Background
Clinical practice guidelines (CPGs) are evidence-based recommendations for healthcare professionals about the care of patients with specific conditions. The uptake of CPGs by healthcare professionals is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage the adoption of new guidelines.This review focuses on the effectiveness of tools developed and distributed by recognised guideline producers to improve the uptake of their CPGs.
Characteristics of included studies
Researchers from Cochrane searched the literature up to February 2016 and identified four randomised studies evaluating the effects of tools developed by recognised guideline producers to implement their guidelines. These were developed by guideline producers in France, the Netherlands and in the USA and Canada. In all four studies the interventions targeted the healthcare professional. None of the tools specifically targeted the organisation of care or the patient. The clinical conditions, and the healthcare professionals' behaviour targeted by the CPG, varied across studies, as did the tools used to improve guideline implementation.
Key results
Two of the four included studies reported on how well healthcare professionals stick to guideline recommendations when providing care to their patients, depending on whether they received a CPG with a tool aimed at improving the use of the CPG, or if they received the CPG only. The results of this review show that healthcare professionals who received a guideline tool together with the CPG on the management of non-specific low back pain or ordering thyroid-function tests probably stick more closely to the recommendations, compared with those who received the CPG only. A guideline tool aimed at improving the use of a guideline, may lead to little or no difference in cost to the health service.
Certainty of the included evidence
The included evidence was from randomised controlled trials, which is considered the highest level of evidence. However, due to high risk of bias in the included studies our confidence in the effect on observing guideline recommendations was moderate. Our confidence in the evidence for cost effectiveness was low, since only a single study provided evidence for this comparison.
Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.
The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs.
To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective.
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites.
We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area.
Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines.
We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.
One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.
Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service.