Why do GPs not implement evidence-based guidelines? A descriptive study

BACKGROUND: There is an acknowledged gap between research findings and their implementation in clinical practice despite the existence of effective educational interventions. OBJECTIVES: Our aim was to identify what is impeding GPs from pursuing currently recognized good practice and implementing evidence-based guidelines in their management of hypertension in the elderly. METHOD: We carried out a qualitative study using semi-structured interviews conducted during focus group outreach visits to 34 GPs from nine practices in Merseyside involved in an educational programme designed to improve the management of hypertension in the elderly. RESULTS: Several barriers to the implementation of evidence-based guidelines in the management of hypertension in the elderly were identified. These included: doubts about the applicability of trial data to particular patients; the poor adherence of GPs to practice protocols; ageist attitudes of some GPs; the effect of time pressure and financial considerations making the subject a low priority; the absence of an effective computer system; and the absence of an educational mentor. All participants demonstrated a very positive attitude to practice-based education. They also welcomed external audit data, which compared their performance with that of other practices. Single-handed GPs were particularly enthusiastic about this approach as it provided them with the peer pressure they lacked. CONCLUSIONS: In order to bridge the gap between research and practice, educators need to address the various 'barriers to change' amongst practitioners.     

Influence of evidence-based guidance on health policy and clinical practice in England

OBJECTIVES: To examine the influence of evidence-based guidance on health care decisions, a study of the use of seven different sources and types of evidence-based guidance was carried out in senior health professionals in England with responsibilities either for directing and purchasing health care based in the health authorities, or providing clinical care to patients in trust hospitals or in primary care. DESIGN: Postal survey. SETTING: Three health settings: 46 health authorities, 162 acute and/or community trust hospitals, and 96 primary care groups in England. SAMPLE: 566 subjects (46 directors of public health, 49 directors of purchasing, 375 clinical directors/consultants in hospitals, and 96 lead general practitioners). MAIN OUTCOME MEASURES: Knowledge of selected evidence-based guidance, previous use ever, beliefs in quality, usefulness, and perceived influence on practice. RESULTS: A usable response rate of 73% (407/560) was achieved; 82% (334/407) of respondents had consulted at least one source of evidence-based guidance ever in the past. Professionals in the health authorities were much more likely to be aware of the evidence-based guidance and had consulted more sources (mean number of different guidelines consulted 4.3) than either the hospital consultants (mean 1.9) or GPs in primary care (mean 1.8). There was little variation in the belief that the evidence-based guidance was of "good quality", but respondents from the health authorities (87%) were significantly more likely than either hospital consultants (52%) or GPs (57%) to perceive that any of the specified evidence-based guidance had influenced a change of practice. Across all settings, the least used route to accessing evidence-based guidance was the Internet. For several sources an effect was observed between use ever, the health region where the health professional worked, and the region where the guidance was produced or published. This was evident for some national sources as well as in those initiatives produced locally with predominantly local distribution networks. CONCLUSIONS: The evidence-based guidance specified was significantly more likely to be seen to have contributed to the decisions of public health specialists and commissioners than those of consultants in hospitals or of GPs in a primary care setting. Appropriate information support and dissemination systems that increase awareness, access, and use of evidence-based guidance at the clinical interface should be developed.     

Clinical guidelines of depression: a qualitative study of GPs' views

BACKGROUND: Clinical guidelines have become an increasingly familiar component of health care, although their passive dissemination does not ensure implementation. This study is concerned with general practitioners' (GPs) views of guideline implementation in general practice. It focuses specifically on their views about guidelines for the management of patients with depression. OBJECTIVE: To elicit and explore GPs' views about clinical guidelines for the management of depression, their use in practice, barriers to their use, and how best to implement guidelines. DESIGN: Qualitative study using in-depth interviews with a purposive sample of GPs. SETTING: General Practices across the Scottish Grampian region, and Northeast England. METHODS: Eleven GPs who had participated in a previous questionnaire based depression study were interviewed. Interviews were transcribed and analyzed using the "framework technique." RESULTS: Several participating GPs did not agree with recommendations of the current depression guidelines; some thought they were insufficiently flexible to use with the variety of patients they see. The volume of guidelines received, lack of time and resources (particularly mental health professionals for referrals) were seen as the main barriers to guideline use. CONCLUSIONS: A range of factors contributes to variability in compliance with guidelines for the management of depression. For guideline use to increase, GPs in this study said they would like to see more resources put in place; a reduction in the number of guidelines they receive; incorporation of guideline recommendations onto computer decision support systems; and regular audit and feedback to allow them to monitor their practice.     

General practitioners' uptake of clinical practice guidelines: a qualitative study

OBJECTIVE: To explain recent rapid audited change in the uptake of locally implemented, evidence-based clinical guidelines for asthma and angina in primary care. METHODS: A case study of primary care in two matched, adjacent districts in Northern England, focusing on a stratified random sample of 49 general practitioners (GPs) from eight primary care groups. Data were collected from three cycles of mainly qualitative interviews carried out at six-monthly intervals, before and after the dissemination of local guidelines and after audit data were gathered. Interviews examined attitudes, awareness and impact of locally disseminated asthma and angina guidelines and the subsequent audit. Audit data on guideline uptake were also available from a parallel study. RESULTS: The rapid increase in guideline uptake observed in both intervention and control groups was not explained by individual practitioners or practice factors. The findings are attributed to GPs' awareness of policies for evidence-based medicine, of new health service institutions and of the clinical governance activities of primary care groups. Behaviour change reflects GPs' decisions about what to record in case notes as well as their clinical decisions, so that findings may reflect changing perceptions about accountability rather than about preferred treatment regimes. CONCLUSIONS: Guideline production and dissemination is best seen in the broader context of policy change. Studies of guideline implementation should report before and after data and incorporate significant qualitative components in order to identify important contextual factors.     

Learning with computerized guidelines in general practice?: A randomized controlled trial

BACKGROUND: Evidence-based guidelines are seen as an important instrument to transfer scientifically generated knowledge into daily clinical practice and to ensure high standards of clinical care. Despite wide promulgation, clinical guidelines so far have a limited impact on individual professional learning and on changing daily medical practice. OBJECTIVES: Our aims were (i) to study a potential knowledge increase among German GPs after implementation of web- and evidence-based guidelines and (ii) to identify and analyse potential barriers to individual professional learning with computerized guidelines. METHODS: A prospective, randomized controlled trial was conducted including 72 GPs (21% female, 79% male). The intervention group (n = 38) had access to clinical guidelines via the Internet or CD-ROM, the control group had not (n = 34). Both groups received a standardized two-part questionnaire. An increase of knowledge was measured with 25 multiple choice questions related to four different medical topics. In addition, reasons for using or not using computerized guidelines were analysed after access to guidelines was open to all participating physicians. RESULTS: There was no significant knowledge increase in the intervention group (P = 0.69). Twenty-two (58%) GPs of the intervention group had used the guidelines. Unspecified curiosity (76%) and a specific medical question (38%) were predominant motives for usage among physicians who had used the guidelines. Among 'non-users', 78% stated 'lack of time' as the main reason for not using guidelines. CONCLUSION: An efficient knowledge transfer through computerized guidelines was not achieved. Usage, individual learning and potential implementation depend on adequate incentives and pragmatic aspects of clinical practice: easy and quick access.     

Designing and implementing behaviour change interventions to improve population health

Improved population health depends on changing behaviour: of those who are healthy (e.g. stopping smoking), those who are ill (e.g. adhering to health advice) and those delivering health care. To design more effective behaviour change interventions, we need more investment in developing the scientific methods for studying behaviour change. Behavioural science is relevant to all phases of the process of implementing evidence-based health care: developing evidence through primary studies, synthesizing the findings in systematic reviews, translating evidence into guidelines and practice recommendations, and implementing these in practice. 'Behaviour change: Implementation and Health', the last research programme to be funded within the MRC HSRC, aimed to develop innovative ways of applying theories and techniques of behaviour change to understand and improve the implementation of evidence-based practice, as a key step to improving health. It focused on four areas of study that apply behaviour change theory:defining and developing a taxonomy of behaviour change techniques to allow replication of studies and the possibility of accumulating evidence; conducting systematic reviews, by categorizing and synthesizing interventions on the basis of behaviour change theory; investigating the process by which evidence is translated into guideline recommendations for practice; developing a theoretical framework to apply to understanding implementation problems and designing interventions. This work will contribute to advancing the science of behaviour change by providing tools for conceptualizing and defining intervention content, and linking techniques of behaviour change to their theoretical base.     

Evidence-based implementation of evidence-based guidelines

PURPOSE: There is evidence that some strategies for guideline implementation are more successful than others. This paper aims to describe the process of developing an evidence-based guideline implementation strategy for use in rural emergency departments. DESIGN/METHODOLOGY/APPROACH: Participation in a nationally funded, research fellowship program involved attendance at workshops run by internationally renowned experts in the field of knowledge translation. Attendance at these workshops, associated reading and a literature review allowed those implementation strategies with the most supportive evidence of effectiveness to be determined. FINDINGS: A multi-faceted implementation strategy was developed. This strategy involved the use of an implementation team as well as addressing issues surrounding individual clinicians, the "emergency department team", the physical structure and processes of the ED and the culture of the department as a whole. Reminders, audit and feedback, education, the use of opinion leaders, and evidence-based formatting of guidelines were all integral to the process. PRACTICAL IMPLICATIONS: It is postulated that an evidence-based implementation strategy will lead to greater changes in clinician behaviour than other strategies used in quality improvement projects. ORIGINALITY/VALUE: This is an important article as it describes the concept and development of evidence-based interventions, which, if tailored to the individual hospital (as evidence-based medicine is tailored to the individual patient), has the potential to improve compliance with clinical guidelines beyond that achieved with most QI projects.     

The attitudes of Australian GPs to evidence-based medicine: a focus group study

BACKGROUND: Over the last 6 years there has been an exponential increase in the publication of medical literature on evidence-based medicine. In Australia, as in many other parts of the world, there have been calls for an increase in the practice of evidence-based medicine. In general practice, two major themes of criticism have been the lack of relevant research evidence in primary care and the failure of evidence-based medicine to take into account the complexity of the consultation. OBJECTIVE: We aimed to explore the attitudes of Australian GPs to evidence-based medicine. METHODS: We conducted a qualitative study using evidence-based guidelines as a model to explore attitudes within focus group interviews. Focus group data were analysed using grounded theory methodology. The study was set in the Australian cities Melbourne, Adelaide and Darwin. The subjects were 27 GPs in five focus groups. RESULTS: Data were used to generate a model illustrating factors affecting the consideration and use of evidence within consultations. Prior beliefs and experience had a strong influence on decision-making. Overall, the GPs had a positive attitude to evidence-based medicine and stated that this could be a helpful strategy for meeting their information needs. These needs arose during the consultation and were frequently generated by patients. The evidence-based approach was regarded as particularly useful when patients required validation of their management or had specific queries. However, the GPs also expressed some concerns, such as the application of evidence from clinical trials to individuals, and the appropriateness of using research evidence with certain patients. They also feared a move away from the 'art of medicine'. None of the GPs expressed a need for critical appraisal skills. CONCLUSIONS: The Australian GPs in this study had mixed views about the increasing profile of evidence-based medicine, and the use of this paradigm in practice. Acceptability was more likely to be influenced by relevance to general practice and local contextual and patient factors than by the strength, or critical quality of the evidence.     

Health policy issues and applications for evidence-based medicine and clinical practice guidelines

Evidence-based medicine and clinical practice guidelines have become increasingly salient to the international health care community in the 1990s. Key issues in health policy in this period can be categorised as costs and access to care, quality of and satisfaction with care, accountability for value in health care, and public health and education. This paper presents a brief overview of evidence-based medicine and clinical practice guidelines and describes how they are likely to influence health policy. Evidence-based medicine focuses on the use of the best available clinical (efficacy) evidence to inform decisions about patient care; guidelines are statements systematically developed from efficacy and effectiveness research and clinical consensus for practitioners and patients to use in making decisions about appropriate care under different clinical circumstances. Both fields have developed methods for evaluating and synthesising available evidence about the outcomes of alternative health care interventions. They have clear implications for health policy analysts: greater reliance should be placed on scientific evidence, policy decisions should be derived systematically, and health care decisionmaking must allow for the active participation of health care providers, policy makers, and patients or their advocates. The methods and information generated from evidence-based guidelines efforts are critical inputs into health policy analysis and decision-making.     

The logic behind a multimethod intervention to improve adherence to clinical practice guidelines in a nationwide network of primary care practices

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.     

An evidence integration triangle for aligning science with policy and practice

Over-reliance on decontextualized, standardized implementation of efficacy evidence has contributed to slow integration of evidence-based interventions into health policy and practice. This article describes an "evidence integration triangle" (EIT) to guide translation, implementation, prevention efforts, comparative effectiveness research, funding, and policymaking. The EIT emphasizes interactions among three related components needed for effective evidence implementation: (1) practical evidence-based interventions; (2) pragmatic, longitudinal measures of progress; and (3) participatory implementation processes. At the center of the EIT is active engagement of key stakeholders and scientific evidence and attention to the context in which a program is implemented. The EIT model is a straightforward framework to guide practice, research, and policy toward greater effectiveness and is designed to be applicable across multiple levels-from individual-focused and patient-provider interventions, to health systems and policy-level change initiatives.     

Do clinical practice education groups result in sustained change in GP prescribing?

BACKGROUND: Concern has been expressed at the poor uptake of evidence into clinical practice. This is despite the fact that continuing education is an embedded feature of quality assurance in general practice. There are a variety of clinical practice education methods available for dissemination of new evidence. Recent systematic reviews indicate that the effectiveness of these different strategies is extremely variable. OBJECTIVE: Our aim was to determine whether a peer-led small group education pilot programme used to promote rational GP prescribing is an effective tool in changing practice when added to prescribing audit and feedback, academic detailing and educational bulletins, and to determine whether any effect seen decays over time. METHODS: A retrospective analysis of a controlled trial of a small group education strategy with 24 month follow-up was carried out. The setting was an independent GPs association (IPA) of 230 GPs in the Christchurch New Zealand urban area. All intervention and control group GPs were already receiving prescribing audit and feedback, academic detailing and educational bulletins. The intervention group were the first 52 GPs to respond to an invitation to pilot the project. Two control groups were used, one group who joined the pilot later and a second group which included all other GPs in the IPA. The main outcome measures were targeted prescribing data for 12 months before and 24 months after each of four education sessions. RESULTS: An effect in the expected direction was seen in six of the eight key messages studied. This effect was statistically significant for five of the eight messages studied. The effect size varied between 7 and 40%. Where a positive effect was seen, the effect decayed with time but persisted to a significant level for 6-24 months of observation. CONCLUSION: The results support a positive effect of the education strategy on prescribing behaviour in the intervention group for most outcomes measured. The effect seen is statistically significant, sustained and is in addition to any effect of the other pharmaceutical educational initiatives already undertaken by the IPA.     

Developing Clinical Practice Guidelines

Clinical practice guidelines have gradually become a normal part of daily life for many clinicians. In order to provide good support for practitioners and patients in their decisions on appropriate care, the practice guidelines should be of high quality, i. e. developed by a credible organisation, based on the best available scientific evidence, tested for applicability, implemented through multiple strategies, and their use and impact continuously monitored.Many of the guideline development programmes in Europe do not meet these criteria. Guideline-setting initiatives in seven European countries are presented in this review. Of these, three specific programmes are described in detail: one that is mainly professionally driven (The Netherlands), one that is primarily academically driven (UK), and one that is mainly based on initiatives by the authorities (France).Large intercountry differences are evident in guideline setting initiatives. These differences include the nature of the guidelines, their aims, the methods used, the measures to promote implementation, and the people involved. Cost considerations have to date rarely been included.Well designed programmes for implementing the guidelines are usually lacking: implementation is often restricted to mailing the guidelines or presenting them in journals.As yet, there is a scarcity of any monitoring of the acceptance, use and impact of these guidelines.Despite these limitations, positive trends can be seen in guideline development in Europe. These include: a shift towards guidelines based on the best evidence available, and developed through formal, systematic and explicit procedures; more attention to effective implementation of practice guidelines; and, more attention to the role of the patient in guideline development, as well as in shared decision-making based on guidelines.Such trends mark the direction in which the development of clinical guidelines in Europe will probably progress. However, in a few year’ time, there will be the danger of an overload of guidelines, which may be conflicting in their advice to doctors thus creating confusion and resistance. Specific criteria for high quality clinical practice guidelines and continuous improvement in the procedures for developing and implementing guidelines will be an important next step.     

Implementation of Guidelines for Diagnosing and Treating Hypertension

Hypertension is an important modifiable risk factor for cardiovascular disease. Despite compelling evidence for the benefits of various treatment strategies and an extensive program of public and professional education, management of hypertension remains suboptimal with marked interphysician variability and inconsistent application of clinical trial evidence. Clinical practice guidelines are often cited as a potential means to improve hypertension management, although trials evaluating the impact of guidelines for various conditions have reported mixed results. Multiple potential barriers to the successful implementation of guidelines exist: these can be broadly classified as arising from the clinician, the patient, the environment, or the guideline itself. The probability of successfully implementing a guideline is highest if multifactorial approaches are pursued, such as: (i) the generation of locally endorsed evidence-based guidelines; (ii) dissemination of the guidelines by academic detailing; (iii) point-of-care reminder systems; and (iv) multiple reinforcements via local opinion leaders and audit with patient-specific feedback.     

Getting evidence into clinical practice: an organisational behaviour perspective

OBJECTIVES: To study the relationship between research evidence and clinical behaviour change in the UK National Health Service (NHS) in the period 1995-1997 by examining the 'careers' of change issues designed to reshape clinical practice, the impact of such change efforts, and the factors shaping change outcomes. METHODS: Comparative case study methods were used. Four clinical change issues were studied using semi-structured interviews (n = 119) and documentary analysis in one English NHS region. For each issue, there was an overview semi-structured interview survey of the issue at regional level, followed by an intensive analysis of its impact at local level on the practice of specific clinical groups. RESULTS: There was a weak relationship between the evidence base and its diffusion. The diffusion and take-up of scientific evidence were shown to be socially constructed. Different forms of evidence were differentially accepted by individuals and groups. Specific organisational and social factors affected this pattern of impact. The general management hierarchy of the NHS played a very limited role in enabling evidence-based clinical change. CONCLUSIONS: The implementation of evidence-based medicine is a complex and contested process. The results of this study confirm a professional dominance model of clinical behaviour change and identify tacit expert knowledge as a key power resource in shaping the way research evidence influences clinical practice.     

Influences on GPs' decision to prescribe new drugs-the importance of who says what

OBJECTIVES: The aim of this study was to understand the range of factors that influence GPs' uptake of new drugs METHODS: A total of 107 GPs selected purposively from high, medium and low new drug prescribing practices in two health authorities in the north west of England were interviewed using the critical incident technique with semi-structured interviews. Interview topics included reasons for prescribing new drugs launched between January 1998 and May 1999; reasons for prescribing the new drug rather than alternatives; and sources of information used for each prescribed drug. RESULTS: Important biomedical influences were the failure of current therapy and adverse effect profile. More influential than these, however, was the pharmaceutical representative. Hospital consultants and observation of hospital prescribing was cited next most frequently. Patient request for a drug, and patient convenience and acceptability were also likely to influence new drug uptake. Written information was of limited importance except for local guidelines. GPs were largely reactive and opportunistic recipients of new drug information, rarely reporting an active information search. The decision to initiate a new drug is heavily influenced by 'who says what', in particular the pharmaceutical industry, hospital consultants and patients. The decision to 'adopt' a new drug is clinched by subsequent personal clinical experience. CONCLUSIONS: Prescribing of new drugs is not simply related to biomedical evaluation and critical appraisal but, more importantly, to the mode of exposure to pharmacological information and social influences on decision making. Viewed within this broad context, prescribing variation becomes more understandable. Findings have implications for the implementation of evidence-based medicine, which requires a multifaceted approach.     

An Evidence-Based Public Health Approach to Climate Change Adaptation

Background: Public health is committed to evidence-based practice, yet there has been minimal discussion of how to apply an evidence-based practice framework to climate change adaptation.Objectives: Our goal was to review the literature on evidence-based public health (EBPH), to determine whether it can be applied to climate change adaptation, and to consider how emphasizing evidence-based practice may influence research and practice decisions related to public health adaptation to climate change.Methods: We conducted a substantive review of EBPH, identified a consensus EBPH framework, and modified it to support an EBPH approach to climate change adaptation. We applied the framework to an example and considered implications for stakeholders.Discussion: A modified EBPH framework can accommodate the wide range of exposures, outcomes, and modes of inquiry associated with climate change adaptation and the variety of settings in which adaptation activities will be pursued. Several factors currently limit application of the framework, including a lack of higher-level evidence of intervention efficacy and a lack of guidelines for reporting climate change health impact projections. To enhance the evidence base, there must be increased attention to designing, evaluating, and reporting adaptation interventions; standardized health impact projection reporting; and increased attention to knowledge translation. This approach has implications for funders, researchers, journal editors, practitioners, and policy makers.Conclusions: The current approach to EBPH can, with modifications, support climate change adaptation activities, but there is little evidence regarding interventions and knowledge translation, and guidelines for projecting health impacts are lacking. Realizing the goal of an evidence-based approach will require systematic, coordinated efforts among various stakeholders.Citation: Hess JJ, Eidson M, Tlumak JE, Raab KK, Luber G. 2014. An evidence-based public health approach to climate change adaptation. Environ Health Perspect 122:1177–1186; http://dx.doi.org/10.1289/ehp.1307396     

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.     

Implementing clinical protocols in oncology: quality gaps and the learning curve phenomenon

BACKGROUND: The quality improvement effort in clinical practice has focused mostly on 'performance quality', i.e. on the development of comprehensive, evidence-based guidelines. This study aimed to assess the 'conformance quality', i.e. the extent to which guidelines once developed are correctly and consistently applied. It also aimed to assess the existence of quality gaps in the treatment of certain patient segments as defined by age or gender and to investigate methods to improve overall conformance quality. METHODS: A retrospective audit of clinical practice in a well-defined oncology setting was undertaken and the results compared to those obtained from prospectively applying an internally developed clinical protocol in the same setting and using specific tools to increase conformance quality. RESULTS: All indicators showed improvement after the implementation of the protocol that in many cases reached statistical significance, while in the entire cohort advanced age was associated (although not significantly) with sub-optimal delivery of care. A 'learning curve' phenomenon in the implementation of quality initiatives was detected, with all indicators improving substantially in the second part of the prospective study. CONCLUSIONS: Clinicians should pay separate attention to the implementation of chosen protocols and employ specific tools to increase conformance quality in patient care.