Guideline Implementation Interventions Research Articles

Factors influencing fidelity to guideline implementation strategies for improving pain care at cancer centres: a qualitative sub-study of the Stop Cancer PAIN Trial

BackgroundThe Stop Cancer PAIN Trial was a phase III pragmatic stepped wedge cluster randomised controlled trial which compared effectiveness of screening and guidelines with or without implementation strategies for improving pain in adults with cancer attending six Australian outpatient comprehensive cancer centres (n = 688). A system for pain screening was introduced before observation of a ‘control’ phase. Implementation strategies introduced in the ‘intervention’ phase included: (1) audit of adherence to guideline recommendations, with feedback to clinical teams; (2) health professional education via an email-administered ‘spaced education’ module; and (3) a patient education booklet and self-management resource. Selection of strategies was informed by the Capability, Opportunity and Motivation Behaviour (COM-B) Model (Michie et al., 2011) and evidence for each strategy’s stand-alone effectiveness. A consultant physician at each centre supported the intervention as a ‘clinical champion’. However, fidelity to the intervention was limited, and the Trial did not demonstrate effectiveness. This paper reports a sub-study of the Trial which aimed to identify factors inhibiting or enabling fidelity to inform future guideline implementation initiatives.MethodsThe qualitative sub-study enabled in-depth exploration of factors from the perspectives of personnel at each centre. Clinical champions, clinicians and clinic receptionists were invited to participate in semi-structured interviews. Analysis used a framework method and a largely deductive approach based on the COM-B Model.ResultsTwenty-four people participated, including 15 physicians, 8 nurses and 1 clinic receptionist. Coding against the COM-B Model identified ‘capability’ to be the most influential component, with ‘opportunity’ and ‘motivation’ playing largely subsidiary roles. Findings suggest that fidelity could have been improved by: considering the readiness for change of each clinical setting; better articulating the intervention’s value proposition; defining clinician roles and responsibilities, addressing perceptions that pain care falls beyond oncology clinicians’ scopes of practice; integrating the intervention within existing systems and processes; promoting patient-clinician partnerships; investing in clinical champions among senior nursing and junior medical personnel, supported by medical leaders; and planning for slow incremental change rather than rapid uptake.ConclusionsFuture guideline implementation interventions may require a ‘meta-implementation’ approach based on complex systems theory to successfully integrate multiple strategies.Trial registrationRegistry: Australian New Zealand Clinical Trials Registry; number: ACTRN 12615000064505; data: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspxid=367236&isReview=true.

Trends in guideline implementation: an updated scoping review protocol.

The objective of this review is to assess trends in guideline implementation, including the interventions used, rationale provided, and the impact on patient or health care professional knowledge, behavior or outcomes. Guidelines must be actively implemented to promote use and achieve beneficial outcomes. A review published in 2015 found that studies of guideline implementation did not employ a range of implementation planning approaches to select and tailor interventions, resulting in inconsistent impact. This study will update the 2015 review and elaborate beyond the four diseases originally covered to determine whether more recent efforts to implement guidelines are informed by best implementation practices. We will include published studies that describe the implementation of guidelines on any clinical topic relevant to primary, secondary, or tertiary care using interventions targeted at patients, families/caregivers, or health care professionals. We will search MEDLINE, Embase, AMED, CINAHL, Scopus, and the Cochrane Library from 2014 (search date in 2015 review) to the present. Two or more reviewers will screen titles and full-text articles, and extract data from included studies. We will use summary statistics, tables, and a narrative summary to describe study characteristics, guideline implementation interventions, the rationale for intervention selection and tailoring (pre-identified barriers, patient or stakeholder preferences, theory), and intervention impact.

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.

Does a tailored guideline implementation strategy have an impact on clinical physiotherapy practice? A nonrandomized controlled study.

Clinical practice guidelines are a common strategy for implementing research findings into practice and facilitating evidence-based practice in health care settings. There is a paucity of knowledge about the impact of different guideline implementation strategies on clinical practice in a physiotherapy context. The study aimed to assess the impact of a guideline implementation intervention on clinical physiotherapy practice. A tailored, multicomponent guideline implementation was compared with usual practice. Clinical practice was evaluated in physiotherapy treatment methods used for 3 common musculoskeletal disorders. Data were collected with a validated web-based questionnaire. Postimplementation data were collected from 168 physiotherapists in the intervention group and 88 in the control group. The most frequently reported treatment methods for low back pain were advice on posture (reported by 95% in the intervention group vs 90% in the control group), advice to stay active (93% vs 90%), and stabilization exercise (88% vs 80%). Differences between groups were not significant. Reported use of body awareness training (23% vs 6%, P=.023) and spinal manipulation (9% vs 23%, P=.044) differed between the groups. The most frequently used treatment methods for neck pain were advice on posture (95% vs 92%), advice to stay active (89% vs 87%), and ROM exercise (85% vs 71%) (no significant differences between groups). Reported use of body awareness training (24% vs 7%, P=.023) differed between the groups. The most frequently used treatment methods for subacromial pain were range of motion exercises (reported by 93% in both groups), advice on posture (90% vs 87%), home exercise (77% vs 74%), and stabilization exercise (69% vs 66%) (no significant difference between groups). Treatment methods used were largely in line with evidence already before the guideline implementation, which may explain why the guideline implementation had only little impact on clinical practice.

Designing for Clinical Change: Creating an Intervention to Implement New Statin Guidelines in a Primary Care Clinic.

BackgroundRecent clinical practice guidelines from major national organizations, including a joint United States Department of Veterans Affairs (VA) and Department of Defense (DoD) committee, have substantially changed recommendations for the use of the cholesterol-lowering statin medications after years of relative stability. Because statin medications are among the most commonly prescribed treatments in the United States, any change in their use may have significant implications for patients and providers alike. Prior research has shown that effective implementation interventions should be both user centered and specifically chosen to address identified barriers.ObjectiveThe objectives of this study were to identify potential determinants of provider uptake of the new statin guidelines and to use that information to tailor a coordinated and streamlined local quality improvement intervention focused on prescribing appropriate statins.MethodsWe employed user-centered design principles to guide the development and testing of a multicomponent guideline implementation intervention to improve statin prescribing. This paper describes the intervention development process whereby semistructured qualitative interviews with providers were conducted to (1) illuminate the knowledge, attitudes, and behaviors of providers and (2) elicit feedback on intervention prototypes developed to align with and support the use of the VA/DoD guidelines. Our aim was to use this information to design a local quality improvement intervention focused on statin prescribing that was tailored to the needs of primary care providers at our facility. Cabana’s Clinical Practice Guidelines Framework for Improvement and Nielsen’s Usability Heuristics were used to guide the analysis of data obtained in the intervention development process.ResultsSemistructured qualitative interviews were conducted with 15 primary care Patient Aligned Care Team professionals (13 physicians and 2 clinical pharmacists) at a single VA medical center. Findings highlight that providers were generally comfortable with the paradigm shift to risk-based guidelines but less clear on the need for the VA/DoD guidelines in specific. Providers preferred a clinical decision support tool that helped them calculate patient risk and guide their care without limiting autonomy. They were less comfortable with risk communication and performance measurement systems that do not account for shared decision making. When possible, we incorporated their recommendations into the intervention.ConclusionsBy combining qualitative methods and user-centered design principles, we could inform the design of a multicomponent guideline implementation intervention to better address the needs and preferences of providers, including clear and direct language, logical decision prompts with an option to dismiss a clinical decision support tool, and logical ordering of feedback information. Additionally, this process allowed us to identify future design considerations for quality improvement interventions.

GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING): a pilot cluster randomised controlled trial of a guideline implementation intervention for the management of maternal obesity by midwives

BackgroundWeight management in pregnancy guidelines exist, although dissemination alone is an ineffective means of implementation. Midwives identify the need for support to overcome complex barriers to practice. An evaluation of an intervention to support midwives’ guideline implementation would require a large-scale cluster randomised controlled trial. A pilot study is necessary to explore the feasibility of delivery and evaluation prior to a definitive trial. The GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING) trial aims to test whether it is feasible and acceptable to deliver a behaviour change intervention to support midwives’ implementation of weight management guidelines.MethodsGLOWING is a multi-centre parallel group pilot cluster randomised controlled trial comparing the delivery of a behaviour change intervention for midwives versus usual practice. Four NHS Trusts (clusters) will be randomised to intervention and control arms, stratified by size of maternity services. The intervention uses social cognitive theory and consists of face-to-face midwifery training plus information resources for routine practice. The main outcomes are whether the intervention and trial procedures are feasible and acceptable to participants and the feasibility of recruitment and data collection for a definitive trial. Target recruitment involves all eligible midwives in the intervention arm recruited to receive the intervention, 30 midwives and pregnant women per arm for baseline and outcome questionnaire data collection and 20 midwives and women to provide qualitative data. All quantitative and qualitative analyses will be descriptive with the purpose of informing the development of the definitive trial.DiscussionThis pilot study has been developed to support community midwives’ implementation of guidelines. Community midwives have been selected as they usually carry out the booking appointment which includes measuring and discussing maternal body mass index. A cluster design is the gold standard in implementation research as there would be a high risk of contamination if randomisation was at individual midwife level: community midwives usually work in locality-based teams, interact on a daily basis, and share care of pregnant women. The results of the pilot trial will be used to further develop and refine GLOWING prior to a definitive trial to evaluate effectiveness and cost-effectiveness.Trial registrationISRCTN46869894; retrospectively registered 25th May 2016.

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention

Lack of guideline knowledge and cognitive biases are barriers that drive overtreatment of catheter-associated asymptomatic bacteriuria (ASB). We explored whether providers' knowledge and attitudes toward management of ASB differed before and after a multifaceted guidelines implementation intervention, reported elsewhere. We surveyed providers' knowledge of guidelines, cognitive-behavioral constructs, and self-reported familiarity with the relevant Infectious Diseases Society of America guidelines. The survey was administered to providers in the preintervention (n = 169) and postintervention (n = 157) periods at the intervention site and postintervention (n = 65) at the comparison site. At the intervention site, the mean knowledge score increased significantly during the postintervention period (from 57.5%-69.9%; P < .0001) and fewer providers reported following incorrect cognitive cues (pyuria and organism type) for treatment of ASB. The knowledge of guidelines was higher in the postintervention sample after adjusting for provider type in the multiple linear regression analysis. Cognitive behavioral constructs (ie, self-efficacy, behavior, social norms, and risk perceptions) and self-reported familiarity with the guidelines also significantly improved during the postintervention period. We identified and targeted specific barriers that drive overtreatment of ASB. Guideline implementation interventions targeting cognitive biases are essential for encouraging the application of ASB guidelines into practice.

Impact of an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes on decisional conflict--study protocol for a randomized controlled trial.

BackgroundCompeting health concerns present real obstacles to people living with diabetes and other chronic diseases as well as to their primary care providers. Guideline implementation interventions rarely acknowledge this, leaving both patients and providers feeling overwhelmed by the volume of recommended actions. Interprofessional (IP) shared decision-making (SDM) with the use of decision aids may help to set treatment priorities. We developed an evidence-based SDM intervention for patients with diabetes and other conditions that was framed by the IP-SDM model and followed a user-centered approach. Our objective in the present study is to pilot an IP-SDM and goal-setting toolkit following the Knowledge-to-Action Framework to assess (1) intervention fidelity and the feasibility of conducting a larger trial and (2) impact on decisional conflict, diabetes distress, health-related quality of life and patient assessment of chronic illness care.Methods/DesignA two-step, parallel-group, clustered randomized controlled trial (RCT) will be conducted, with the primary goal being to assess intervention fidelity and the feasibility of conducting a larger RCT. The first step is a provider-directed implementation only; the second (after a 6-month delay) involves both provider- and patient-directed implementation. Half of the clusters will be assigned to receive the IP-SDM toolkit, and the other will be assigned to be mailed a diabetes guidelines summary. Individual interviews with patients, their family members and health care providers will be conducted upon trial completion to explore toolkit use. A secondary purpose of this trial is to gather estimates of the toolkit’s impact on decisional conflict. Secondary outcomes include diabetes distress, quality of life and chronic illness care, which will be assessed on the basis of patient-completed questionnaires of validated scales at baseline and at 6 and 12 months. Multilevel hierarchical regression models will be used to account for the clustered nature of the data.DiscussionAn individualized approach to patients with multiple chronic conditions using SDM and goal setting is a desirable strategy for achieving guideline-concordant treatment in a patient-centered fashion. Our pilot trial will provide insights regarding strategies for the routine implementation of such interventions in clinical practice, and it will offer an assessment of the impact of this approach.Trial registrationClinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-0797-8) contains supplementary material, which is available to authorized users.

Guideline dissemination and implementation interventions for nursing

Background: The implementation of practice guidelines by nurses may reduce variations in practice and improve patient care. Research is needed to identify the most effective implementation interventions to increase the use of guidelines in practice and the impact of guideline implementation. Objective: To conduct a systematic review to identify and assess the effects of the interventions employed to increase the use of practice guidelines in nursing. Methods: Systematic review searching Cochrane EPOC Group specialized register, MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO to 2013 for randomized controlled trials, controlled before-and-after studies and controlled interrupted time series analyses. Two reviewers independently assessed study quality and extracted data. Results: Over 21,000 titles screened to identify 26 studies (reported in 28 papers); 25 RCTs, 1 CBA; 15 studies from North American, 8 from Europe; 3 studies at high risk of bias; most common implementation interventions: educational meetings (n = 19); distribution of educational material (N = 19); outreach visits (n = 12). Educational meetings plus distribution of educational material plus other interventions had largest effect on nursing practice (medium ARD 18–40%). Interventions improved knowledge of nurses (median ARD 6–10%); improved practice of nurses (median ARD 3–40%); and improved patient outcomes (median ARD −2–7.7%). Discussion: Implementation interventions to increase guideline use by nurses generally improved their knowledge and practice, and patient outcomes. Conclusion: When implemented practice guidelines in nursing, improves process of care and patient health outcomes. Research on guideline implementation continues to evolve and suggest that nursing may be different than medicine.

Examining the use of facilitation within guideline dissemination and implementation studies in nursing.

Facilitation is a mechanism for implementing practice guidelines in nursing. Facilitation aims to prepare clinicians and organisations for implementation and to provide support and help in problem-solving as implementation progresses. However, any evidence supporting its effectiveness is limited due to a lack of empirical testing. : To examine the presence and role of facilitation in studies included in an existing systematic review of guideline dissemination and implementation in nursing. Using a descriptive, exploratory approach, we examined 28 studies for elements of facilitation that were included in a review of the effectiveness of interventions to increase the use of practice guidelines in nursing. We conducted a content analysis of a subset of studies that included facilitation activity to gather descriptions of study interventions, characteristics and skills required, use of theory, and effectiveness. Extracted data were analysed using a previously developed taxonomy containing 53 activities related to facilitation. Ten of the 28 studies exhibited evidence of facilitation process and activity. Only two of the 10 studies explicitly referred to 'facilitators,' with just one indicating that facilitators were a part of the implementation intervention being tested. We identified facilitation processes in the eight remaining studies even though the authors did not report it as such. All studies used facilitation activities in combination with other interventions, the most common being educational meetings or distribution of educational materials. We found evidence related to facilitation for 37 of the 53 facilitation activities (70%) in the taxonomy in at least one study or across studies. An additional three novel facilitation-related activities were identified. Most studies exhibited evidence of external facilitation activity whereby researchers outside of the setting assisted nurses to implement guidelines. Theory informed the development or selection of implementation interventions in 60% (n = 6) of the studies. Drawing conclusions regarding effectiveness of interventions involving facilitation was difficult due to the small number of studies that were included. Furthermore, the included studies varied in the detail provided about the intervention or combination of interventions tested and how interventions were delivered. Using an existing systematic review for the purpose of gaining insight into additional research questions was valuable. Although facilitation process and activities are used in interventions to enhance guideline uptake in nursing, these were not conceptualized or referred to by researchers as 'facilitation.' As such, facilitation may be a broader intervention that includes organizing and delivering other interventions. Further research is required to evaluate the relationship between facilitation and other guideline implementation interventions in nursing. The facilitation uncovered within included studies was located primarily in the context of research as it was the researchers who performed most of the facilitation activities. Future inquiries must explore non-researcher-initiated and delivered facilitation intervention activities by following local groups naturally within clinical contexts.

Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial

BackgroundClinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden.MethodsAn implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson’s χ2 test and approximative z-test.Results168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes.ConclusionsA tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.

Implementation of a guideline for physical therapy in the postoperative period of upper abdominal surgery reduces the incidence of atelectasis and length of hospital stay

ObjectiveThe aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery (UAS) in reducing the incidence of atelectasis and length of hospital stay in the postoperative period. Materials and methodsA “before and after” study design with historical control was used. The “before” period included consecutive patients who underwent UAS before guideline implementation (intervention). The “after” period included consecutive patients after guideline implementation. Patients in the pre‐intervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional. On the other hand, patients who were included in the post‐intervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies (EPAP, incentive spirometry and early mobilization). ResultsThere was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation. Moreover, it was observed that early ambulation occurred in all patients in the post‐intervention period. No patient who adhered totally to the guideline in the post‐intervention period developed atelectasis. Individuals in the post‐intervention period presented a shorter length of hospital stay (9.2±4.1 days) compared to patients in the pre‐intervention period (12.1±8.3 days) (p<0.05). ConclusionThe implementation of a physical therapy guideline for patients undergoing UAS resulted in reduced incidence of atelectasis and reduction in length of hospital stay in the postoperative period.

Designing and evaluating an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes in clinical care--systematic decision aid development and study protocol.

BackgroundCare of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Guideline implementation interventions to date do not acknowledge these intricacies of clinical practice. As a result, patients and providers are left overwhelmed and paralyzed by the sheer volume of recommendations and tasks. An individualized approach to the patient with diabetes and multiple comorbid conditions using shared decision-making (SDM) and goal setting has been advocated as a patient-centred approach that may facilitate prioritization of treatment options. Furthermore, incorporating interprofessional integration into practice may overcome barriers to implementation. However, these strategies have not been taken up extensively in clinical practice.ObjectivesTo systematically develop and test an interprofessional SDM and goal-setting toolkit for patients with diabetes and other chronic diseases, following the Knowledge to Action framework.Methods1. Feasibility study: Individual interviews with primary care physicians, nurses, dietitians, pharmacists, and patients with diabetes will be conducted, exploring their experiences with shared decision-making and priority-setting, including facilitators and barriers, the relevance of a decision aid and toolkit for priority-setting, and how best to integrate it into practice.2. Toolkit development: Based on this data, an evidence-based multi-component SDM toolkit will be developed. The toolkit will be reviewed by content experts (primary care, endocrinology, geriatricians, nurses, dietitians, pharmacists, patients) for accuracy and comprehensiveness.3. Heuristic evaluation: A human factors engineer will review the toolkit and identify, list and categorize usability issues by severity.4. Usability testing: This will be done using cognitive task analysis.5. Iterative refinement: Throughout the development process, the toolkit will be refined through several iterative cycles of feedback and redesign.DiscussionInterprofessional shared decision-making regarding priority-setting with the use of a decision aid toolkit may help prioritize care of individuals with multiple comorbid conditions. Adhering to principles of user-centered design, we will develop and refine a toolkit to assess the feasibility of this approach.

Implementation of a guideline for physical therapy in the postoperative period of upper abdominal surgery reduces the incidence of atelectasis and length of hospital stay

ObjectiveThe aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery (UAS) in reducing the incidence of atelectasis and length of hospital stay in the postoperative period. Materials and methodsA “before and after” study design with historical control was used. The “before” period included consecutive patients who underwent UAS before guideline implementation (intervention). The “after” period included consecutive patients after guideline implementation. Patients in the pre-intervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional. On the other hand, patients who were included in the post-intervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies (EPAP, incentive spirometry and early mobilization). ResultsThere was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation. Moreover, it was observed that early ambulation occurred in all patients in the post-intervention period. No patient who adhered totally to the guideline in the post-intervention period developed atelectasis. Individuals in the post-intervention period presented a shorter length of hospital stay (9.2±4.1 days) compared to patients in the pre-intervention period (12.1±8.3 days) (p<0.05). ConclusionThe implementation of a physical therapy guideline for patients undergoing UAS resulted in reduced incidence of atelectasis and reduction in length of hospital stay in the postoperative period.

Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study

BackgroundAntihypertensive drug choices and treatment levels are not in accordance with the existing guidelines. We aimed to assess the impact of a guideline implementation intervention on antihypertensive drug prescribing.MethodsIn this controlled before and after study, the effects of a multifaceted (education, audit and feedback, local care pathway) quality programme was evaluated. The intervention was carried out in a health centre between 2002 and 2003. From each health care unit (n = 31), a doctor-nurse pair was trained to act as peer facilitators in the intervention.All antihypertensive drugs prescribed by 25 facilitator general practitioners (intervention GPs) and 53 control GPs were retrieved from the nationwide Prescription Register for three-month periods in 2001 and 2003. The proportions of patients receiving specific antihypertensive drugs and multiple antihypertensive drugs were measured before and after the intervention for three subgroups of hypertension patients: hypertension only, with coronary heart disease, and with diabetes.ResultsIn all subgroups, the use of multiple concurrent medications increased. For intervention patients with hypertension only, the odds ratio (OR) was 1.12 (95% CI 0.99, 1.25; p = 0.06) and for controls 1.13 (1.05, 1.21; p = 0.002). We observed no statistically significant differences in the change in the prescribing of specific antihypertensive agents between the intervention and control groups. The use of agents acting on the renin-angiotensin-aldosterone system increased in all subgroups (hypertension only intervention patients OR 1.19 (1.06, 1.34; p = 0.004) and controls OR 1.24 (1.15, 1.34; p < 0.0001).ConclusionsA multifaceted guideline implementation intervention does not necessarily lead to significant changes in prescribing performance. Rigorous planning of the interventions and quality projects and their evaluation are essential.

Factors Affecting the Cost Effectiveness of Antibiotics

In an era of spiraling health care costs and limited resources, policy makers and health care payers are concerned about the cost effectiveness of antibiotics. The aim of this study is to draw on published economic evaluations with a view to identify and illustrate the factors affecting the cost effectiveness of antibiotic treatment of bacterial infections. The findings indicate that the cost effectiveness of antibiotics is influenced by factors relating to the characteristics and the use of antibiotics (i.e., diagnosis, comparative costs and comparative effectiveness, resistance, patient compliance with treatment, and treatment failure) and by external factors (i.e., funding source, clinical pharmacy interventions, and guideline implementation interventions). Physicians need to take into account these factors when prescribing an antibiotic and assess whether a specific antibiotic treatment adds sufficient value to justify its costs.

What should be our approach to knowledge translation in primary care?

Evaluations of delivered care have consistently demonstrated gaps between existing medical knowledge and current practice. Studies examining the quality of care across disciplines and jurisdictions have estimated that 30% to 45% of patients are not offered evidence-based best care, and 20% to 30% receive contraindicated and potentially harmful care [1,2]. Respiratory disease care gaps are equally alarming, with only 48% of recommended care delivered to patients with asthma exacerbations, and only 46% of routine recommended care delivered to patients with COPD [3]. Knowledge translation (KT) is a methodological approach developed specifically to address these care gaps. Because the most prevalent conditions are managed predominantly in primary care, there has been a great deal of interest in developing KT interventions targeting the primary care environment. A meta-analysis of randomized trials of guideline implementation interventions has demonstrated only modest effects on care across a wide range of disciplines, care settings, recommendation types and intervention types [4]. However, few of these studies employed behavioral theories to inform intervention design, and this lack of an appropriate theoretical underpinning may be partly responsible for their limited success [5]. A multi-step approach to KT intervention design might improve success. Knowledge implementers should start by investigating the theory-based factors that underlie existing clinical practice, in order to identify the theoretical constructs that should be targeted by an intervention. Once these factors are known, one can design interventions to enhance the processes supporting change in these specific constructs [6]. When targeting individual behaviour change, relevant theoretical categories include motivational theories (which explain how individuals wish, intend and ultimately decide to change behaviour), action theories (which explain how individuals move from intention to actual behaviour change), and stage theories (which describe an orderly progression through discrete stages toward behaviour change) [6]. Concepts of behavioural intention and self-efficacy are among the best predictors of subsequent health behaviour and are found in virtually all social cognitive models of health behaviour. Baseline factors influencing current behaviour can be identified directly through previous literature, or through direct measurement via interviews, questionnaires or group methods. An alternative approach is to analyze practice variation with respect to its determinants. With this technique, determinants identified predominantly in practices which adhere to or do not adhere to behaviour can be characterized as facilitators or barriers, respectively. Finally, researchers can analyze previously effective KT interventions to retrospectively ascertain which factors were likely influencing behaviour [7]. After having thus identified the relevant components of a behavior that should be targeted, an appropriate intervention can be developed based on approaches previously shown to be effective in other settings. General categories of interventions include educational interventions, which can be passive or interactive; audit-and-feedback; provision of “just-in-time” information, including reminders and clinical decision support systems; organizational changes such as role revisions or financial incentives; and patient-directed interventions such as pre-consultation questionnaires. Electronic tools are emerging as a modality to facilitate a wide range of these interventions and require further study.

Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol

BackgroundVariability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care. A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines. Further, the review recommended the use of theory in the development of implementation interventions. A clinical practice guideline for the management of acute low-back pain has been developed in Australia (2003). Acute low-back pain is a common condition, has a high burden, and there is some indication of an evidence-practice gap in the allied health setting. This provides an opportunity to develop and test a theory-based implementation intervention which, if effective, may provide benefits for patients with this condition.AimsThis study aims to estimate the effectiveness of a theory-based intervention to increase allied health practitioners' (physiotherapists and chiropractors in Victoria, Australia) compliance with a clinical practice guideline for acute non-specific low back pain (LBP), compared with providing practitioners with a printed copy of the guideline. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray, and improving mean level of disability for patients three months post-onset of acute LBP.MethodsThe design of the study is a cluster randomised trial. Restricted randomisation was used to randomise 210 practices (clusters) to an intervention or control group. Practitioners in the control group received a printed copy of the guideline. Practitioners in the intervention group received a theory-based intervention developed to address prospectively identified barriers to practitioner compliance with the guideline. The intervention primarily consisted of an educational symposium. Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period, three months post the intervention symposia, are eligible for inclusion. Sample size calculations are based on recruiting between 15 to 40 patients per practice. Outcome assessors will be blinded to group allocation.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12609001022257 (date registered 25th November 2009)

Bridging the Guideline–Practice Gap in Critical Care Nutrition

Several clinical practice guidelines focusing on nutrition therapy in mechanically ventilated, critically ill patients are available to assist busy critical care practitioners in making decisions regarding feeding their patients. However, large gaps have been observed between guideline recommendations and actual practice. To be effective in optimizing nutrition practice, guideline development must be followed by systematic guideline implementation strategies. Systematic reviews of studies evaluating guideline implementation interventions outside the critical care setting found that these strategies, such as reminders, educational outreach, and audit and feedback, produce modest to moderate improvements in processes of care, with considerable variation observed both within and across studies. Unfortunately, the optimal strategies to implement guidelines in the intensive care unit are poorly understood, with scarce data available to guide our decisions on which strategies to use. The authors identified 3 cluster randomized trials evaluating the implementation of nutrition guidelines in the critical care setting. These studies demonstrated small improvements in nutrition practice, but no significant effect on patient outcomes. There are some data to suggest that tailoring guideline implementation strategies to overcome identified barriers to change might be a more effective approach than the multifaceted "one size fits all" strategy used in previous studies. Adopting this tailored approach to guideline implementation in future studies may help bridge the current guideline-practice gap and lead to significant improvements in nutrition practices and patient outcomes.