Vol.5, No.2, 188-192 (2013) Health
http://dx.doi.org/10.4236/health.2013.52026
Positive attitudes towards priority setting in clinical
guidelines among Danish general practitioners: A
web based survey
Ann Nielsen1, Benedicte Carlsen2*, Pia K. Kjellberg1
1KORA—Danish Institute for Local and Regional Government Research, Copenhagen, Denmark
2Uni Rokkan Centre, Uni Research, Bergen, Norway; *Corresponding Author:
Received 4 January 2013; revised 3 February 2013; accepted 10 February 2013
ABSTRACT
Aims: Increasing focus on improvement and
optimisation of the treatment in primary care
and reduction of healthcare costs emphasize the
need to understand which factors determines
adherence and non-adherence to clinical guide-
lines. In the present study, we examined atti-
tudes towards clinical guidelines in Danish ge-
neral practitioners (GPs). Methods: We con-
ducted a survey among Danish GPs from all five
regions of Denmark. In total, 443 GPs answered
the web-based questionnaire that contained
questions about a ttit udes and ba rrier s to clinical
guidelines. Results: More than 90% of the GPs
reported that they have good knowledge of the
guidelines and in general follows the guidelines.
A majority of the GPs (81%) found it acceptable
that economic considerations are part of the
guidelines. The most important factors for non-
adherence to guidelines were “need of adjust-
ment to clinical practice” and “lack of confi-
dence in guidelines”. The attitudes to clinical
guidelines were not significantly associated
with practice characteristics such as gender,
years of experience, practice organisation and
localisation. Conclusions: Our findings show
that clinical guidelines are an integrated or inter-
nalised part of everyday practice among GPs in
Denmark. Furthermore, the findings indicate
that Danish GPs are positive towards applying
priority setting in their practice. This is decisive
in the light of rising healthcare costs due to
development of new expensive technologies
and ageing populations that puts pressure on
the healthcare system in general and primary
healthcare in particular.
Keywords: Clinical Guidelines; General
Practitioners; Adherence; Attitudes; Barriers
1. INTRODUCTION
The definition of clinical practice guidelines is “syste-
matically developed statements to assist practitioner and
patient decisions about appropriate healthcare for spe-
cific clinical circumstances” [1].
Francke et al. conducted in 2008 a meta-review to un-
derstand which factors that affect the implementation of
guidelines [2]. Based on twelve reviews and meta-
analyses the key restraints for following clinical guide-
lines were: complexity of the guideline, accessibility,
lack of confidence in guidelines, and time constraints.
Easily understood guidelines and guidelines developed
by the target group or end users were more likely to be
implemented. Lack of awareness of guideline and lack of
agreement with guideline reduced likelihood of imple-
mentation and limited time and personnel resources as
well as work pressure also made implementation less
likely [2].
In 2010, the Danish Medical Association conducted a
survey about use of clinical guidelines among 1675 cli-
nicians within a wide range of specialties. The study
showed that format, accessibility and appropriate imple-
mentation strategies are crucial to successful implemen-
tation and use of clinical guidelines among clinicians. In
2008, we conducted a qualitative interview study among
18 Danish GPs from the capital area, which showed
similar trends [3]. The views that emerged from this
study were that GPs found it difficult to keep updated on
new treatments and research evidence and some of the
GPs expressed that they missed a single comprehensive
source of guidelines. Another key finding was that the
GPs sometimes experienced a dilemma between stan-
dardisation practice and individual treatment of the pa-
tient. But most importantly the study revealed that Dan-
ish GPs have a positive attitude towards inclusion of
economic considerations and priority setting through the

A. Nielsen et al. / Health 5 (2013) 188-192 189
guidelines [3].
In Denmark there is a fairly long history of issuing
clinical guidelines. Clinical guidelines targeting GPs has
since the 1980s been issued by The Danish College of
General Practitioners, The national Board of Health and
since 1999 the Institute for Rational Pharmacotherapy
[6,13]. Internationally there has also been an increasing
focus on optimising the treatment in primary care and
reduction of healthcare costs. In England, NICE (Na-
tional Institute for Clinical Excellence) was established
to develop, disseminate and implement guidelines on a
range of clinical activities [4,5]. Large amounts of re-
sources are used continuously to develop new guidelines
and update existing guidelines within the field of primary
care. Thus knowledge about adherence and non-adher-
ence to clinical guidelines are of interest from a clinical
and a political point of view. To gain broader under-
standing of the attitudes towards clinical guideline in a
Danish setting and to update our knowledge of barriers to
implementation of guidelines, we conducted a survey
among GPs located in all five regions of Denmark.
2. METHODS
The survey was carried out in March 2011. An invita-
tion letter with a link to the web-based questionnaire was
e-mailed to all general practitioners (GP) in Denmark (n
= 3649) in March 2011. One reminder was distributed
and the link was open for two weeks. Responding to the
invitation was possible through the received link to the
web. In all, 487 GPs responded to the invitation. Of those,
10 GPs refused to participate and 34 did not answer the
questions regarding attitudes and barriers to clinical
guidelines, leaving us with a study population of 443
Danish GPs.
The questionnaire was developed in close cooperation
with Norwegian researchers as the survey was carried
out in both countries. Details on the questionnaire have
been described previously [7]. Briefly, the questionnaire
was composed of two parts, namely the clinical guide-
lines questions and a discrete choice experiment (DCE).
The DCE is not included in the present study, but will be
reported later. In the guideline section the GPs were
asked about attitudes and barriers to guidelines. All the
questions were asked as statements to which the GP, by
use of a four-point Likert scale, could express the extent
of their agreement (completely and partly agree/disagree)
or in the case of barriers to guidelines, the importance of
the statement (not, slightly, fairly or very important). The
questions included were based on the findings from pre-
vious international reviews [8-11] and from a compara-
tive interview study carried out among 45 Danish and
Norwegian GPs [3,12]. In addition, we added questions
regarding GP and practice characteristics in the Danish
survey (e.g. practice organization, GPs age, gender and
years since graduation). The questionnaire was further
validated in a Danish context by testing the questionnaire
among a couple of GPs and among persons with know-
ledge about survey methodology.
St atistical Analyses
We estimated the proportions of GPs who agreed with
the attitudes or barriers to guidelines. Furthermore asso-
ciations between adherence and attitudes to guidelines
and practice characteristics were assessed in univariate
logistic regression models (STATA 10.1). Practice char-
acteristics were organisation of the practice (single-
handed, partnership), localisation (region of Denmark),
and characteristics of the GP (gender and years since
graduation).
The measure of association was the odds ratio (OR)
with the corresponding 95% confidence interval (CI).
3. RESULTS
The mean age of the GPs was 52 years (range 32 - 75
years) and 42% were men. We do not have comparable
data on the age of all Danish GPs. The gender distribu-
tion was, however, the same among the participating GPs
(p = 0.99) as among the invited population [17]. The
mean number of years since graduation was 24 years
(range 5 - 45 years). The female GPs had slightly fewer
years of experience compared with their male colleagues
(women; 21 years vs. men; 25 years). The proportion of
GPs from single-handed practices was 17%, whereas the
remaining GPs were part of partnerships practices or
shared single-handed practices. The GPs represented the
entire country with one third being located in the Capital.
The distribution were as follows; Capital: 33%, Zealand:
19%, North: 8%, Central: 18%, South: 22%. This distri-
bution was, however, slightly different from the invited
participants where the distribution was the following;
capital: 35%, Zealand: 17%, North 11%, Central: 10%,
South: 27% (p < 0.01).
The attitudes and adherence to clinical guidelines
among the study population are shown in Table 1. In
general the GPs are positive to clinical guidelines. The
majority of the GPs report, that they have good know-
ledge of the guidelines (93.2%) and have confidence in
guidelines from the health authorities (88.9%) and the
Danish medical societies (88.3%). A significantly lower
proportion have confidence in guidelines from the phar-
maceutical industry (13.8%). In general, the GPs claim
that they follow the guidelines (95.7%) and only a minor
proportion see guidelines as a threat to their professional
work (17.2%). A majority of the GPs find it acceptable
that economic considerations are part of the guidelines,
as long as they are informed about it (80.8%).
Table 2 display different reasons for non-adherence to

A. Nielsen et al. / Health 5 (2013) 188-192
190
Table 1. Attitudes and adherence to guidelines among Danish
GPs (n = 443).
Partly or
totally agree
n (%)
I have good knowledge of guidelines in my specialty 413(93.2)
I have confidence in guidelines from the health
authorities 394 (88.9)
I have confidence in guidelines from the Danish
Medical Societies 391 (88.3)
I have confidence in guidelines from the
pharmaceutical industry 61 (13.8)
Guidelines pose a threat to my professional
judgment/autonomy 76 (17.2)
Generally, I follow the guidelines 424(95.7)
The guidelines are integrated in my practice, I do
not need to look them up 284 (64.1)
Inclusion of economic considerations are acceptable,
if it is stated in the guideline 358 (80.8)
Table 2. Barriers to use of clinical guidelines (n = 443).
Fairly or very
important
n (%)
Economic factors
Guidelines are driven by economic incentives 154(34.8)
Guidelines are driven by the government cost-savings 174(39.3)
Economic concerns overshadow clinical concerns 25.3
Time factors
Guidelines are bothersome or time consuming to
get hold of 185 (41.8)
Cannot spend time negotiating with the patient
only to follow a guideline 109 (24.6)
Do not have the time to update on new guidelines 128(28.9)
Evidence
Sceptical about the evidence 200(45.2)
Disagree frequently with the recommendations of
the guidelines 72 (16.3)
Guidelines are only suggestions, clinical judgment
should be applied 285 (64.3)
Patient perspective
Guidelines does not fit the individual patient 219(49.4)
The recommendation is contrary to the patients
preferences 172 (38.8)
guidelines. The barriers most frequently rated as fairly or
very important for non-adherence were related to the
need for adjustment to clinical practice and to the lack of
confidence in guidelines. Thus the three most important
factors mentioned were as follows; “guidelines are only
suggestions, clinical judgment should be applied” (64.3%),
“guidelines does not fit the individual patient” (49.4%)
and “I am sceptical about the evidence” (45.2%). How-
ever, the statements do not provide us with information
about how often non-adherence to guidelines occurs.
In Ta b l e 3 , we examine the associations between dif-
ferent GP and practice characteristics and adherence and
attitudes towards guidelines. We examined whether ad-
herence and attitudes to clinical guidelines were associ-
ated with the following GP and practice characteristics:
gender of the GP, years since graduation, practice or-
ganisation and localisation. The most experienced GPs
tended to be more likely to follow guidelines compared
with less experienced colleagues. Furthermore, GPs out-
side the capital area was not as likely to follow the
guidelines as GPs from the capital area. However, none
of these tendencies were statistically significant. GPs
outside the capital area were less likely to find economic
considerations acceptable in guidelines. Particularly, GPs
from Region South were less likely to accept economic
considerations.
Table 3. Associations between GP and practice characteristics
and adherence and attitudes towards guidelines.
Generally. follow the
guidelines
Economic
considerations are
acceptable. if stated
in the guideline
OR* 95% CI
OR*95% CI
Gender
Women 1.00 ref.
1.00 ref.
Men 0.67 0.25 - 1.82 1.450.88 - 2.39
Years since graduation
<10 1.00 ref.
1.00 ref.
11 - 15 1.11 0.20 - 6.07 0.810.24 - 2.73
16 - 20 1.98 0.31 - 12.46 0.700.21 - 2.33
21 - 25 2.15 0.29 - 16.07 0.630.18 - 2.15
≥26 2.27 0.44 - 11.83 0.770.25 - 2.36
Practice organisation
Single-handed 1.00 ref.
1.00 ref.
Partnership 1.50 0.46 - 4.83 0.820.40 - 1.66
Shared/group of single-
handed 0.62 0.13 - 2.93 0.530.20 - 1.43
Combination - 1.420.36 - 5.53
Region
The capital 1.00 ref.
1.00 ref.
Zealand 0.23 0.04 - 1.20 0.630.30 - 1.31
North 0.47 0.04 - 5.32 0.680.25 - 1.86
Central 0.28 0.05 - 1.54 0.670.32 - 1.44
South 0.22 0.04 - 1.10 0.480.24 - 0.94
*Crude odds ratio.

A. Nielsen et al. / Health 5 (2013) 188-192 191
Finally, we examined, whether barriers to guidelines
were associated with the above mentioned practice char-
acteristics, but no associations were found between prac-
tice characteristics and barriers to use of guidelines (data
not shown).
4. DISCUSSION
In our study, we find generally positive attitudes to-
wards guidelines. The vast majority of the GPs report
that they use guidelines is well aware of the guidelines,
and have confidence in guidelines from the government
and the medical societies. These findings indicate that
clinical guidelines are an integrated or internalised part
of the everyday practice among GPs in Denmark.
Also a previous study finds that the majority of Danish
GPs use clinical guidelines [14]. In an international per-
spective, a review by Farquhar et al. concluded, that GPs
and other healthcare professionals are very satisfied with
guidelines [10]. However, in studies where use of spe-
cific guidelines have been examined guideline adherence
has not necessarily corresponded with the revealed gene-
ral attitudes towards guidelines [2]. In a Norwegian study,
GPs were asked about their knowledge of specific guide-
lines and their use of the same guidelines [15]. The study
revealed that in most situations the knowledge of the
guideline was substantially greater than the actual use of
the guideline.
Maybe more surprisingly, we found that the majority
of Danish GPs agree with the statement that economic
considerations or incentives may be incorporated in the
guidelines as long as it is stated in the guideline. This
view is more positive than what earlier studies generally
show; a qualitative meta-study of international studies on
GPs’ attitudes to guidelines found that doctors often ex-
press scepticism to elements of cost containment in
clinical guidelines [20]. On the other hand, our finding
supports previous findings from the interview study
conducted in 2008 among eighteen GPs in the Copenha-
gen area [3]. In the interviews the GPs described that
they accepted economic considerations as long as they
were transparent to the healthcare professional. Findings
from Norwegian GPs in the same study showed a mark-
edly more sceptical view on economic considerations
and priority setting in Norwegian GPs [3].
Another key factor that supports Danish GPs integra-
tion of clinical guidelines in practice is the high propor-
tion of GPs that see clinical guidelines as suggestions to
which clinical judgment should be applied. In the late
1990’s Woolf et al. described clinical guidelines as only
one option for improving the quality of care [16]. They
described guidelines as useful in situations where clini-
cians are uncertain about the treatment, or as a tool to
reassure clinicians about the appropriateness of their
treatment and to improve the consistency of care [16]. In
this perspective clinical judgment of the individual pa-
tient is important to take into account in the daily use of
clinical guidelines and our findings indicate that this
practice is implemented among the majority of GPs in
Denmark.
Finally, we revealed no significant associations be-
tween GP and practice characteristics and adherence and
attitudes to guidelines. Beforehand, we tended to expect
that more experienced GPs and GPs in single-handed
practices may be less likely to adhere to guidelines and
may be more sceptical about economic considerations.
Our results, however, did not support these hypotheses.
Some strengths and limitations of the study merit dis-
cussion. We decided to conduct a web-based survey as
opposed to a postal survey because of the easy and low
cost distribution and attainment of responses. In addition,
methodological studies indicate that web based surveys
yield better quality data in terms of less missing and
nonsense responses [18]. However, web-surveys are fre-
quently limited by low response rates, and so also in our
study, which had a response rate of 13%. Still, this is
within the range of published studies based on Internet-
surveys with health professionals [19], and the results
show that the study group profile is quite similar to the
whole population of GPs in Denmark according to the
observable characteristics.
The GPs participating must be considered as being
highly motivated as they received no compensation for
participation in the study. Being highly motivated or in-
terested in the on-going debate about clinical guidelines
may, have facilitated GPs with strong opinions about
clinical guidelines to participate. On the other hands, our
findings are largely in line with previous findings in
Denmark as well as in settings outside Denmark, indi-
cating that the participating GPs largely represent the
attitudes in GPs in general.
A potential strength of our study is the inclusion of
questions about several aspects of barriers for imple-
mentation of guidelines. According to the review by Ca-
bana et al. only a few studies have considered the variety
of barriers that influence the implementation of clinical
guidelines. Most studies have rather focused on a few
specific barriers [8]. Cabana divides barriers into differ-
ent categories related to knowledge, attitudes and be-
haviour. In our study aspects from all three groups of
barriers have been considered, which may have ensured a
more profound examination of perceived barriers to
guidelines among Danish GPs.
In summary, we observed that Danish GPs perceive
clinical guideline as an integrated part of their everyday
practice and have great confidence in guidelines from the
Danish health authorities. Danish GPs also find that as
long as there is transparency, it is acceptable to incorpo-
rate economic incentives in the guidelines. This under-

A. Nielsen et al. / Health 5 (2013) 188-192
192
lines that Danish GPs are accustomed to apply priority
setting in their everyday practice and see clinical guide-
lines as a part of this paradigm, a paradigm, that recently
has been debated extensively, as there in the future will
be rising health care costs due to development of more
expensive technologies and ageing populations. More
elderly and more chronically ill patients with an in-
creased need of treatment, put pressure on the health-
care system in general and on primary healthcare in par-
ticular.
5. FUNDING ACKNOWLEDGE MENTS
The study has received funding from DSI, Danish Institute for
Health Services Research, Copenhagen and The Research Council of
Norway (Grant number 196311).
REFERENCES
[1] Field, M. (1990) Attributes of good practice guidelines. In:
Clinical Practice Guidelines: Directions for a New Pro-
gram, National Academy Press, Washington DC, 53-77.
[2] Francke, A.L., Smit, M.C., de Veer, A.J., et al. (2008)
Factors influencing the implementation of clinical guide-
lines for health care professionals: A systematic meta-re-
view. BMC Medical Informatics and Decision Making, 8,
38. doi:10.1186/1472-6947-8-38
[3] Carlsen, B. and Kjellberg, P.K. (2010) Guidelines; from
foe to friend? Comparative interviews with GPs in Nor-
way and Denmark. BMC Health Service Research, 10, 17.
doi:10.1186/1472-6963-10-17
[4] Jones, R., Dowie, R. and Robinson, M. (2000) Guidelines
implementation and research in the future. Family Prac-
tice, 17, 36-37. doi:10.1093/fampra/17.suppl_1.S36
[5] Dowie, R., Robinson, M. and Jones, R. (2000) Research
on guidelines implementation in primary care. Introduc-
tion. Family Practi ce , 17, 1-2.
doi:10.1093/fampra/17.suppl_1.S1
[6] The Danish College of General Practitioners (1996) Kli-
niske vejledninger i almen medicin [Clinical guidelines in
general practice]. DSAM, Copenhagen.
[7] Carlsen, B. and Bringedal, B. (2011) Attitudes to clinical
guidelines—Do GPs differ from other medical doctors?
BMJ Quality and Safety, 20, 158-162.
doi:10.1136/bmjqs.2009.034249
[8] Cabana, M.D., Rand, C.S., Powe, N.R., et al. (1999) Why
don’t physicians follow clinical practice guidelines? A
framework for improvement. Journal of the American
Medical Associa tion, 282, 1458-1465.
doi:10.1001/jama.282.15.1458
[9] Carlsen, B., Glenton, C. and Pope, C. (2007) Thou shalt
versus thou shalt not: A meta-synthesis of GPs’ attitudes
to clinical practice guidelines. British Journal of General
Practice, 57, 971-978.
doi:10.3399/096016407782604820
[10] Farquhar, C.M., Kofa, E.W. and Slutsky, J.R. (2002) Clini-
cians’ attitudes to clinical practice guidelines: A system-
atic review. Medical Journal of Australia, 177, 502-506.
[11] Grimshaw, J., Eccles, M. and Tetroe, J. (2004) Imple-
menting clinical guidelines: Current evidence and future
implications. Journal of Cont inuing Educati on in the H e a l t h
Professions, 24, S31-S37. doi:10.1002/chp.1340240506
[12] Carlsen, B. and Norheim, O.F. (2008) “What lies beneath
it all?”—An interview study of GPs’ attitudes to the use
of guidelines. BMC Health Service Research, 8, 218.
doi:10.1186/1472-6963-8-218
[13] Institute for rational pharmacotherapy (2011).
http://www.irf.dk/dk/om_irf/irfs_historie/
[14] Danish Medical Association (2010) Doctors use of clini-
cal guidelines [Sådan bruger læger kliniske retningslin-
jer].
[15] Treweek, S., Flottorp, S., Fretheim, A., et al. (2005) Guide-
lines in general practice—Are they read and are they used?
Tidsskrift for Den norske Laegeforening, 125, 300-303.
[16] Woolf, S.H., Grol, R., Hutchinson, A., et al. (1999) Clini-
cal guidelines: Potential benefits, limitations, and harms
of clinical guidelines. British Medical Journal, 318, 527-
530. doi:10.1136/bmj.318.7182.527
[17] Organisation of general practitioners in Denmark (2011).
http://www.laeger.dk/portal/page/portal/LAEGERDK/Lae
gerdk/P_L_O/Om%20PLO/Tal%20og%20publikationer/
Statistik%20om%20almen%20praksis/praksist%C3%A6l
ling_2009.pdf
[18] Matteson, K.A., Anderson, B.L., Pinto, S.B., Lopes, V.,
Schulkin, J. and Clark, M.A. (2011) Surveying ourselves:
Examining the use of a web-based approach for a physi-
cian survey. Evaluation & the Health Profession s, 34, 448-
463. doi:10.1177/0163278710391086
[19] Braithwaite, D., Emery, J., de Lusignan, S. and Sutton, S.
(2003) Using the internet to conduct surveys of health
professionals: A valid alternative? Family Practice, 20,
545-551. doi:10.1093/fampra/cmg509
[20] Carlsen, B., Glenton, C. and Pope, C. (2007) Thou shalt
versus thou shalt not. A qualitative meta-synthesis of GPs’
attitudes to clinical practice guidelines. British Journal of
General Practice, 57, 971-978.
doi:10.3399/096016407782604820