Effectiveness and efficiency of guideline dissemination and implementation strategies.
ABSTRACT To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.
MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group.
Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care.
In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources.
There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.
Full-textDOI: · Available from: Graeme Maclennan, Jun 27, 2015
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ABSTRACT: Nurses are increasingly expected to engage in evidence-informed decision making (EIDM); the use of research evidence with information about patient preferences, clinical context and resources, and their clinical expertise in decision making. Strategies for enhancing EIDM have been synthesized in high-quality systematic reviews, yet most relate to physicians or mixed disciplines. Existing reviews, specific to nursing, have not captured a broad range of strategies for promoting the knowledge and skills for EIDM, patient outcomes as a result of EIDM, or contextual information for why these strategies "work."Worldviews on Evidence-Based Nursing 06/2014; 11(3):156-67. DOI:10.1111/wvn.12043 · 2.32 Impact Factor
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ABSTRACT: OBJECTIVE: The aim of the present study was to develop process quality indicators for physiotherapy care based on key recommendations of the Dutch physiotherapy guideline on hip and knee osteoarthritis (OA). METHODS: Guideline recommendations were rated for their relevance by an expert panel, transformed into potential indicators and incorporated into a questionnaire, the Quality Indicators for Physiotherapy in Hip and Knee Osteoarthritis (QIP-HKOA). Adherence with each indicator was rated on a Likert scale (0 = never to 4 = always). The QIP-HKOA was administered to groups of expert (n = 51) and general (n = 134) physiotherapists (PTs) to test its discriminative power. Reliability was tested in a subgroup of 118 PTs by computing the intraclass correlation coefficient (ICC). QIP-HKOA items were included if they were considered to be related to the cornerstones of physiotherapy in hip and knee OA (exercises and education), had discriminative power and/or if they were followed by <75% of PTs in both groups. RESULTS: Nineteen indicators were derived from 41 recommendations. Twelve indicators were considered to be the cornerstones of physiotherapy care; six indicators had discriminative power and/or were followed by <75% PTs in both groups, resulting in an 18-item QIP- HKOA. The QIP-HKOA score was significantly higher with expert [60.73; standard deviation (SD) 5.67] than with general PTs (54.65; SD 6.17) (p < 0.001). The ICC of the QIP-HKOA among 46/118 PTs was 0.89. CONCLUSION: The QIP-HKOA, based on 18 process indicators derived from a physiotherapy guideline on hip and knee OA was found to be reliable and discriminated between expert and general PTs. Its ability to measure improvement in the quality of the process of physiotherapy care needs to be further examined. Copyright © 2012 John Wiley & Sons, Ltd.Musculoskeletal Care 12/2013; 11(4). DOI:10.1002/msc.1041
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ABSTRACT: Bridging the research-practice gap is an important research focus in continuing care facilities, because the population of older adults (aged 65 years and over) requiring continuing care services is the fastest growing demographic among countries in the Organisation for Economic Co-operation and Development (OECD). Unlicensed practitioners, known as health care aides, provide the majority of care for residents living in continuing care facilities. However, little research examines how to sustain health care aide behavior change following initial adoption of current research evidence.Methods/designWe will conduct a phase III, multicentre, cluster randomized controlled trial (RCT) using a stratified 2 x 2 additive factorial design, including an embedded process evaluation, in 24 supportive living facilities within the health zone of Edmonton, AB, Canada. We will determine which combination of frequency and intensity of reminders most effectively sustains the completion of the sit-to-stand activity by health care aides with residents. Frequency refers to how often a reminder is implemented; intensity refers to whether a reminder is social or paper-based. We will compare monthly reminders with reminders implemented every 3 months, and we will compare low intensity, paper-based reminders and high intensity reminders provided by a health care aide peer.Using interviews, questionnaires, and observations, Sustaining Transfers through Affordable Research Translation (START) will evaluate the processes that inhibit or promote the mobility innovation's sustainability among health care aides in daily practice. We will examine how the reminders are implemented and perceived by health care aides and licensed practical nurses, as well as how health care aides providing peer reminders are identified, received by their peers, and supported by their supervisors. START will connect up-to-date innovation research with the practice of health care aides providing direct care to a growing population of older Albertans. The project's reach extends to both supportive living and long-term care settings. Furthermore, START has the potential to introduce and sustain a broad range of innovations in various care areas, such as dementia care, wound care, and pain management -- domains where the uptake and sustainability of innovations also encounter significant challenges. By identifying the optimal frequency and intensity of knowledge translation interventions, we hope to enable continuing care organizations to efficiently integrate care innovations into the day-to-day care of residents.Trial registrationClinicalTrials.gov: NCT01746459.Trials 10/2013; 14(1):355. DOI:10.1186/1745-6215-14-355 · 2.12 Impact Factor