Guideline Implementation Strategies Research Articles

Meta-regression analyses to explain statistical heterogeneity in a systematic review of strategies for guideline implementation in primary health care.

This study is an in-depth-analysis to explain statistical heterogeneity in a systematic review of implementation strategies to improve guideline adherence of primary care physicians in the treatment of patients with cardiovascular diseases. The systematic review included randomized controlled trials from a systematic search in MEDLINE, EMBASE, CENTRAL, conference proceedings and registers of ongoing studies. Implementation strategies were shown to be effective with substantial heterogeneity of treatment effects across all investigated strategies. Primary aim of this study was to explain different effects of eligible trials and to identify methodological and clinical effect modifiers. Random effects meta-regression models were used to simultaneously assess the influence of multimodal implementation strategies and effect modifiers on physician adherence. Effect modifiers included the staff responsible for implementation, level of prevention and definition pf the primary outcome, unit of randomization, duration of follow-up and risk of bias. Six clinical and methodological factors were investigated as potential effect modifiers of the efficacy of different implementation strategies on guideline adherence in primary care practices on the basis of information from 75 eligible trials. Five effect modifiers were able to explain a substantial amount of statistical heterogeneity. Physician adherence was improved by 62% (95% confidence interval (95% CI) 29 to 104%) or 29% (95% CI 5 to 60%) in trials where other non-medical professionals or nurses were included in the implementation process. Improvement of physician adherence was more successful in primary and secondary prevention of cardiovascular diseases by around 30% (30%; 95% CI -2 to 71% and 31%; 95% CI 9 to 57%, respectively) compared to tertiary prevention. This study aimed to identify effect modifiers of implementation strategies on physician adherence. Especially the cooperation of different health professionals in primary care practices might increase efficacy and guideline implementation seems to be more difficult in tertiary prevention of cardiovascular diseases.

Developing a clinical practice guideline implementation strategy based on needs, evidence and theory

Background Clinical practice guidelines (CPGs) are used to standardize care according to evidence-based recommendations. However, the implementation of CPGs in the real world varies; a possible reason for this is the lack of a systematic approach to the implementation of CPG. We, therefore, aimed to develop an intervention to improve the implementation of a local hypertension CPG based on the needs of healthcare professionals (HCPs), best available evidence, and theories.

Implementation of treatment guidelines for specialist mental health care.

Although treatment guidelines are commonly employed in healthcare settings, it remains unclear whether their use has any positive impact on the performance of mental health services or whether they improve patient outcomes. This systematic review is based on a search carried out in March 2012 and includes 5 randomized studies that examined the effectiveness of guideline implementation strategies in improving healthcare services and outcomes for people with mental illness. The 5 studies were generally at unclear risk of bias, and all evidence in the “Summary of Findings” table was graded by review authors as of very low quality. Although single studies provided initial evidence that implementation of treatment guidelines may achieve small changes in mental health practice, with only 5 studies meeting inclusion criteria, and with limited usable information, it is not possible to arrive at definitive conclusions. A gap in knowledge still exists about how guideline implementation strategies might improve patient outcomes and health services. This leaves scant information for people with mental health problems, health professionals, and policy makers. More large-scale, well-designed and well-conducted studies are necessary to fill this gap in knowledge.

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.

Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings.

BackgroundAlthough dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence.Methods/DesignGuided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines—staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers’ tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence.DiscussionWe hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices.Trial registrationNCT01615237.

Development and evaluation of an implementation strategy for insurance medicine guidelines for depression

Development and evaluation of an implementation strategy for insurance medicine guidelines for depression

Strategies for guideline implementation in primary care focusing on patients with cardiovascular disease: a systematic review

Guidelines should reduce inappropriate practice and improve the efficiency of treatment. Not only methodological quality but also acceptance and successful implementation in daily practice are crucial for the benefit on patients. Focusing on cardiovascular diseases (CVD), it is still unclear which implementation strategy can improve physician adherence to the recommendations of guidelines in primary care. We conducted a systematic review on randomized controlled trials about guideline implementation strategies on CVD. Medline, Embase, CENTRAL, conference proceedings and registers of ongoing studies were searched. Eighty-four trials met our predefined inclusion criteria, of them 54 trials compared unimodal strategies and 30 multimodal strategies to usual care. Concerning unimodal strategies, 15 trials investigated provider reminder systems, 3 audit and feedback, 15 provider education, 4 patient education, 5 promotion of self-management and 14 organizational change. The strongest benefit of a unimodal implementation strategy was found due to organizational change (odds ratio 1.96; 95% CI 1.4 to 2.75), followed by patient education, provider education and provider reminder systems. Trials on the efficacy of audit and feedback and patient self-management showed differing results or small advantages in terms of physician adherence. Multimodal interventions showed almost similar effect measures and ranking of strategies. The use of implementation strategies for the distribution of guidelines on CVD can be convincingly effective on physician adherence, regardless whether based on a unimodal or multimodal design. Three distinct strategies should be well considered in such an attempt: organizational changes in the primary care team, patient education and provider education.

The Canadian Critical Care Nutrition Guidelines in 2013

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific clinical circumstances, and are designed to minimize practice variation, improve costs, and improve clinical outcomes. The Canadian Critical Care Practice Guidelines (CCPGs) were first published in 2003 and most recently updated in 2013. A total of 68 new randomized controlled trials were identified since the last version in 2009, 50 of them published between 2009 and 2013. The remaining articles were trials published before 2009 but were not identified in previous iterations of the CCPGs. For clinical practice guidelines to be useful to practitioners, they need to be up-to-date and be reflective of the current body of evidence. Herein we describe the process by which the CCPGs were updated. This process resulted in 10 new sections or clinical topics. Of the old clinical topics, 3 recommendations were upgraded, 4 were downgraded, and 27 remained the same. To influence decision making at the bedside, these updated guidelines need to be accompanied by active guideline implementation strategies. Optimal implementation strategies should be guided by local contextual factors including barriers and facilitators to best practice recommendations. Moreover, evaluating and monitoring performance, such as participating in the International Nutrition Survey of practice, should be part of any intensive care unit's performance improvement strategy. The active implementation of the updated CCPGs may lead to better nutrition care and improved patient outcomes in the critical care setting.

Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients

BackgroundTo successfully implement the recommendations of critical care nutrition guidelines, one potential approach is to identify barriers to providing optimal enteral nutrition (EN) in the intensive care unit (ICU), and then address these barriers systematically. Therefore, the purpose of this study was to develop a questionnaire to assess barriers to enterally feeding critically ill patients and to conduct preliminary validity testing of the new instrument.MethodsThe content of the questionnaire was guided by a published conceptual framework, literature review, and consultation with experts. The questionnaire was pre-tested on a convenience sample of 32 critical care practitioners, and then field tested with 186 critical care providers working at 5 hospitals in North America. The revised questionnaire was pilot tested at another ICU (n = 43). Finally, the questionnaire was distributed to a random sample of ICU nurses twice, two weeks apart, to determine test retest reliability (n = 17). Descriptive statistics, exploratory factor analysis, Cronbach alpha, intraclass correlations (ICC), and kappa coefficients were conducted to assess validity and reliability.ResultsWe developed a questionnaire with 26 potential barriers to delivery of EN asking respondents to rate their importance as barriers in their ICU. Face and content validity of the questionnaire was established through literature review and expert input. The factor analysis indicated a five-factor solution and accounted for 72% of the variance in barriers: guideline recommendations and implementation strategies, delivery of EN to the patient, critical care provider attitudes and behavior, dietitian support, and ICU resources. Overall, the indices of internal reliability for the derived factor subscales and the overall instrument were acceptable (subscale Cronbach alphas range 0.84 – 0.89). However, the test retest reliability was variable and below acceptable thresholds for the majority of items (ICC’s range −0.13 to 0.70). The within group agreement, an indices reflecting the reliability of aggregating individual responses to the ICU level was also variable (ICC’s range 0.0 to 0.82).ConclusionsWe developed a questionnaire to identify barriers to enteral feeding in critically ill patients. Additional studies are planned to further revise and evaluate the reliability and validity of the instrument.

Determinants of Guideline Use in Primary Care Physical Therapy: A Cross-Sectional Survey of Attitudes, Knowledge, and Behavior

Understanding of attitudes, knowledge, and behavior related to evidence-based practice (EBP) and use of evidence-based clinical practice guidelines in primary care physical therapy is limited. The objectives of this study were: (1) to investigate self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guideline use among physical therapists in primary care and (2) to explore associations of self-reported use of guidelines with these social cognitive factors along with demographic and workplace characteristics. This was a cross-sectional survey. A web-based survey of 419 physical therapists in primary care in western Sweden was performed. Multiple logistic regression analysis was performed to examine factors associated with guideline use. The response rate was 64.7%. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. Approximately two thirds reported confidence in finding and using evidence. One third reported being aware of guidelines. Thirteen percent knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. The most important barriers to using guidelines were lack of time, poor availability, and limited access to guidelines. Young age and brief work experience were associated with positive attitudes toward EBP. A postgraduate degree was associated with higher application of EBP. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. Data were self-reported, which may have increased the risk of social desirability bias. Use of guidelines was not as frequent as could be expected in view of the positive attitudes toward EBP and guidelines among physical therapists. Awareness of and perceived access to guidelines were limited. The identified determinants can be addressed when developing guideline implementation strategies.

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

Are high mastectomy rates associated with unwanted variation in other aspects of breast cancer treatment? An overview of practice patterns in Alberta, Canada in 2009-2010.

102 Background: The Canadian Partnership Against Cancer recently released a system performance report identifying large variation in breast cancer treatment across Canada. Contrary to provincial guidelines, Alberta had higher than average rates of mastectomy (56%); however, factors driving this variation remain unknown. We sought to (1) determine if practice patterns of primary breast surgery and adjuvant therapy adhered to guidelines and (2) to describe influencing factors on treatment practices between the two major cancer programs in Alberta to inform future knowledge translation strategies for guideline implementation. Methods: All patients diagnosed with breast cancer (ICD 9-174) between January 2009 and December 2010 were identified from the Alberta Cancer Registry. Demographic, surgical, treatment, and pathology data were abstracted from the electronic health record. Descriptive statistics and t-testing comparing mastectomy rates, axillary surgery and adjuvant therapy between the two major cancer programs were performed. Results: There were 2,817 surgeries for early breast cancer in the study cohort between 2009 and 2010. Conclusions: Practice patterns identify variance from current guidelines. Mastectomy rates are influenced by surgeon volume and tumor size. Management of positive SN and adjuvant therapy is variable and may reflect under treatment. Further investigation of drivers for mastectomy and adjuvant therapy are necessary. [Table: see text]

Determinants of implementation of maternal health guidelines in Kosovo: mixed methods study

BackgroundOne of the challenges to implementing clinical practice guidelines is the need to adapt guidelines to the local context and identify barriers to their uptake. Several models of framework are available to consider for use in guideline adaptation.MethodsWe completed a multiphase study to explore the implementation of maternal health guidelines in Kosovo, focusing on determinants of uptake and methods to contextualize for local use. The study involved a survey, individual interviews, focus groups, and a consensus meeting with relevant stakeholders, including clinicians (obstetricians, midwives), managers, researchers, and policy makers from the national Ministry of Health and the World Health Organization office in Pristina, Kosovo.ResultsParticipants identified several important barriers to implementation. First, lack of communication between clinicians and ministry representatives was seen as leading to duplication of effort in creating or adapting guidelines, as well as substantial mistrust between clinicians and policy makers. Second, there was a lack of communication across clinical groups that provide obstetric care and a lack of integration across the entire healthcare system, including rural and urban centers. This fragmentation was thought to have directly resulted from the war in 1998 – 1999. Third, the conflict substantially and adversely affected the healthcare infrastructure in Kosovo, which has resulted in an inability to monitor quality of care across the country. Furthermore, the impact on infrastructure has affected the ability to access required medications consistently and to smoothly transfer patients from rural to urban centers. Another issue raised during this project was the appropriateness of including guideline recommendations perceived to be ‘aspirational’.ConclusionsImplementing clinical practice guidelines in low- and middle-income countries (LMICs) requires consideration of several specific barriers. Particularly pertinent to this study were the effects of recent conflict and the resulting fragmentation of healthcare and communication strategies among relevant stakeholders. However, as Kosovo rebuilds and invests in infrastructure after the conflict, there is a tremendous opportunity to create comprehensive, thoughtful strategies to monitor and improve quality of care. To avoid duplication of effort, it may be beneficial for LMICs to share information on assessing barriers as well as on guideline implementation strategies.

070 Strategies for Health System Implementation of Guidelines on Overweight and Obesity

BackgroundEvidence-based clinical practice guidelines (CPGs) for adult obesity and overweight provide recommendations to clinicians on interventions for weight loss and maintenance. organisation-wide implementation of these guidelines is critical to achieve...

P244 Development Of A Tailor-Made Implementation Strategy To Facilitate Adherence To The Dutch Postpartum Hemorrhage Guideline And Moet-Instructions

BackgroundDespite the introduction of a national guideline and the Managing Obstetric Emergencies and Trauma (MOET) course the incidence of postpartum haemorrhage (PPH) is increasing. We suspected inadequate guideline implementation to...

P146 Adapting and Implementing Guidelines For Chronic Obstructive Pulmonary Disease (COPD)

BackgroundAdaptation of high-quality external guidelines can be an efficient and effective means to develop guidance more rapidly, allowing for shifting of resources to knowledge transfer and health system implementation efforts.ContextTo...

P212 Review of Systematic Reviews Related to Clinical Guidelines Implementation

BackgroundClinical guidelines should be implemented using evidence-based implementation strategies. However, guideline development programmes rarely allocate resources to perform evidence-based reviews of implementation strategies required to implement their guidelines. A streamlined...

027 Determinants Of Guideline Use Among Primary Care Physiotherapists In Western Sweden: A Cross-Sectional Study

BackgroundThe understanding of attitudes, knowledge, and behaviour related to evidence-based practice (EBP), in particular evidence-based clinical practice guidelines, in primary care physical therapy is limited.ObjectivesTo investigate self-reported attitudes, knowledge, behaviour,...

P153 Successful Strategies In The Implementation Of Clinical Practice Guidelines: Creating Evidence-Informed Practice Cultures

For over a decade, a professional nursing association has lead a programme focused on the development, dissemination, implementation and evaluation of clinical and healthy work environment guidelines. This programme has...

P300 Theory-Informed Tailored Implementation Of Guidelines In Swedish Primary Care Physiotherapy: Development Of A Strategy

BackgroundThere is little knowledge about effective guideline implementation strategies in primary care physiotherapy. The use of theory for the development of implementation strategies is advocated by some, a pragmatic approach...