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Open Access Highly Accessed Research article

Labour intensity of guidelines may have a greater effect on adherence than GPs' workload

Michael J van den Berg12*, Dinny H de Bakker12, Peter Spreeuwenberg1, Gert P Westert26, Jozé CC Braspenning3, Jouke van der Zee14 and Peter P Groenewegen15

Author Affiliations

1 NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands

2 Tilburg University, Faculty of Social and Behavioural Sciences, Tilburg, The Netherlands

3 UMC St Radboud, IQ healthcare, Nijmegen, The Netherlands

4 Maastricht University, Faculty of Health Sciences, Maastricht, The Netherlands

5 Utrecht University, Faculty of Social sciences, Utrecht, The Netherlands

6 RIVM, Netherlands Institute for Public Health and the Environment, Bilthoven, The Netherlands

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BMC Family Practice 2009, 10:74  doi:10.1186/1471-2296-10-74

Published: 28 November 2009



Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time.


Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.

A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines.


On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.

84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR = 0.46), while those that can save time have much higher adherence levels: OR = 1.55). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR = 3.13).


No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to.