Table 4 Barriers to the use of clinical prediction rules in practice identified in the literature

Knowledge

Awareness

Unaware:

• That CPR exists

• Of clinical problem or burden of clinical problem to which CPR applies

Unable to choose from multiple CPRs

Familiarity

Unfamiliar with CPR

Understanding

Lack of knowledge and understanding of the purpose, development and application of CPRs in general

Forgetting

Clinician forgets to use CPR despite best intentions

Attitudes

Negative beliefs about CPRs

Belief that:

• CPRs threaten autonomy

• CPRs are too ‘cook-book’, and oversimplify the clinical assessment process

• Clinical judgement is superior to CPRs

• Clinical judgement is not error prone

• Use of CPRs causes intellectual laziness

• The development of the CPR was biased

• Patients will deem clinicians less capable if using a CPR

• CPRs only apply to the less experienced

• Probabilities are not helpful for decision-making

Dislike of the term ‘rule’

Clinician had a false negative result when using a CPR in the past

Existing CPRs are not ready for clinical application

Outcome expectancy

Belief that:

• CPRs will not lead to improved patient or process outcomes

• The information provided by the CPR is not sufficient to alter clinical decisions

Clinician:

• Fears unintended consequences of use

• Is uncertain about using the CPR in patients with an atypical presentation

• Worries that improving efficiency threatens patient safety

Self-efficacy

Belief that the CPR is too difficult to use

Clinician uncertain how to interpret or use CPR output

Motivation

Clinician lacks motivation to use the CPR

Behaviour

Patient factors

Patients expectations are not consistent with the CPR

Features of the CPR

Clinician:

• Finds CPR too complicated

• Finds CPR ‘too much trouble’ to apply

Perception that:

• The CPR is not an efficient use of time

• The CPR does not have face validity or that important predictors are missing

• The CPR does not fit in with usual work flow or approach to decision-making

• The CPR is not generalisable to the clinician’s patient

• The CPR is static and does not consider the dynamic nature of clinical practice

• Overruling the CPR is often justified

Data required for the CPR is difficult to obtain

Environmental factors

Lack of:

• Time

• Organisational support

• Peer support for use

Perceived increased risk of litigation

Insufficient incentives or reimbursement for use of the CPR