Knowing the guidelines is not enough: Barriers to the implementation of gastrointestinal endoscopy guidelines in clinical practice

Clinical practice guidelines are essential to achieve quality in gastrointestinal (GI) endoscopy, yet a persistent gap separates what guidelines recommend from what is delivered at the point of care. Drawing on a body of adherence studies spanning a variety of procedures and conditions, this narrative review examines why endoscopists do not consistently follow the guidelines. The reported adherence across the literature is variable, and deviation occurs in both directions: as under-utilization, exemplified by under-surveillance of dysplastic Barrett's esophagus, and as over-utilization, exemplified by inappropriately short colonoscopy surveillance intervals. Knowledge of a recommendation is, by itself, a weak predictor of adherence; the clinician's belief in the recommendation and the surrounding clinical system are frequently decisive. Recommendations to improve implementation of guidelines are also suggested in this paper.