Guideline Implementation In Primary Care Research Articles

Economic evaluation of guideline implementation in primary care: a systematic review.

To review the economic evaluation of the guideline implementation in primary care. Medline and Embase. Electronic search was conducted on April 1, 2019, focusing on studies published in the previous ten years in developed countries about guidelines of non-communicable diseases of adult (≥18 years) population, the interventions targeting the primary care provider. Data extraction was performed by two independent researchers using a Microsoft Access based form. Among the 1338 studies assessed by title or abstract, 212 qualified for full text reading. From the final 39 clinically eligible studies, 14 reported economic evaluation. Cost consequences analysis, presented in four studies, provided limited information. Cost-benefit analysis was reported in five studies. Patient mediated intervention, and outreach visit applied in two studies showed no saving. Audit resulted significant savings in lipid lowering medication. Audit plus financial intervention was estimated to reduce referrals into secondary care. Analysis of incremental cost-effectiveness ratios was applied in four studies. Educational meeting evaluated in a simulated practice was cost-effective. Educational meeting extended with motivational interview showed no improvement; likewise two studies of multifaceted intervention. Cost-utility analysis of educational meeting supported with other educational materials showed unfavourable outcome. Only a minor proportion of studies reporting clinical effectiveness of guideline implementation interventions included any type of economic evaluation. Rigorous and standardized cost-effectiveness analysis would be required, supporting decision-making between simple and multifaceted interventions through comparability.

General practitioners\u2019 views on managing knee osteoarthritis: a thematic analysis of factors influencing clinical practice guideline implementation in primary care

BackgroundOsteoarthritis (OA) is diagnosed and managed primarily by general practitioners (GPs). OA guidelines recommend using clinical criteria, without x-ray, for diagnosis, and advising strengthening exercise, aerobic activity and, if appropriate, weight loss as first-line treatments. These recommendations are often not implemented by GPs. To facilitate GP uptake of guidelines, greater understanding of GP practice behaviour is required. This qualitative study identified key factors influencing implementation of these recommendations in the primary-care setting.MethodsSemi-structured interviews with eleven GPs were conducted, transcribed verbatim, coded by two independent researchers and analysed with an interpretive thematic approach using the COM-B model (Capability/Opportunity/Motivation-Behaviour) as a framework.ResultsEleven themes were identified. Psychological capability themes: knowledge gaps, confidence to effectively manage OA, and skills to facilitate lifestyle change. Physical opportunity themes: system-related factors including time limitations, and patient resources. Social opportunity theme: influences from patients. Reflective motivation themes: GP’s perceived role, and assumptions about people with knee OA. Automatic motivation themes: optimism, habit, and unease discussing weight. The findings demonstrated diverse and interacting influences on GPs’ practice.ConclusionThe identified themes provide insight into potential interventions to improve OA management in primary-care settings. Key suggestions include: improvements to OA clinical guidelines; targeting GP education to focus on identified knowledge gaps, confidence, and communication skills; development and implementation of new models of service delivery; and utilising positive social influences to facilitate best-practice behaviours. Complex, multimodal interventions that address multiple factors (both barriers and facilitators) are likely to be necessary.

General practitioners' views on managing knee osteoarthritis: factors influencing clinical practice guideline implementation in primary care

General practitioners' views on managing knee osteoarthritis: factors influencing clinical practice guideline implementation in primary care

Results from the CLUES study: a cluster randomized trial for the evaluation of cardiovascular guideline implementation in primary care in Spain

BackgroundThe implementation of evidence-based clinical practice guidelines (CPG) can improve patients care. To date, the impact of implementation strategies has not been evaluated in our context. This study is aimed to evaluate the effectiveness of a multifaceted tailored intervention targeting clinician education for the implementation of three cardiovascular risk-related CPGs (type 2 diabetes, hypertension and dyslipidemia) in primary care at the Basque Health Service compared with usual implementation.MethodsWe conducted a cluster randomized controlled trial in two urban districts with 43 primary care units (PCU). Data from all patients diagnosed with diabetes, hypertension and all those eligible for coronary risk (CR) assessment were included.In the control group, guidelines were introduced in the usual way (by email, intranet and clinical meetings). In the intervention group, the implementation also included a specific website and workshops.Primary endpoints were annual HbA1c testing (diabetes), annual general laboratory testing (hypertension) and annual CR assessment (dyslipidemia). Secondary endpoints were process, prescription and clinical endpoints related with guideline recommendations. Analysis was performed at a PCU level weighted by cluster size.ResultsSignificant differences between groups were observed in primary outcomes in the dyslipidemia CPG: increased CR assessment for both women and men (weighted mean difference, WMD, 13.58 and 12.91%). No significant differences were observed in diabetes and hypertension CPGs primary outcomes. Regarding secondary endpoints, annual CR assessment was significantly higher in both diabetic and hypertensive patients in the intervention group (WMD 28.16 and 27.55%). Rates of CR assessment before starting new statin treatments also increased (WMD 23.09%), resulting in a lower rate of statin prescribing in low risk women. Diuretic prescribing was higher in the intervention group (WMD 20.59%). Clinical outcomes (HbA1c and blood pressure control) did not differ between groups.ConclusionsThe multifaceted implementation proved to be effective to increase the CR assessment and to improve prescription, but ineffective to improve diabetes and hypertension related outcomes. In order to obtain real improvements when cardiovascular issues are tackled, perhaps other or additional interventions need to be implemented besides education of professionals.Trial registrationCurrent Controlled Trials, ISRCTN 88876909 (retrospectively registered on January 13, 2009)

Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study.

Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care.

Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial.

Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions. Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.

The CLUES study: a cluster randomized clinical trial for the evaluation of cardiovascular guideline implementation in primary care.

BackgroundThe appropriate care for people with cardiovascular risk factors can reduce morbidity and mortality. One strategy for improving the care for these patients involves the implementation of evidence-based guidelines. To date, little research concerning the impact of such implementation strategies in our setting has been published. Aims. To evaluate the effectiveness of a multifaceted tailored intervention in the implementation of three cardiovascular risk-related guidelines (hypertension, type 2 diabetes and dyslipidemia) in primary care in the Basque Health Service compared with usual implementation.Methods/DesignA two-year cluster randomized clinical trial in primary care in two districts in the Basque Health Service. All primary care units are randomized. Data from all patients with diabetes, hypertension and those susceptible to coronary risk screening will be analyzed.Interventions. The control group will receive standard implementation. The experimental group will receive a multifaceted tailored implementation strategy, including a specific web page and workshops for family physicians and nurses.Endpoints. Primary endpoints: annual request for glycosylated hemoglobin, basic laboratory tests for hypertension, cardiovascular risk screening (women between 45–74 and men between 40–74 years old). Secondary endpoints: other process and clinical guideline indicators.Analysis: Data will be extracted from centralized computerized medical records. Analysis will be performed at a primary care unit level weighted by cluster size.DiscussionThe main contribution of our study is that it seeks to identify an effective strategy for cardiovascular guideline implementation in primary care in our setting.Trial registrationCurrent Controlled Trials, ISRCTN88876909

Evidence into practice: a theory based study of achieving national health targets in primary care.

This study investigates reasons why general practices achieve nationally set milestones to different extents. It compares the beliefs, self-reported behaviours and organizational context of general practitioners (GPs) who have been successful in achieving milestones set out in the UK's National Service Framework (NSF) for Coronary Heart Disease (CHD) with those who have been less successful. Sixteen London GPs were interviewed, eight 'high implementers' (having met five or more of six CHD NSF milestones) and eight 'low implementers' (having met one or two milestones). Practices were matched for practice size across the groups as far as possible. The interview consisted of open-ended questions, based on theoretical constructs identified as key to implementation research in a previous project. Interviews were transcribed and analysed with Interpretative Phenomenological Analysis (IPA). There were three main areas that differentiated high and low implementers: beliefs about evidence-based practice, control over professional practice and consequences of achieving the milestones. Low implementers: (i) expressed less belief in evidence-based guidelines as the basis of their practice; (ii) were more concerned about their lack of control over the development and implementation of the guidelines (lack of ownership), and over their own practice (lack of autonomy); and (iii) perceived more negative consequences and fewer positive consequences, both for themselves and for patient care. This study demonstrates the application of psychological theory in trying to understand and improve professional practice. The results suggest areas that could be targeted in developing interventions to increase guideline implementation in primary care.

Clinical variation. GPs' knowledge and attitudes regarding treatment of UTI and asthma in Sweden. A randomized controlled educational trial on guideline implementation

Background: Guidelines need effective means of implementation. An educational model was developed, aiming at improving treatment through guideline implementation in primary care. As knowledge of and attitudes in accordance with guideline content is one important piece in implementation, the model developed was evaluated regarding these issues. Methods: Thirty-six general practitioner (GP) groups (204 GPs) participated in this Swedish study, which was carried out within The European Drug Education Project. Each group was randomised to education on treatment of uncomplicated urinary tract infection (UTI) or asthma (parallel study arms which acted as controls for each other). The education comprised outreach visits to each group in which individual feedback was discussed and related to the guidelines. A questionnaire on knowledge and attitudes related to the guidelines (44 items) was completed individually before and after the education. Analysis of aggregated data on single items and multilevel analysis of sum scores per GP were used to assess intervention effects. Results: For drug choice in UTI, the Increase in agreement with the guidelines was significant, 31 percentage points in the intervention arm compared to three in the control arm (p=0.028). For asthma, knowledge was already high (>90% correct responses) for many items, e.g. concerning the use of inhaled corticosteroids, before the intervention with no significant intervention effects. A significant time trend (p<0.03) was seen for sum scores of knowledge for both UTI and asthma. The response rate was 88% before and 77% after the intervention. Conclusion: An improvement in knowledge of first-choice antibiotics for UTI was seen using the educational model developed.

A review of research in the United Kingdom to evaluate the implementation of clinical guidelines in general practice.

An advisory group for the NHS research and development (R&D) programme recommended in 1993 that the impact of clinical guidelines at the interface between primary and secondary care should be a research priority area. In 1994, a systematic review of 91 published evaluations of implementing clinical guidelines identified only seven UK general practice studies. In this inquiry we aimed to determine the number of randomized studies of clinical guideline implementation in primary care being conducted in the UK in 1996 and to review the research designs. A national health research register was interrogated for all projects relating to clinical guidelines. The investigators were contacted to establish the nature of their project and to identify implementation studies that they knew to be going on elsewhere. Copies of protocols or briefing documents were obtained from the project teams for the identified studies. Thirteen randomized studies in general medical practice and one in general dental practice were identified. Guidelines were being introduced to aid diagnostic decision-making, prescribing practice or referral to hospital-based services. Eight strategies for promoting guideline adherence were being evaluated. Six studies proposed to conduct economic evaluations of the intervention packages. Twelve of the 14 studies were funded by the NHS R&D programme. Since there will be a considerable time delay before all 14 studies and a number of newer studies are fully reported, it seems imperative that information of the sort collected in this inquiry be made available, preferably in the National Research Register.

Numerical dynamic analysis of calcite twin lamellae in the Greenport Center Syncline

<h3>PURPOSE</h3> Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. <h3>METHODS</h3> In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute’s Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar’s test and multivariate modeling were used to evaluate the impact of the interventions. <h3>RESULTS</h3> Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (<i>P</i> ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7–3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5–3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. <h3>CONCLUSIONS</h3> Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.