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Patterns of ‘leakage’ in the utilisation of clinical guidelines: a systematic review
  1. Sharon Mickan1,
  2. Amanda Burls1,
  3. Paul Glasziou2
  1. 1Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, Oxford, UK
  2. 2Centre for Research in Evidence-Based Practice, Faculty of Health Sciences, Bond University, Gold Coast, Queensland, Australia
  1. Correspondence to Sharon Mickan, Department of Primary Health Care, International Program in Evidence Based Health Care, University of Oxford, 2nd Floor, 23-38 Hythe Bridge Street, Oxford OX1 2ET, UK; sharon.mickan{at}


Background Research evidence is insufficient to change physicians' behaviour. In 1996, Pathman developed a four step model: that physicians need to be aware of, agree with, adopt, and adhere to guidelines.

Objective To review evidence in different settings on the patterns of ‘leakage’ in the utilisation of clinical guidelines using Pathman's awareness-to-adherence model.

Methods A systematic review was conducted in June 2010. Primary studies were included if they reported on rates of awareness and agreement and adoption and/or adherence.

Results 11 primary studies were identified, reporting on 29 recommendations. Descriptive analyses of patterns and causes of leakage were tabulated and graphed. Leakage was progressive across all four steps. Median adherence from all recommendations was 34%, suggesting that potential benefits for patients from health research may be lost. There was considerable variation across different types of guidelines. Recommendations for drug interventions, vaccination and health promotion activities showed high rates of awareness. Leakage was most pronounced between adoption and adherence for drug recommendations and between awareness and agreement for medical management recommendations. Barriers were reported differentially for all steps of the model.

Conclusion Leakage from research publication to guideline utilisation occurs in a wide variety of clinical settings and at all steps of the awareness-to-adherence pathway. This review confirms that clinical guidelines are insufficient to implement research and suggests there may be different factors influencing clinicians at each step of this pathway. Recommendations to improve guideline adherence need to be tailored to each step.

  • Practice guideline
  • evidence-based practice
  • guideline adherence
  • protocols & guidelines
  • medical education & training
  • statistics & research methods

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Competing interests All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that (1) SM, AB and PG have support from the Department of Primary HealthCare, University of Oxford, and Bond University for the submitted work; (2) have no relationships with any companies that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) SM, AB and PG have no non-financial interests that may be relevant to the submitted work.

  • Ethics approval This study did not require ethical approval. It was funded from the working budget of the Department of Primary HealthCare and there were no additional sponsors. All authors had full access to all of the data, on a shared internal drive, and take responsibility for the integrity of the data and its accuracy.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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