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Clinical practice guidelines aim to contribute to efficient and high quality care.1 Efforts are already made to overcome barriers to implementation such as lack of credibility because of financial or intellectual conflicts of interests, and clinicians’ inability to change habits or keep up to date with new recommendations. However, what is rarely acknowledged is that implementing guidelines may require appreciable clinician time and therefore have considerable opportunity costs in the clinical encounter. Including an assessment of time needed to implement might alter the recommendations of guideline committees and help clinicians to prioritise.
Squeezed time
Several studies have shown the impossibility of meeting all guideline recommendations. For example, a simulation study applying all guidelines for preventive care, chronic disease care, and acute care to a panel of 2500 adults representative of the US population estimated that US primary care physicians would require up to 27 hours a working day to implement (and document) all applicable guidelines.2 To fully satisfy only the recommendations from the US Preventive Services Task Force would require 7.4 hours a day.3
Similarly, to implement the European hypertension guidelines in Norwegian adults, Norway would need more general practitioners than are currently in practice.4 And in the UK, implementing all lifestyle interventions recommended by the National Institute for Health and Care Excellence (NICE) may require more physicians (from all specialties) and more nurses than currently available, according to our estimates (unpublished data). Furthermore, healthcare policies also need to account for the time clinicians should spend listening in silence, noticing carefully, and co-creating sensible plans of care with patients.5 If clinicians followed all pertinent guidelines, there would be no time left to care for other ill patients and the healthcare system would collapse.
Clinicians clearly have to make choices about which recommendations to follow in which patients. This involves interpreting, prioritising, and applying them to a diverse group of patients with needs and wishes that may or may not align with practice guidelines. But without guidance, and under the pressure of time, decisions about which guidelines to implement at the point of care will be implicit, variable, and potentially misguided.
To help guide such prioritisation, policy makers may choose a few of the guideline recommendations and tie them to incentives,...