Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelines—for example, evidence based, controversial, concrete.

Setting: General practice in the Netherlands.

Subjects: 61 general practitioners who made 12 880 decisions in their contacts with patients.

Main outcome measures: Compliance of decisions with clinical guidelines according to the attribute of the guideline.

Results: Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)).

Conclusions: People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.


  • Accepted 27 August 1998
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