Abstract

Background. Despite their growing influence on patient management and outcomes, very little is known about patients’ perceptions of clinical guidelines. This is a significant omission, particularly for services advocating patient-centred care and informed decision making.

Objectives. To explore the knowledge and attitudes of women with menstrual disorders towards the use of evidence-based clinical guidelines for their condition.

Methods. Semi-structured interviews were conducted with women with menstrual disorders.

Results. Some women were not aware of the existence of clinical guidelines for their condition. Many were unsure as to their exact nature. The most consistent interpretation of guidelines was as a ‘set of rules’. Numerous positive aspects of the use of guidelines were identified, for example, ensuring quality and safety for patients, earlier diagnosis, reducing waiting times and improving continuity of care. Negative views involved seeing guidelines as a tool for rationing and concerns over inflexibility. Patients recognized that implementation of guidelines in general practice can be problematic, especially if resources are not made available. An unmet need for information became apparent in this group of patients. Many women felt that they should have access to guidelines that are being used in their medical care and that guidelines had the potential to act as an information resource for patients.

Conclusions. A patient-centred service should endeavour to increase patient awareness of the existence and use of clinical guidelines. A patient version of clinical guidelines may be useful in promoting patients involvement in decision making and may improve outcomes.

Introduction

There is some published literature concerning clinical guidelines, including their development,1,2 implementation,3 effect on practice,4,5 legal aspects6 and clinicians’ attitudes towards their use.7–11 Guideline development is based on research evidence, but is not value free,12 and public involvement is often invited in the process.

The potential role of guidelines in influencing patients’ choices is reflected in the definitions such as that adopted by the Institute of Medicine, which defines guidelines as ‘systematically developed statements to assist practitioner and patient (our italics) decisions about appropriate health care for specific clinical circumstances’.13 But while the patients’ perspective is sometimes considered especially in the development of national guidelines,12 very little is known about patients’ perceptions of them. Patients’ understanding and support is also important when guideline development affects the development and provision of services. A study that explored patients’ and physicians’ views about the Canadian Task Force guidelines on Preventative Health Care suggested that patients and physicians regard these guidelines with suspicion and that their rejection of the issued guidelines may stem from divergent value judgements.14 A study of the use of the breast cancer treatment guidelines in Australia showed that 37% of surgeons routinely issued patients with the relevant consumer’s guide,15 but there is no data on how patients perceived this information.

The question of how patients perceive clinical guidelines is important because some guidelines are perceived negatively by patients and doctors and also because of the important differences between what doctors and patients regard as good quality health care.16 Failing to consider the patient’s viewpoint risks limiting the utility of potentially good programmes, as they do not achieve optimal user adherence to recommendations.17 This research aims to explore the perception and attitudes of women with menstrual disorders towards evidence-based clinical guidelines introduced both in primary and in secondary care.

Methods

Leicestershire Research Ethics Committee approved the study, and all participants gave written consent. Participants for interviews were selected from women attending secondary care and managed according to an evidence-based clinical pathway.18 We used a maximum variation sampling to ensure the views of a range of women with menstrual disorders were represented in the study.19 The sampling frame included 200 women seen in secondary care because of menstrual abnormalities. Their symptom mix included heavy bleeding (79%), irregular bleeding (62%), dysmenorrhoea (42%) and premenstrual tension (28%). The duration of symptoms prior to attendance varied from >1 year (46%) to <6 months (31%). Participants’ age range was 22–54 years and parity range was 0–6. The majority (80%) were of white ethnicity. In total, 41% were in full-time employment; 15% were not in paid work and 19%, 29%, 2% and 5% were in managerial, clerical, small employer and lower supervisory jobs, respectively. In total, 55% had no structural pathology, 22% had fibroids, 2% had endometrial cancer and 2% had endometriosis. The treatments patients received following referral were surgical (21%) or medical (39%), while 40% discontinued or received no medical treatment at the end of 8 months. Using maximum variation sampling, we approached women at extremes of age and the spectrum of socio-economic group, different ethnicity, different symptoms, including extreme duration of symptoms, different diagnostic groups and receiving different treatment options. Two women approached declined to participate, one owing to family illness and the other because of time pressures; two women with similar characteristics were interviewed instead. The age range of participants was 22–54 years (Table 1).

TABLE 1

Demographic characteristics of participants

 Number of women 
Ethnicity 
    White 21 
    Non-White 
Socio-economic group 
    Managerial/professional 
    Clerical/intermediate 
    Small employer/own account worker 
    Lower supervisory/technical 
    Routine/semi-routine 
    Not working 
Diagnosis 
    No structural pathology 14 
    Polyps/fibroids 
    Endometrial carcinoma 
    Endometriosis 
Treatment 
    None 
    Medical treatment 
    Surgical treatment 11 
 Number of women 
Ethnicity 
    White 21 
    Non-White 
Socio-economic group 
    Managerial/professional 
    Clerical/intermediate 
    Small employer/own account worker 
    Lower supervisory/technical 
    Routine/semi-routine 
    Not working 
Diagnosis 
    No structural pathology 14 
    Polyps/fibroids 
    Endometrial carcinoma 
    Endometriosis 
Treatment 
    None 
    Medical treatment 
    Surgical treatment 11 

Participants were free to choose the day, time and venue for the interview. With three exceptions, women were interviewed in their homes. Participants were allocated a study number to ensure confidentiality. The prompt guide (Table 2) was developed through discussion following a literature review and modified after initial piloting. The interviews aimed to explore issues raised by participants.

TABLE 2

Interview prompt guide

Interview topics Patients’ concerns Questions to ask 
Attitudes towards the service received before attending hospital. Perceived interest of GP in problem Doctors and choice What sort of service did you receive from your doctor? Did your doctor know much about it? 
Problem taken seriously. Appropriate timely action Examination Was your doctor interested in your problem? Was your problem taken seriously? 
Hopes/expectations for outcome Information provision What did you want/expect your doctor to do? 
Resources GPs draw upon in making decisions. CME, Books, Peers, Experience, RCGP. Is this the way it should be? Patient's understanding of evidence-based pathways Education How do you think your GP decides on the best way to help you? How do they decide/keep up to date? What do you think about that? How do you feel about doctors using guidelines to decide your treatment? 
Are there any perceived benefits? Transparency Flexibility Good and bad things about this system 
Progression to resolution. Validation for menstrual disorders Clinical freedom Would it speed up treatment? Would it give more importance to period problems? 
Reducing inequalities and wait. Getting the best available treatment. Treatments proven to be of benefit Patient centred Is it fairer? Should patients have access to guidelines? 
The importance of a hospital visit Continuity of care Is going to the OPD important? Why? 
Is contact with the specialist in itself important? How did you feel What about seeing the specialist? 
Is the specialist a gatekeeper to investigation and surgical treatment Embarrassment What did you expect the specialist to do? 
Facilitation of progression Relationship What did you want the specialist to do? 
What resources to specialists draw upon in order to make decisions? CME, Books, Peers, Experience, RCOG Knowledge How does the specialist decide on the best way to treat you? How do they decide/keep up to date? What do you think about that? Is it different from the GP? 
Perceived differences between GP and hospital services. Time, knowledge, access to tests, provide prescription, access to surgery Value What is the difference between seeing the specialist and your GP 
Interview topics Patients’ concerns Questions to ask 
Attitudes towards the service received before attending hospital. Perceived interest of GP in problem Doctors and choice What sort of service did you receive from your doctor? Did your doctor know much about it? 
Problem taken seriously. Appropriate timely action Examination Was your doctor interested in your problem? Was your problem taken seriously? 
Hopes/expectations for outcome Information provision What did you want/expect your doctor to do? 
Resources GPs draw upon in making decisions. CME, Books, Peers, Experience, RCGP. Is this the way it should be? Patient's understanding of evidence-based pathways Education How do you think your GP decides on the best way to help you? How do they decide/keep up to date? What do you think about that? How do you feel about doctors using guidelines to decide your treatment? 
Are there any perceived benefits? Transparency Flexibility Good and bad things about this system 
Progression to resolution. Validation for menstrual disorders Clinical freedom Would it speed up treatment? Would it give more importance to period problems? 
Reducing inequalities and wait. Getting the best available treatment. Treatments proven to be of benefit Patient centred Is it fairer? Should patients have access to guidelines? 
The importance of a hospital visit Continuity of care Is going to the OPD important? Why? 
Is contact with the specialist in itself important? How did you feel What about seeing the specialist? 
Is the specialist a gatekeeper to investigation and surgical treatment Embarrassment What did you expect the specialist to do? 
Facilitation of progression Relationship What did you want the specialist to do? 
What resources to specialists draw upon in order to make decisions? CME, Books, Peers, Experience, RCOG Knowledge How does the specialist decide on the best way to treat you? How do they decide/keep up to date? What do you think about that? Is it different from the GP? 
Perceived differences between GP and hospital services. Time, knowledge, access to tests, provide prescription, access to surgery Value What is the difference between seeing the specialist and your GP 

CME, Continuing Medical Education; OPD, Outpatient Department; RCGP, Royal College of General Practitioners; RCOG, Royal College of Obstetricians and Gynaecologists.

All interviews were audiotaped, transcribed verbatim and analysed according to the principles of the constant comparative method19 supported by QSR NUD*IST v4 software package.20 The first stage of analysis was the generation of open codes from the first six interviews. An open code was assigned to each event in the data. The codes were then organized into categories of recurring themes constituting a coding frame, capable of accommodating all the data.21 Interviews were conducted in batches of six concurrently with analysis of earlier transcripts. This allowed emergent themes to be explored in subsequent interviews. The coding frame was modified when necessary to accommodate new data and all changes were logged. It appeared that after 18 interviews no new themes were emerging, the point of ‘theoretical saturation’ being reached.19 One more batch of six interviews was undertaken to test this assertion, making the total number of interviews 24.

Results

Defining guidelines and their function

Most women were able to explain what they understood by clinical guidelines, although five women found it very difficult and were unable to provide a description. Two women were familiar with the use of guidelines in their own place of work.

Guidelines as rules.

The most common interpretation concerned ‘rules’ to be adhered to, with 10 women constructing guidelines in this way. The description often expressed a degree of strictness and rigidity:

506: Sets of procedures that you have to follow … as in Health and Safety and Basic Food Hygiene, you can’t just sort of do your own thing, you have got to follow the rules.

A predefined process.

Women often expanded on their interpretation to include a description of the kinds of processes involved in using guidelines as care proceeding in a sequential fashion:

60: I s'pose it's like a flow chart … and they map the patients on this flowchart …

Guidelines were seen as signposts used to direct patients towards secondary care in predefined ‘footsteps’ and in response to them fitting sets of criteria or ‘similarities’. There were three accounts that linked this with rationing:

735: You read that many things that are open to some and not to others so like I didn't know whether they're kind of ruled by that.

Ensure quality of care.

Two participants connected guidelines with ensuring quality of care. One woman discussed guidelines in the use of a chaperone as an example of patient and doctor protection.

30: … not necessarily rules, but a set of bullet points whereby … erm … you know, if you've got this kind of thing then you need to be doing such and such I would see it as that … or p'raps safety … safety guidelines that, that kind of thing.

How guidelines influence doctors’ decisions?

The interviews sought to explore patients’ perceptions of doctors’ decision making and the extent to which patients feel guidelines can usefully (or otherwise) inform this process. Most participants found this area difficult. Only a minority, however, were indifferent to clinical processes, indicating that doctors’ decision making did not or should not concern them:

581: Well I just think well he's the doctor, you know, I'll just try that, you know, go along with that.

Accounts of decision making were of two broad types. The first construction was of a definite patient-centred process where individual patients had distinct problems. Addressing need thus becomes dependent on the doctor's personal knowledge of the patient:

3055: … when I went and he's looked at it and thought, ‘Well, she's never been to me before and all of a sudden she's got these problems and, you know, she is forty’, erm … so p'raps he's took that all into consideration … And that's why … you know he dealt with it like he did.

The second construction was based on the premise that women with menstrual disorders are essentially all the same:

16: I s'pose he can just go on a … his other patients and … if any of them have had the same problem and … you know, it's all in the sort of the same routine really isn't it?

In this scenario, the most important aspect relevant to decision making is the doctor's previous experience and knowledge of other women with similar problems. Participants did not volunteer guidelines as the basis of decision making in everyday practice. Accordingly, women presenting both types of account were likely to view doctors’ treatment choices as imprecise, inexact or speculative but perhaps not totally unstructured or haphazard. Patients were dissatisfied and somewhat perplexed by what sometimes appeared as a process of elimination:

1: So it's all done on what information you give them and trial and error … so you are a guinea pig aren't you?

Some attributed what they see as an unsatisfactory process to inadequate knowledge or to financial constraints:

754: I think you get a quick fix, a cheap option and a quick fix and ‘we'll see if that works'.

A few patients expressed a hope or belief that guidelines may help remedy this through providing an educational update or raising awareness, but this was tempered by scepticism that guidelines may not be practical because of the infinite medical conditions for which they will be needed:

8: Keeping up to date with current facilities available and medicines available and any sort of procedures and, you know, success rates with these things.

There were concerns that guidelines would be unworkable. Patients expressed concern that deferring to guidelines can impair patient–doctor relationships; in that, it reduces patients’ confidence but also because of a potential to create conflict between patients and doctors:

754: And they'd just be sitting there looking through … I don't know if that would actually give you the confidence.

32: I know a lot of people would start misusing that, I mean, ‘Well it says here I can do that’. you know, and then whether he has actually got, what's the, the backing in terms of the NHS kinda, of being able to send so many patients there, that would be sort of a clashing point.

Guidelines as a way of validating the problem

Thirteen women interviewed indicated that they had struggled to prove the legitimacy of their problem to the doctor. For most, this involved several visits over months or years.

646: you know, that you've got a problem and you … you have to try and get that problem over to the doctor, it's a bit like being on trial really I think. You know, you have to try and convince that doctor that you are ill … to get past them to get into the hospital and I don't think that's right.

Four women (all in the younger age range) reported feeling a sense of isolation, leading to self-doubt about the authenticity of their complaints and to them seeking assurances from friends and colleagues:

81: But then you think, ‘Well, people think I'm … making a big deal out of it, is it as bad as that?’

Many thought that the introduction of a guideline for menstrual disorders would reduce the need for patients to have to ‘prove their case’ in this way and consequently that guidelines would improve access to care, by providing external validation of the complaint, reassuring women that they were not alone in their experience:

60: … I think in a way you start to understand that … it's not just you … and that they're taking you seriously because they are following a pattern.

Guidelines can facilitate or hinder progress

Some patients regarded guidelines with optimism and hoped that once a patient has convinced her doctor of the validity of her complaint she could begin to progress towards resolution. Those women felt that there were a number of advantages to guideline-based care at all stages, starting with earlier diagnosis. The optimism stemmed from a view of guidelines as allowing patients to view their own progress in a more structured health care aimed at cure:

754: That's like … erm a proper starting point isn't it? Erm … there is a particular, you know, a goal of success at the end of it, some sort of direction erm, which I think would certainly be lacking in my case.

Others were more sceptical and viewed guidelines as a tool for procrastination by the health care providers. Those women saw the potential for guidelines to be used as a tool to limiting access:

16: Erm … but if you're continuously having to go back … and nothing's helping and, you know, you're not getting anywhere, because the doctors are following these guidelines that they should do this … before they refer … then er … doesn't help you does it?

Guidelines may ensure uniformity

Women recognized that the care they receive can vary according to several factors, including the degree of priority assigned to the clinical condition and the cost of treatment. Some felt that they were being managed according to an undisclosed list of priorities. Many felt that guidelines can ensure a uniform standard of care.

60: … but if you follow certain guidelines for the, for the multitude, as a whole, you're gonna get more people having proper care, and then the odd few then still having the odd few that still don't match the guidelines and other people getting … feel the care they got wasn't satisfactory.

Guidelines can be inflexible

Those women who gave accounts of decision making as a patient-centred process expressed concerns about standardization. They tended to view guidelines as interfering with decisions that need to be tailor made for the individual patient and restricting doctors’ choices and thus impairing the clinical process, in some cases making the situation completely untenable:

45: Erm The only thing is er every woman's body is different.

623: I think it would help if they were allowed to move beyond those guidelines.

Women were also concerned about the impact of guidelines on their own ability to choose:

581: Well while, these guidelines are what you're working to, if there's something there I don't agree with then where do you go from there?

Information

More than half the participants (n = 15) believed that patients should be able to access the guidelines that their doctors use. Most thought that this should be offered routinely. Women indicated that knowledge of the health care process and their place in the system would increase their sense of ownership:

30: … you would know what route you were taking, and where you were on that route.

Guidelines were not seen as a tool to circumvent doctors’ advice. But access to the guidelines, by improving transparency of the decision making, was seen to provide confirmation that patients are being taken seriously and improved confidence in the management plan.

754: Well, you'd be … erm more reassured that erm … you are actually following a path towards your goal of, of being better.

On the other hand, some women felt that it was only necessary for patients to see the guidelines when the patient was not making adequate progress. In this context, guidelines were seen as delimiting what care could be provided in order to justify the doctor's management, not outlining a range of choices that could be abused.

570: … I s'pose some people might sort of add them to their symptoms if they knew what was needed to get things pushed through quicker.

Three participants were unsure whether patients would benefit from actually seeing the guidelines but would like to know that their doctor is using them. Three thought that guidelines should not be offered to patients at all because of fear of provoking anxiety or that patients may have difficulty understanding the content of the guidelines:

60: I just I think it would be above you, above your head. And then, if you don't understand it, you'd worry the fact that you don't understand what's happening to you.

Discussion

The main emerging theme from this study is that women attempting to access health care for a menstrual disorder face a number of difficulties. First, there is a need to convince their doctor of the legitimacy of the problem. Many women reported the need for repeated attendances before their problem was accepted as genuine. This influenced patients’ perception of the role of clinical guidelines, with some hoping that guidelines would facilitate access, but others were fearful that they would be used as a means of rationing. Clearly, much will depend on how the guidelines are drawn and explained to patients. Guidelines are issued to aid clinical decision making and may, in the process, facilitate or restrict access of some groups to particular treatment options. This can create frustration, especially as it may not be sufficiently clear to patients. More effort is needed to explain to patients the rationale on which guidelines are based and also to assess the impact of guidelines on different patient groups. The availability of a consumer version of guidelines, particularly where it includes recommendations on how patients can identify and assess disease severity and access care, might address some of the issues raised by patients as well as issues of labelling and prejudice among physicians.

Patients’ perception of clinical guidelines was also influenced by whether they viewed menstrual disorders as being unique to the individual patient and requiring personal treatment or as a process in which women experience similar symptoms requiring similar treatment. Not surprisingly, the different emphases resulted in contrasting views of the role of guidelines. Doctors’ knowledge of the individual patient as a factor in decision making was valued, but only a few examples were presented of how it was actuated. Regardless of which explanation was dominant in women's accounts, many experienced doctors’ decision making as a process of ‘trial and error’ in which they became ‘guinea pigs’, clearly an unsatisfactory situation. There appears to be a greater need for doctors to explain the concepts of a therapeutic trial and clinical uncertainty and also a need to develop better predictors of successful outcome in those areas where such predictors are lacking or weak. It is important to recognize that repeat cycles of therapeutic trial can prolong patient suffering, resulting in frustration and diminishing trust.

Many patients had some understanding of the concept of guidelines but not in the context of clinical decision making. The use of clinical guidelines in routine practice was generally well received. Women identified a number of benefits to guideline-based management and it is interesting to note that their ideas are in accord with those usually presented in connection with the use of guidelines, such as ensuring the quality and uniformity of health care and as a source of educational material for doctors.4 Women felt that the use of guidelines also had the potential to assist with some of the difficulties they face when accessing health care, by providing external validity for the complaint and facilitating progress. Participants also recognized that guideline-based care is not a panacea. The potential problems they highlighted, such as inflexibility, are in agreement with physicians’ views.7

Patients require not only clinical information but also an understanding of health care process and where they are in the system.22 Many of the women interviewed indicated that they would find it helpful to be able to see the guidelines used by their doctors. Beaulieu et al.14 argued for a better realization that people are sensitive to the limits of scientific knowledge and that many physicians and patients regard science as expressed through evidence-based guidelines with suspicion. While this may be more evident in the area of preventative medicine, our research suggests that women with menstrual disorders were inclined to view guidelines pragmatically and to evaluate their potential for achieving resolution.

A potential methodological concern may be that the interviews were conducted and analysed by a health professional.23 For transparency, this was made explicit to participants before the interview and it is possible that participants’ accounts became more focussed on selected aspects of their care.

It is also important to point out that women’s perceptions of guidelines for menstrual disorders may well be different to the views of other groups of patients to different conditions, and therefore, the findings in this study should not be extrapolated to other clinical areas. Nevertheless, the findings do show that patients have definite views on clinical guidelines. These views need to be understood and taken into account in promoting the wider use of evidence-based guidelines in health care.

There is a need to increase awareness among patients about the existence, nature and role of clinical guidelines. It is also possible that better patient education may improve the uptake and use of guidelines.24 The dissemination of patient versions of guidelines could facilitate partnership with patients and promote more patient-centred care, especially relevant in conditions such as menstrual disorders where treatment decisions are often made by doctors on the basis of subjective symptoms with a focus on improving the quality of life for patients. Using guidelines to involve patients in decision making may lead to improved outcomes. More research is needed to explore how best to prepare and present guidelines to those patients who may wish to access them and, subsequently, to assess their experience. Particularly relevant to patients are issues of access to services, identification of disease and assessment of severity. Guidelines will be especially useful in this area because patients will need to address some or all these issues before they present for medical help. Guidelines may also have an educational role that enables patients’ compliance.

Declaration

Funding: Policy and Practice R&D Programme. NHS-Trent Regional Office.

Ethical approval: Leicestershire Research Ethics Committee.

Conflicts of interest: The views expressed are those of the authors, and the sponsor had no influence over the execution of the research, collating the results or data analysis.

We acknowledge the contribution of Mr NJ Naftalin, Emeritus Consultant Gynaecologist, Leicester Royal Infirmary, in the design and conduct of this research.

Contribution to authorship: SJ performed the study and undertook data collection and analysis; AR, RB and AS contributed to study design and to the manuscript. MH obtained funding, led the design of the study, contributed to data analysis and co-wrote the manuscript. All authors approved the final version.

Condensation: Women are inclined to view clinical guidelines pragmatically, based on their potential impact on care provision. There is a need to better inform patients about the value of clinical guidelines.

References

1
Shekelle
PG
Ortiz
E
Rhodes
S
, et al.  . 
Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated?
JAMA
 , 
2001
, vol. 
286
 (pg. 
1461
-
7
)
2
Shekelle
PG
Woolf
SH
Eccles
M
Grimshaw
J
Clinical guidelines: developing guidelines
Br Med J
 , 
1999
, vol. 
318
 (pg. 
593
-
6
)
3
Young
JM
Ward
JE
Evidence-based medicine in general practice: beliefs and barriers among Australian GPs
J Eval Clin Pract
 , 
2001
, vol. 
7
 (pg. 
201
-
10
)
4
Woolf
SH
Grol
R
Hutchinson
A
Eccles
M
Grimshaw
J
Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines
BMJ
 , 
1999
, vol. 
318
 (pg. 
527
-
30
)
5
Grimshaw
JM
Russell
IT
Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations
Lancet
 , 
1993
, vol. 
342
 (pg. 
1317
-
22
)
6
Hurwitz
B
Legal and political considerations of clinical practice guidelines
BMJ
 , 
1999
, vol. 
318
 (pg. 
661
-
4
)
7
Farquhar
CM
Kofa
EW
Slutsky
JR
Clinicians’ attitudes to clinical practice guidelines: a systematic review
Med J Aust
 , 
2002
, vol. 
177
 (pg. 
502
-
6
)
8
Farquhar
CM
Kofa
E
Power
ML
Zinberg
S
Schulkin
J
Clinical practice guidelines as educational tools for obstetrician-gynecologists
J Reprod Med
 , 
2002
, vol. 
47
 (pg. 
897
-
902
)
9
McEwen
A
Akotia
N
West
R
General practitioners’ views on the English national smoking cessation guidelines
Addiction
 , 
2001
, vol. 
96
 (pg. 
997
-
1000
)
10
Newton
J
Knight
D
Woolhead
G
General practitioners and clinical guidelines: a survey of knowledge, use and beliefs
Br J Gen Pract
 , 
1996
, vol. 
46
 (pg. 
513
-
7
)
11
Smith
L
Walker
A
Gilhooly
K
Clinical guidelines of depression: a qualitative study of GPs’ views
J Fam Pract
 , 
2004
, vol. 
53
 (pg. 
556
-
61
)
12
NICE
The Guidelines Manual
 , 
2007
London
National Institute for Health and Clinical Excellence
 
13
Field
MJ
Lohr
KN
Guidelines for Clinical Practice: From Development to Use
 , 
1992
Washington, DC
Committee on Clinical Practice Guidelines, Institute of Medicine
14
Beaulieu
MD
Hudon
E
Roberge
D
, et al.  . 
Practice guidelines for clinical prevention: do patients, physicians and experts share common ground?
CMAJ
 , 
1999
, vol. 
161
 (pg. 
519
-
23
)
15
Carrick
SE
Bonevski
B
Redman
S
, et al.  . 
Surgeons’ opinions about the NHMRC clinical practice guidelines for the management of early breast cancer
Med J Aust
 , 
1998
, vol. 
169
 (pg. 
300
-
5
)
16
Garson
A
Jr
Yong
CM
Yock
CA
McClellan
MB
International differences in patient and physician perceptions of “high quality” healthcare: a model from pediatric cardiology
Am J Cardiol
 , 
2006
, vol. 
97
 (pg. 
1073
-
5
)
17
McInnes
E
Askie
L
Evidence review on older people's views and experiences of falls prevention strategies
Worldviews Evid Based Nurs
 , 
2004
, vol. 
1
 (pg. 
20
-
37
)
18
Julian
S
Naftalin
NJ
Clark
M
, et al.  . 
An integrated care pathway for menorrhagia across the primary-secondary interface: patients’ experience, clinical outcomes, and service utilisation
Qual Saf Health Care
 , 
2007
, vol. 
16
 (pg. 
110
-
5
)
19
Strauss
A
Corbin
J
Basics of Qualitative Research: Grounded Theory Procedures and Techniques
 , 
1990
Newbury Park, CA
Sage
20
Gahan
C
Hannibal
M
Doing Qualitative Analysis With QSR NUD*IST 4
 , 
1998
London
Sage
21
Seale
C
The Quality of Qualitative Research
 , 
1999
Thousand Oaks, CA
Sage
22
Preston
C
Cheater
F
Baker
R
Hearnshaw
H
Left in limbo: patients’ views on care across the primary/secondary interface
Qual Health Care
 , 
1999
, vol. 
8
 (pg. 
16
-
21
)
23
Richards
H
Emslie
C
The ‘doctor’ or the ‘girl from the University'? Considering the influence of professional roles on qualitative interviewing
Fam Pract
 , 
2000
, vol. 
17
 (pg. 
71
-
5
)
24
Hobbs
FD
Erhardt
L
Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey
Fam Pract
 , 
2002
, vol. 
19
 (pg. 
596
-
604
)