Background
The implementation of practical guidelines in routine clinical practice is a challenge. It is a well-known problem that in spite of a multitude of existing clinical guidelines, the implementation in clinical practice remains insufficient worldwide [
1‐
4]. For this reason, the focus of research has increasingly shifted from the development to the implementation of guidelines [
5].
However, why is the implementation of clinical guidelines so important? Non-maleficence is one of the four basic principles in medical ethics. It is impossible in clinical practice to never do harm; however, decision-making in healthcare requires a thorough consideration of doing no net harm [
6]. Evidence-based guidelines are intended to support clinicians in making decisions, not only by ensuring that harm is prevented, but also by providing optimal healthcare [
6]. However, studies in different countries show that many patients receive care that is not needed or even potentially harmful [
3,
7,
8]. Moreover, guidelines support optimizing health outcomes [
5,
9‐
13]. This illustrates the importance of improving the implementation of guidelines in clinical practice.
In 2019, the German evidence- and consensus-based S3 guideline for schizophrenia [
14,
15] was published. A recent preceding study conducted in the year of publication of the guideline showed that in spite of a high acceptance of this guideline, more than half of the participants did not use the guideline in everyday clinical care [
16].
One reason for these results are the multifaceted barriers and facilitating factors in guideline adherence [
5,
16‐
18]. Several frameworks exist allocating the barriers and facilitators to different categories. One of them is the in 1996 by Pathman and colleagues developed awareness-to-adherence model [
19], a four-step model including awareness, agreement, adoption, and adherence. It postulates that a sequence of cognitive and behavioral processes is necessary so that guidelines can have an impact on physicians’ clinical behavior. Clinicians follow practical guidelines if they are aware of the guidelines, intellectually agree with them and then decide to follow them for some patients. Finally, the path to guideline adherence also requires regular adherence to it for most patients. A progressive drop off over the four steps is observed in general, which is described as a ‘pipeline’, with research evidence ‘leaks’ leading to a reduced guideline implementation [
20].
A further reason is the fact that medical knowledge is increasing exponentially; consequently, many guidelines are already out of date when published [
21‐
25]. Moreover, most clinicians cannot keep up with the amount of increasing knowledge [
21,
26]. One strategy to address this problem is the development of so-called living guidelines. Living guidelines are an optimization of the guideline development process as individual recommendations can be updated as soon as relevant new evidence is available [
22]. In that regard, the user’s perspective on the concept of living guidelines has not yet been investigated.
This study aims to explore the current implementation status of the German evidence-and consensus-based guideline for schizophrenia [
14,
15] and its key recommendations as well as the attitude of users toward a future living guideline for schizophrenia
.
Discussion
This study ascertained the current implementation of the German guideline for schizophrenia approximately three years after its publication in March 2019. It further provides an initial assessment of the attitude toward the German living guideline for schizophrenia (currently under development).
In a previous study, an insufficient implementation status of the guideline for schizophrenia was shown [
16]. Beyond this, we investigated the implementation status of four key recommendations and differences in implementation between professions. As a living guideline for schizophrenia is currently under development, we examined the attitude toward a living guideline and discrepancies among different age groups.
Two-fifths of the participants were aware of, agreed with, and adopted [
19] the guideline for schizophrenia, less than one-tenth of the surveyed mental healthcare professionals reported to adhere to the schizophrenia guideline as a whole, showing an awareness-, agreement-, as well as an adoption-to-adherence gap in guideline use. This result is consistent with findings of a study on the current German schizophrenia guideline conducted in 2019 directly after its publication [
16], and other mental health or somatic guidelines [
32,
33]. Similarly, a large discrepancy between awareness and adherence as well as between agreement and adherence was also shown for specific recommendations. The greatest awareness-to-adherence gap for all four professions together was detected for the psychotherapy recommendation—68% of the participants fell off the track from awareness to adherence and 74% agreed on the recommendation but did not adhere to it. A possible reason could be the lack of time [
34] for psychotherapy in an inpatient setting due to work load and/or a lack of prioritization of psychotherapy compared to other treatment forms, e.g., pharmacological treatment. Moreover, recommendation 3 regarding severe weight gain exhibited the lowest rates on awareness, agreement, adoption, and adherence out of all recommendations in total. This may be the result of a lack of experience with prescribing the recommended metformin (Evidence level A) and concerns regarding side effects or interaction with other drugs. Another potential explanation is that the consequences of antipsychotic-induced weight gain are underestimated [
35]. A close look regarding barriers and facilitators influencing the gap to adherence will, therefore, be of importance for further research.
Moreover, analyses showed significant differences between professions by showing higher awareness and agreement rates of the current schizophrenia guideline as a whole as well as for all four recommendations among medical doctors compared to psychosocial therapists and caregivers. Psychologists/psychotherapists were more aware and agreed more to the psychotherapy recommendation than psychosocial therapists and caregivers and regarded the recommendation as more appropriate and feasible in the treatment of patients with schizophrenia (adoption) than any other profession (medical doctors, psychosocial therapists, caregivers). Profession-specific differences in guideline implementation are in line with previously conducted studies in mental health as well as general health provision [
16,
36] and highlight the need for greater attention to profession-specific barriers and facilitators in further research. The reasons for physicians’ higher awareness and agreement with the guideline may be that they usually represent the case-leading professional group in multiprofessional inpatient settings. Furthermore, these results could also be explained by the fact that the guideline as a whole contains a greater number of and more specific recommendations for medical doctors compared with other professional groups and that the majority of the experts involved in the development of the guideline are physicians [
14].
The different curricula of the professions in Germany may play a substantial role. For example, medical doctors have a smaller proportion of psychotherapeutic content in their training compared to psychotherapists. Psychotherapists are taught various psychotherapeutic interventions during their studies, and this knowledge is expanded during three to five years of practical and theoretical training of psychotherapy. Medical doctors have far less modules on that topic, as psychotherapy is solely one component of a comprehensive specialist training program. It should be further investigated how the training/studies of various professions may differ regarding guidelines (e.g., guidelines are more used in training of medical doctors, and in training of psychotherapists, manuals are more predominant) and how this may influence the implementation of such.
Our results show higher awareness, agreement, and adoption rates among specialist doctors for the schizophrenia guideline as a whole compared to assistant doctors. Specialist doctors were not only more aware of the recommendation regarding dose of antipsychotics and psychotherapy but also agreed more to the latter recommendation than assistant doctors. This may be a reflection of the expertise associated with an increased professional experience.
On contrary, recommendation 3 (severe weight gain) exhibited higher agreement, adoption, and adherence rates among assistant doctors than specialist doctors showing further differences between the more experienced and usually older professionals and assistants. Further research is needed investigating whether a more recent education and/or the amount of experience influences the present results.
Our results indicate acceptance of the concept of a living guideline among the surveyed mental healthcare professionals—about two-thirds showed positive attitude toward the presented concept of a living guideline. More than half of the subjects evaluate the living guideline as clearer, more practical and generally preferable to the print version. However, less than half of the subjects regarded the living guideline as more informative than the print version. This implies an assumption among clinicians that the living format might not be an improvement regarding additional information content.
We detected significant differences between age groups on attitude toward the living guideline. Young mental healthcare professionals showed a more positive attitude throughout all categories than older participants did, and a higher mean positive attitude than middle-aged respondents did. An uncertainty dealing with new technology is very common in older professionals [
31]. In addition, younger professionals tend to have a greater affinity for technology. Living guidelines are being increasingly used in practice [
31] and could, therefore, be more incorporated into the training of younger practitioners. Further research should investigate if these findings are in agreement with perceived potential barriers and facilitating factors in the use of the upcoming living guideline for schizophrenia.
Limitations regarding the results of this study first include disadvantages related to online surveys, e.g., survey frauds, response bias, and lack of representativeness [
37]. Due to data protection settings of the used software and the anonymous nature of our study, we did not implement tracking of IT addresses. Thus, we cannot exclude, e.g., that some participants participated more than one time. However, this scenario appears to be unlikely as our sample consisted of professionals from inpatient and outpatient settings of our model region and all participants were asked to answer the questionnaire only one time. Our setting differs significantly from, e.g., settings with recruitment from social media platforms where multiple participants are a relevant source of bias. However, our approach may have resulted in a sampling bias as specific clinics in the south of Germany were contacted to participate in the survey. Although the questionnaire is predominantly based on theoretical frameworks [
19,
38], it was developed and adjusted for specific research questions, and thus be potentially biased by the researchers. Further, the reader should bear in mind that the living guideline is still under development and our participants received only a conceptual presentation. Moreover, significant differences in demographic information such as age, gender, work setting and experience with the treatment of schizophrenia between professions were detected. Additionally, significant differences between included and excluded participants could be identified concerning gender, profession (medical doctors and other professions), setting (public hospital, research, and other) as well as age (Supplementary Tables 3–6). Therefore, analyses should be interpreted with caution.
Conclusion
Overall, our findings show a high number of non-adherers to the current guideline of schizophrenia. More specifically, a discrepancy between awareness and adherence, not only for the current schizophrenia guideline as a whole, but also for selected four key recommendations was found. Differences between professions were detected—medical doctors showed higher awareness and agreement on the guideline for schizophrenia as well as on its key recommendations compared to caregivers and psychosocial therapists. Therefore, the role of different profession-specific curricula should be considered in the efforts to increase guideline knowledge and acceptance and, consequently, in the process of implementation. In addition to profession-specific differences, our results indicate a crucial role of clinician’s experience in guideline implementation—higher rates of awareness, agreement, and adoption of the overall schizophrenia guideline were found among specialists compared to assistant doctors.
Overall, our results show promising positive attitudes toward the living guideline for schizophrenia among healthcare providers, suggesting that a living guideline may be a supportive tool in everyday clinical practice. Nevertheless, the development of new guideline formats (e.g., living) cannot address all challenges in guideline implementation. Yet, living guidelines can be helpful to provide more versatile, responsive, and, thus, more user-oriented guidelines (e.g., adapted to profession, experience level, age).
Declarations
Conflict of interest
C. Lorenz, N. Khorikian-Ghazari, G. Gaigl, C. Pielenz, M. Schneider, E. Salveridou-Hof, M. Flick, D. Güler, T. Halms, A. Burschinski. A. Röh report no conflicts of interest. P. Falkai received research support/honoraria for lectures or advisory activities from: Abbott, Boehringer-Ingelheim, Janssen, Essex, Lundbeck, Otsuka, Recordati, Richter, Servier and Takeda. He holds a payed position as Chairman of the Psychiatric Department of the University Munich; is full professor at the Psychiatric Department of the University Munich. He has received and is currently receiving grants from several national and international foundations and institutions, e.g., from the “German Science Foundation”, the “German Ministry of Science” and the “German Ministry of Health”. S. Leucht reported personal fees from Alkermes, Angelini Pharma, Eisai, Gedeon Richter, Janssen Pharmaceuticals, Johnson & Johnson, Lundbeck, Medichem, Merck Sharp & Dohme, Otsuka Pharmaceutical, Casen Recordati, Rovi, Sandoz, Sanofi, Sunovion, Teva Pharmaceuticals, Boehringer Ingelheim, and LTS Lohmann. W. Gaebel is a member of the Lundbeck International Neuroscience Foundation. A.H. is editor of the German (DGPPN) Schizophrenia treatment guidelines and first-author of the WFSBP schizophrenia treatment guidelines. He has been on the advisory boards of Janssen, Lundbeck, Recordati, Rovi and Otsuka and received speaker fees from those companies and from AbbVie.E. Wagner has been invited to advisory boards from Recordati.