Clinical practice guidelines (CPGs) are considered as one of the most powerful and effective tools for the promotion of evidence-based medicine (EBM) (1). CPGs are expected to reduce medical costs by minimizing unnecessary variations in treatment and improve the outcome of patient care (2), and an analysis of empirical studies has confirmed their effectiveness (3). Many countries have been actively promoting the development of CPGs through the provision of financial and administrative support (4). In Korea, various academic associations have been developing CPGs independently and sporadically. In 2006, the Korean Academy of Medical Sciences (KAMS), which represents 130 medical academic societies, reported that 52 CPGs have been developed in Korea to the date, and since 2007, the Korean Ministry for Health, Welfare and Family Affairs has been providing KAMS with financial support for the development and implementation of CPGs by professional groups. As a result, KAMS has directed the development and dissemination of EBM-based CPG for asthma, depression, and breast cancer.

Despite efforts to encourage them, several studies have reported that CPG implementation at clinical sites remains low (5, 6). According to Farquhar et al., clinicians view CPGs as anti-intellectual, standardizing practice at around average levels, preventing discretion in individual cases, cost-cutting, limiting innovation and clinical freedom, and encouraging litigation; and these negative attitudes are critical barriers toward CPG implementation (7). Representative groups of Korean physicians such as the Korean Medical Association have adopted a skeptical or negative attitude toward CPG. In particular, their belief is that CPG are often used as a basis of retrenchment in insurance claims and lead to an increase in regulations, which limit their flexible use for the diversely different situations encountered in clinical practice.

CPGs can be difficult to apply, and the use of CPGs by physicians in clinical practice has not been sufficiently studied (8). In order to promote CPG implementation, the factors that affect clinicians' resistance toward them must be identified and addressed. Several previous studies have investigated the relationship between CPG implementation and clinician attitudes (9) and reported associations between clinician attitude toward CPGs and clinician characteristics (10), patient characteristics (11), and the passage of time (12).

Cabana et al. (13-15) have aimed to identify specific barrier factors to CPGs implementation, including lack of awareness and familiarity toward CPG, lack of agreement, lack of self-efficacy, lack of outcome expectancy, inertia of previous practice, and care environment. In applying this theoretical model to a survey of 829 pediatricians, factors such as lack of agreement, lack of self-efficacy, and lack of outcome expectancy were found to be negatively associated with CPG implementation (16). Although their research was successful in expanding the explanatory power for the CPG compliance-related factors beyond the variables of clinician attitudes, they did not include these variables in their analytic model with an integration of such variables still unresolved.

Furthermore, previous studies have primarily been carried out in Western countries, where healthcare practices and attitudes differ from Korea. The present study aims to develop a comprehensive analysis model that includes both clinician attitudes toward CPGs and barriers to CPG implementation. As a secondary objective, we have attempted to determine whether the attitudes and barriers affecting CPG implementation remain similar across countries with different cultures and healthcare systems.

The results of present study showed that the degree of awareness and familiarity and agreement with CPGs was very high among our respondents. In contrast, the degree of self-efficacy in implementing CPGs was relatively low. Overall, 84.6% of respondents were aware of CPGs; however, only 48.8% of the total respondents claimed to recognize CPGs very well. This finding is similar to that of a previous study conducted in Ontario, in which 86% of the physicians surveyed were familiar with CPGs, but only 5% were familiar with the details of CPGs (17). These results suggest that publicity and activities aimed at actively delivering the detailed contents of CPGs are the most important for facilitating of CPG implementation, because physicians are lacking in detailed knowledge regarding CPGs rather than awareness of CPGs in general. Our identification of low self-efficacy in implementing CPGs as a major problem of implementation is also consistent with previous studies which have reported that the specific skills required for CPG implementation at clinical sites are relatively lower than physicians' awareness of and familiarity with CPGs (16, 18, 19). Therefore, comprehensive practice manuals should be provided to clinicians to promote their familiarity with new guidelines.

The highly expected outcomes of CPGs included the items of 'increase in the quality of patient care' and 'improvement in systematic education and communication', and outcome expectancy among independent or group practice clinicians was higher than among clinicians employed by university hospitals. This disparity may be due to independent or group practice clinicians having less access to systematic support for medical decisions in the provision of patient care, and it indicates the importance of meeting the demand of these clinicians. We observed CPG implementation to be quite high, with 72.5% of respondents regularly or moderately implementing CPGs. However, clinicians regularly implementing CPGs account for only 11.7% of the entire sample, and thus, the systematic and routine use of CPGs remains low. Similar findings have been previously reported (20). Several studies have reported that the mere development and dissemination of CPGs could rarely lead to changes in clinical practice (20-23). And the present study supports these reports.

Overall, in this study, positive attitudes were more prevalent than negative attitudes toward CPGs. However, compared to other studies (10, 24) that adopted the same survey instruments concerning clinicians' attitude toward CPGs (9), we observed a similar rate of response for positive aspects but higher response rates for negative aspects in the present study. Physician attitudes toward CPGs are affected by the socio-cultural characteristics and healthcare systems of their country. And this result indicates that Korean clinicians remain highly concerned about the negative influence of CPGs. Korean clinicians have long been apprehensive of the Korea Republic of Government applying a strong regulation policy toward CPGs in light of their previous experience with the national health insurance system, which operates under strong cost containment regulations. A survey of Canadian oncologists' attitudes toward CPGs also found that their perception as being intended to reduce healthcare costs was the most prevalent negative attitude toward CPGs (10). Therefore, regulatory agencies' ability to reach an appropriate compromise between service quality and cost containment is necessary to enhance CPG compliance.

Furthermore, the present study included attitude variables toward CPGs and confirmed that CPG implementation is high when positive attitudes are dominant (10). Because it includes both barrier factors and attitude variables, the regression model established in the present study is by far the most comprehensive model for the analysis of factors related to CPGs, and this study has verified that these factors are relevant to CPG implementation.

Although this study has produced meaningful results, it has several limitations. The primary limitation of this study is that data were collected through convenient sampling, leading to the problem of representativeness. Clinicians were not generally cooperative toward participating in the survey, and this study was based only on the responses of those who were willing to participate. The clinicians who participated in the survey were more likely to be familiar with CPG development than those who did not, indicating that the findings of this study may not be representative of the general consensus of all clinicians in Korea. In support of this hypothesis, we observed higher recognition levels and positive attitudes toward CPGs than anticipated. Nevertheless, the negative concerns and low level of self-efficacy and knowledge reported by clinicians surveyed in this study indicate that education programs are necessary for Korean clinicians on the importance and benefits of CPGs. Additionally, the survey instrument was originally developed in another language, and data from 2 yr were pooled for analysis because of similarity of responses across the 2 yr. The effect of translation and the discrepancy in response time may also be pointed out as limitations of the present study. In the future, research on CPGs should be conducted on a more representative sample, and studies should examine whether physicians in different socio-cultural settings show similar propensities toward CPG.

Clinician's awareness and familiarity, agreement, and self-efficacy in implementing CPGs and the prevalence of positive attitudes toward CPGs have been consistently identified as important factors affecting CPG implementation. And the present study has further verified through the development of a comprehensive assessment tool that addresses both barriers and attitudes toward CPGs. Most of previous studies regarding CPGs were conducted in Western countries, and the similarity of the findings of this Korean study may imply that the aforementioned variables are globally identifiable factors independent of sociocultural characteristics and healthcare systems. Furthermore, we have shown that global principles in the promotion of CPG implementation and propagation can be established. Sharing the results of detailed propagation strategies attempted by various countries will aid in the continuous improvement of CPG implementation methods.