General practitioners' reasons for the failure of a randomized controlled trial (the TIGER trial) to implement epilepsy guidelines in primary care

Purpose: To explore reasons for the failure of a randomized controlled trial to influence implementation of epilepsy guidelines in primary care, and to generate theory about likely contexts in which guidelines would lead to changes in clinician behavior. Methods: Qualitative study based on focus groups and a single in-depth interview. Participants included 47 primary health care staff selected from a purposive sample of 13 urban and rural general practices. Results: The key reason for the lack of implementation of the Scottish Intercollegiate Guidelines Network epilepsy guideline was an established pattern of general practitioner behavior, supported by practice staff, with which there was little perceived need to change. Secondary to this was a lack of knowledge of the existence and/or content of the guideline and perceived difficulties in implementing them in practice stemming from resource constraints and possible patient resistance. The individual behavior of clinicians was therefore rooted in wider service structures and policies. Conclusions: Guidelines may be more likely to be implemented where there are perceived problems with current service delivery. Attempts to facilitate the implementation of guidelines could also focus on areas where there is already a perceived need for guidance or a disruption in one of the underlying variables that maintain the health professional's role and practice. They may also be more likely where initiatives are focused more widely than individual physician behavior and are more broadly directed toward redesigning the wider care delivery systems by incorporating other providers to provide care coordination, enhancing patient self-management, and using information technology tools.