Optimal Methods for Guideline Implementation: Conclusions From Leeds Castle Meeting

The implementation of guidelines in palliative care - a scoping review

BACKGROUND

Guidelines are essential tools for ensuring high-quality healthcare. However, discrepancies exist between their availability and practical implementation. In the context of palliative care, the extent to which guidelines are implemented and the barriers and facilitators that influence this process remain unknown.

AIM

The present study aimed at systematically reviewing the international literature on the implementation of palliative care guidelines to evaluate factors that support or hinder implementation of palliative care guidelines globally.

METHOD

A scoping review was conducted following the methodological approach of Arksey and O'Malley (2005). After the formulation of research questions and development of a search string, relevant studies investigating the implementation of guidelines were identified and retrieved from the databases CINAHL, LIVIO, PubMed and Web of Science Core Collection on 4 January 2024. Two researchers independently selected articles for inclusion, employing a blinded process with predefined inclusion and exclusion criteria. The results were subsequently categorised deductively by the same researchers using Petermann's (2014) taxonomy of implementation outcomes. The results were summarised and presented in tabular form.

RESULTS

The search yielded 2,086 records, of which 1,252 were included in the title and abstract screening. Subsequently, 113 full-text articles were reviewed for eligibility, resulting in 29 articles deemed suitable for the final analysis. Six implementation outcomes were identified in the included literature: (1) acceptability (n = 15 articles), (2) adoption (n = 6 articles), (3) appropriateness (n = 9 articles), (4) feasibility (n = 9 articles), (5) fidelity/adherence (n = 14 articles) and (6) penetration (n = 14 articles). The majority of studies employed quantitative approaches (n = 22) and considered the perspective of healthcare professionals and their opinions regarding guideline implementation in palliative care. Only 4 articles considered patient related outcomes or the perspectives of the family caregivers. Ten articles reported on facilitators and barriers. Facilitators included healthcare professionals' motivation and managerial support, while barriers primarily referred to time constraints and limited knowledge.

CONCLUSIONS

Guideline implementation in palliative care is highly variable. Future research should aim at comprehensively analysing facilitators of and barriers to this process, considering diverse implementation outcomes. For these evaluations, mixed-method approaches are recommended.

Guidelines or mindlines? - implementing a new CKD guideline in German primary care

BACKGROUND

The development of clinical guidelines aimed at GPs is a key strategy to improving the management of chronic kidney disease (CKD). In 2019, the first CKD guideline aimed specifically at GPs practicing in Germany was published by the German College of General Practitioners and Family Physicians (DEGAM.) AIMS: The aim of this study is to identify the barriers and enablers for the implementation of this guideline. The results of this project, together with quantitative evaluation against quality indicators for CKD in primary care will inform an update to the guideline.

METHODS

We performed 17 semi-structured interviews with GPs practicing in Berlin and Brandenburg. Transcripts were analysed using qualitative content analysis as described by Mayring.

RESULTS

We found that the perception of low clinical priority of CKD compared to other chronic diseases, opportunity cost of using guidelines, as well as poor patient understanding were significant barriers. GPs expressed that improved graphic design or integration of guideline recommendations in clinical decision support systems were enabling factors. Clinical problems concerning CKD were mostly solved by recourse to informal communication with specialists. GPs reported that they rarely consulted CKD guidelines as an aide to clinical decision making.

CONCLUSION

The most significant barrier to use was that guidelines were not used as step-by-step decision aide in consultations with patients. Our analysis suggests that informal contact between primary and secondary care is significant conduit for evidence-based information on CKD in German primary care. Implementation projects should support the development of these relationships.

Implementation of quality indicators for palliative care for patients with incurable cancer at palliative care units in Germany (Quincie): a study protocol for a mixed-methods study

INTRODUCTION

Guidelines are important tools for supporting quality management in the care of patients with cancer. However, in clinical practice barriers exist to their implementation. Consequently, Quincie aims at: (1) gaining a comprehensive picture of the implementation of quality indicators from the national guideline on palliative care for patients with incurable cancer in palliative care units and (2) describing the factors that facilitate and hinder their implementation to develop recommendations.

METHODS AND ANALYSIS

The Quincie study follows a mixed-methods approach across two study phases. In phase 1, routinely collected data of 845 patients with incurable cancer from eight palliative care units in the commuting area of the Comprehensive Cancer Centre Lower Saxony will be analysed, regarding the implementation of 10 quality indicators from the national guideline on palliative care. Structural characteristics of the palliative care units will also be collected. In phase 2, recommendations for the practical implementation of the quality indicators, focusing on the achievement of the quality objectives identified in phase 1, will be developed in an implementation workshop. These recommendations will be subsequently agreed on via a Delphi survey.

ETHICS AND DISSEMINATION

Ethical approval has been given by the ethics committee of the Hannover Medical School (first vote, No. 10567_BO_K_2022) and other relevant institutions. The results will provide urgently needed insights on the implementation of the national guideline on palliative care in clinical care and on the factors that facilitate and hinder this implementation. The results are expected to promote better care for patients with incurable cancer. The results will be directly reported to the participating palliative care units and will be published in relevant peer-reviewed journals. They will also be presented at national conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00029965).

Impact of Individual, Organizational, and Technological Factors on the Implementation of an Online Portal to Support a Clinical Pathway Addressing Psycho-Oncology Care: Mixed Methods Study

Background

Clinical pathways (CPs) can improve patient outcomes but can be complex to implement. Technologies, such as clinical decision support (CDS) tools, can facilitate their use, but require end-user testing in clinical settings.

Objective

This study applied the Technology Acceptance Model to evaluate the individual, organizational, and technological contexts impacting application of a portal to facilitate a CP for anxiety and depression (the ADAPT Portal) in a metropolitan cancer service. The ADAPT Portal triggers patient screening on patient reported outcomes, alerts staff to high scores, recommends evidence-based management, and triggers review and rescreening at set intervals.

Methods

Quantitative and qualitative data on portal activity, data accuracy, and health service staff perspectives were collected. Quantitative data were analyzed descriptively, and thematic analysis was applied to qualitative data.

Results

Overall, 15 (100% of those invited) health service staff agreed to be interviewed. During the pilot, 73 users (36 health service staff members and 37 patients) were registered on the ADAPT Portal. Of the 37 patients registered, 16 (43%) completed screening at least once, with seven screening positive and triaged appropriately. In total, 34 support requests were lodged, resulting in 17 portal enhancements (technical issues). Health service staff considered the ADAPT Portal easy to use and useful; however, some deemed it unnecessary or burdensome (individual issues), particularly in a busy cancer service (organizational issues).

Conclusions

User testing of a CDS to facilitate screening and assessment of anxiety and depression in cancer patients highlighted some technological issues in implementing the ADAPT CDS, resulting in 17 enhancements. Our results highlight the importance of obtaining health service staff feedback when piloting specialized CDS tools and addressing contextual factors when implementing them.

Primary open angle glaucoma management in a tertiary eye care center in Saudi Arabia: a best practice implementation pilot project

AIM

Primary open angle glaucoma (POAG) is a leading cause of permanent visual loss affecting significant numbers in Saudi Arabia. There is no cure for glaucoma but there is mounting evidence to guide ophthalmologists in diagnosing and managing this disease. The aim of this pilot project was to assess the compliance with evidence-based criteria and to implement an adapted clinical practice guideline (CPG) for the management of patients with POAG at a tertiary eye care center in Riyadh, Saudi Arabia that will lead to improving quality, consistency and optimizing patients' care.

METHODS

The project consisted of three phases using audit and feedback strategy. It has utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. Eleven evidence-based audit criteria were developed. A baseline audit was then conducted. Barriers behind areas of noncompliance were identified and a number of strategies were implemented to overcome them. A follow-up postimplementation audit was then conducted.

RESULTS

Twenty electronic medical files were randomly selected for baseline audit. The results of the audit have identified a number of possible areas to improve in the diagnosis and management of POAG in compliance with the adapted CPG with compliance rate as low as 20% (4/20) in some criteria. Multifaceted interventions were implemented targeting mainly attitude and lack of knowledge and time and resource barriers. Significant improvement occurred in most criteria audited postimplementation.

CONCLUSION

The project demonstrates that audit and feedback is a feasible and effective tool to change glaucoma practice in a teaching hospital in Saudi Arabia. The success was due to multifaceted interventions including clear communication to promote awareness, an easily accessible CPG, and regular reminders to improve knowledge and change behavior. We propose our pilot implementation to be generalized to promote implementing evidence-based ophthalmology.

Asthma dissemination around patient-centered treatments in North Carolina (ADAPT-NC): a cluster randomized control trial evaluating dissemination of an evidence-based shared decision-making intervention for asthma management

Objective: To compare three dissemination approaches for implementing an asthma shared decision-making (SDM) intervention into primary care practices. Methods: We randomized thirty practices into three study arms: (1) a facilitator-led approach to implementing SDM; (2) a one-hour lunch-and-learn training on SDM; and (3) a control group with no active intervention. Patient perceptions of SDM were assessed in the active intervention arms using a one-question anonymous survey. Logistic regression models compared the frequency of asthma exacerbations (emergency department (ED) visits, hospitalizations, and oral steroid prescriptions) between the three arms. Results: We collected 705 surveys from facilitator-led sites and 523 from lunch-and-learn sites. Patients were more likely to report that they participated equally with the provider in making the treatment decision in the facilitator-led sites (75% vs. 66%, p = 0.001). Comparisons of outcomes for patients in the facilitator-led (n = 1,658) and lunch-and-learn (n = 2,613) arms respectively vs. control (n = 2,273) showed no significant differences for ED visits (Odds Ratio [OR] [95%CI] = 0.77[0.57-1.04]; 0.83[0.66-1.07]), hospitalizations (OR [95%CI] = 1.30[0.59-2.89]; 1.40 [0.68-3.06]), or oral steroids (OR [95%CI] =0.95[0.79-1.15]; 1.03[0.81-1.06]). Conclusion: Facilitator-led dissemination was associated with a significantly higher proportion of patients sharing equally in decision-making with the provider compared to a traditional lunch-and-learn approach. While there was no significant difference in health outcomes between the three arms, the results were most likely confounded by a concurrent statewide asthma initiative and the pragmatic implementation of the intervention. These results offer support for the use of structured approaches such as facilitator-led dissemination of complex interventions into primary care practices.

Relation between Severe Illness and Non-Completion of Quality-of-Life Questionnaires by Patients with Rectal Cancer

Quality of life (QoL) is an important outcome measure in clinical studies, but interpretation is hindered by incompleteness of data. We addressed this issue in a population-based cohort study of 146 patients with newly diagnosed rectal cancer. QoL was assessed by means of European Organization for the Research and Treatment of Cancer questionnaires at discharge from hospital after primary treatment and then every 3 months for 2 years. In parallel, objective clinical data were documented. Analyses were conducted in three steps: participants versus non-participants with QoL-assessment; poor compliers who filled in only one or two questionnaires (n=20) versus good compliers who filled in all or nearly all questionnaires (n=18); and the proportion of missing forms and critical (very poor) QoL scores in risk patients versus non-risk patients over the course of 2 years. Non-participants and poor compliers were older, were more likely to receive palliative (rather than curative) treatment, and had worse scores for physical status. Tumour progression and therapeutic interventions were more frequent in poor compliers than in good-compliers. Patients with risk factors (age 475 years, poor physical status, palliative treatment) were more likely to have missing questionnaires and critical QoL scores in respect of physical functioning and global quality of life over the course of 2 years. Missing values for QoL have clinical as well as methodological implications, because QoL scores can enhance a clinician's insight. Unwillingness to fill in a questionnaire is an indicator of serious illness. Studies that report sample statistics without specifying compliance rates and the characteristics of non-compliers will give a misleadingly positive picture.

An Official American Thoracic Society Research Statement: Implementation Science in Pulmonary, Critical Care, and Sleep Medicine

BACKGROUND

Many advances in health care fail to reach patients. Implementation science is the study of novel approaches to mitigate this evidence-to-practice gap.

METHODS

The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement on implementation science in pulmonary, critical care, and sleep medicine. The committee used an iterative consensus process to define implementation science and review the use of conceptual frameworks to guide implementation science for the pulmonary, critical care, and sleep community and to explore how professional medical societies such as the ATS can promote implementation science.

RESULTS

The committee defined implementation science as the study of the mechanisms by which effective health care interventions are either adopted or not adopted in clinical and community settings. The committee also distinguished implementation science from the act of implementation. Ideally, implementation science should include early and continuous stakeholder involvement and the use of conceptual frameworks (i.e., models to systematize the conduct of studies and standardize the communication of findings). Multiple conceptual frameworks are available, and we suggest the selection of one or more frameworks on the basis of the specific research question and setting. Professional medical societies such as the ATS can have an important role in promoting implementation science. Recommendations for professional societies to consider include: unifying implementation science activities through a single organizational structure, linking front-line clinicians with implementation scientists, seeking collaborations to prioritize and conduct implementation science studies, supporting implementation science projects through funding opportunities, working with research funding bodies to set the research agenda in the field, collaborating with external bodies responsible for health care delivery, disseminating results of implementation science through scientific journals and conferences, and teaching the next generation about implementation science through courses and other media.

CONCLUSIONS

Implementation science plays an increasingly important role in health care. Through support of implementation science, the ATS and other professional medical societies can work with other stakeholders to lead this effort.

Practice Doesn't Always Make Perfect: A Qualitative Study Explaining Why a Trial of an Educational Toolkit Did Not Improve Quality of Care

BACKGROUND

Diabetes is a chronic disease commonly managed by family physicians, with the most prevalent complication being cardiovascular disease (CVD). Clinical practice guidelines have been developed to support clinicians in the care of diabetic patients. We conducted a pragmatic cluster randomized controlled trial (RCT) of a printed educational toolkit aimed at improving CVD management in diabetes in primary care, and found no effect, and indeed, the possibility of some harm. We conducted a qualitative evaluation to study the strategy for guideline implementation employed in this trial, and to understand its effects. This paper focuses solely on the qualitative findings, as the RCT's quantitative results have already been reported elsewhere.

METHODS AND FINDINGS

All family practices in the province of Ontario had been randomized to receive the educational toolkit by mail, in either the summer of 2009 (intervention arm) or the spring of 2010 (control arm).A subset of 80 family physicians (representing approximately 10% of the practices randomized and approached, with records on 1,592 randomly selected patients with diabetes at high risk for CVD) then took part in a chart audit and reflective feedback exercise related to their own practice in comparison to the guideline recommendations. They were asked to complete two forms (one pre- and one post-audit) in order to understand their awareness of the guidelines pre-trial, their expectations regarding their individual performance pre-audit, and their reflections on their audit results. In addition, individual interviews with thirteen other family physicians were conducted. Textual data from interview transcripts and written commentary from the pre- and post-audit forms underwent qualitative descriptive analysis to identify common themes and patterns. Analysis revealed four main themes: impressions of the toolkit, awareness was not the issue, 'it's not me it's my patients', and chart audit as a more effective intervention than the toolkit. Participants saw neither the toolkit content nor its dissemination strategy to be effective, indicating they perceived themselves to be aware of the guidelines pre-trial. However, their accounts also indicated that they may be struggling to prioritize CVD management in the midst of competing demands for their attention. Upon receiving their chart audit results, many participants expressed surprise that they had not performed better. They reported that the audit results would be an important motivator for behaviour change.

CONCLUSIONS

The qualitative findings outlined in this paper offer important insights into why the intervention was not effective. They also demonstrate that physicians have unperceived needs relative to CVD management and that the chart audit served to identify shortcomings in their practice of which they had been hitherto unaware. The findings also indicate that new methods of intervention development and implementation should be explored. This is important given the high prevalence of diabetes worldwide; appropriate CVD management is critical to addressing the morbidity and mortality associated with the disease.

Hepatitis C virus testing perspectives among primary care physicians in four large primary care settings

BACKGROUND

In 1998, the Centers for Disease Control and Prevention (CDC) published Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease, recommending HCV testing for populations most likely to be infected with HCV. However, the implementation of risk-based screening has not been widely adopted in health care settings, and 45% to 85% of infected U.S. adults remain unidentified.

OBJECTIVES

To develop a better understanding of why CDC's 1998 recommendations have had limited success in identifying persons with HCV infection and provide information about how CDC's 2012 Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945-1965 may be implemented more effectively.

DESIGN

Qualitative data were collected and analyzed from a multidisciplinary team as part of the Birth Cohort Evaluation to Advance Screening and Testing for Hepatitis C project.

RESPONDENTS

Nineteen providers were asked open-ended questions to identify current perspectives, practices, facilitators, and barriers to HCV screening and testing. Providers were affiliated with Henry Ford Hospital, Mount Sinai Hospital, the University of Alabama, and the University of Texas Health Science Center.

RESULTS

Respondents reported the complexity of the 1998 recommendations, and numerous indicated risk factors were major barriers to effective implementation. Other hindrances to hepatitis C testing included physician discomfort in asking questions about socially undesirable behaviors and physician uncertainty about patient insurance coverage.

CONCLUSION

Implementation of the CDC's 2012 recommendations could be more successful than the 1998 recommendations due to their relative simplicity; however, effective strategies need to be used for dissemination and implementation for full success.

Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers' antibiotic prescribing knowledge

BACKGROUND

Inpatient providers have varying levels of knowledge in managing patients with drug and/or penicillin (PCN) allergy.

OBJECTIVES

Our objectives were (1) to survey inpatient providers to ascertain their baseline drug allergy knowledge and preparedness in caring for patients with PCN allergy, and (2) to assess the impact of an educational program paired with the implementation of a hospital-based clinical guideline.

METHODS

We electronically surveyed 521 inpatient providers at a tertiary care medical center at baseline and again 6 weeks after an educational initiative paired with clinical guideline implementation. The guideline informed providers on drug allergy history taking and antibiotic prescribing for inpatients with PCN or cephalosporin allergy.

RESULTS

Of 323 unique responders, 42% (95% CI, 37-48%) reported no prior education in drug allergy. When considering those who responded to both surveys (n = 213), we observed a significant increase in knowledge about PCN skin testing (35% vs 54%; P < .001) and loss of PCN allergy over time (54% vs 80%; P < .0001). Among those who reported attending an educational session (n = 62), preparedness to determine if an allergy was severe significantly improved (77% vs 92%; P = .03). Other areas, including understanding absolute contraindications to receiving a drug again and PCN cross-reactivity with other antimicrobials, did not improve significantly.

CONCLUSIONS

Inpatient providers have drug allergy knowledge deficits but are interested in tools to help them care for inpatients with drug allergies. Our educational initiative and hospital guideline implementation were associated with increased PCN allergy knowledge in several crucial areas. To improve care of inpatients with drug allergy, more research is needed to evaluate hospital policies and sustainable educational tools.

Effect of an educational toolkit on quality of care: a pragmatic cluster randomized trial

BACKGROUND

Printed educational materials for clinician education are one of the most commonly used approaches for quality improvement. The objective of this pragmatic cluster randomized trial was to evaluate the effectiveness of an educational toolkit focusing on cardiovascular disease screening and risk reduction in people with diabetes.

METHODS AND FINDINGS

All 933,789 people aged ≥40 years with diagnosed diabetes in Ontario, Canada were studied using population-level administrative databases, with additional clinical outcome data collected from a random sample of 1,592 high risk patients. Family practices were randomly assigned to receive the educational toolkit in June 2009 (intervention group) or May 2010 (control group). The primary outcome in the administrative data study, death or non-fatal myocardial infarction, occurred in 11,736 (2.5%) patients in the intervention group and 11,536 (2.5%) in the control group (p = 0.77). The primary outcome in the clinical data study, use of a statin, occurred in 700 (88.1%) patients in the intervention group and 725 (90.1%) in the control group (p = 0.26). Pre-specified secondary outcomes, including other clinical events, processes of care, and measures of risk factor control, were also not improved by the intervention. A limitation is the high baseline rate of statin prescribing in this population.

CONCLUSIONS

The educational toolkit did not improve quality of care or cardiovascular outcomes in a population with diabetes. Despite being relatively easy and inexpensive to implement, printed educational materials were not effective. The study highlights the need for a rigorous and scientifically based approach to the development, dissemination, and evaluation of quality improvement interventions.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov NCT01411865 and NCT01026688.

Impact of guideline implementation on transfusion practices in a surgical intensive care unit

BACKGROUND

Anemia is a common clinical problem in cardiac surgery patients in the postoperative period and may result in transfusion in up to 90% of this population. There is tremendous variation in transfusion rates by hospital and individual physician. It is unknown if implementation of a clinical practice guideline lowers unnecessary transfusion in hospital practices that already have a restrictive transfusion culture .

OBJECTIVE

To evaluate transfusion practice before and after implementation of a clinical practice guideline.

DESIGN

Pre/post intervention study.

SETTING

Sixteen bed surgical intensive care unit in an academic hospital.

PARTICIPANTS

Four hundred ninety-five adult patients undergoing cardiac surgery.

INTERVENTIONS

Implementation of an anemia clinical practice guideline reinforced with education and retrospective audit/feedback.

MEASUREMENTS AND MAIN RESULTS

A total of 252 pre-intervention and 243 postintervention cases were examined. Unnecessary transfusion occurred in 14.7% of pre-intervention patients and decreased to a rate of 8.1% after guideline implementation (p = 0.016).

CONCLUSIONS

This study suggests that clinical guideline implementation utilizing guideline development, education, and compliance audit/feedback may reduce unnecessary transfusion in cardiac surgery patients. A fully powered prospective trial would be necessary to validate these findings.

APN-led nursing rounds: an emphasis on evidence-based nursing care

In today's healthcare environment, nursing staff are challenged to care for patients with increasingly complex needs in an ever-changing environment. Nurses are expected to stay up to date on a tremendous number of institutional initiatives, best practice guidelines, and policies and procedures. These practice imperatives are often disseminated through passive means of information-sharing such as staff meetings and electronic mail. In this setting, it is difficult for nurses to simultaneously focus on incorporating practice updates while continuing to value basic nursing functions such as oral care, skin care, and incontinence management. The concept of Interventional Patient Hygiene emphasises that basic nursing functions are not only tasks, but also important evidence-based interventions that contribute to improved health for the patient. Interventional Patient Hygiene facilitates the integration of science and practice. This article describes a quality improvement intervention, Advanced practice nurse-led nursing rounds, which supports Interventional Patient Hygiene and be used to help staff integrate best practices while balancing the multiple priorities inherent in nursing care.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

OBJECTIVES

To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

SEARCH METHODS

For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

MAIN RESULTS

The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

AUTHORS' CONCLUSIONS

The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Interdisziplinäre S3-Leitlinien für substanzbezogene Störungen

Hintergrund: Im Jahr 2006 wurde erstmals eine deutsche evidenzbasierte Leitlinie für substanzbezogene Störungen veröffentlicht. Seitdem hat sich der Kenntnisstand bezüglich des Screenings, der Diagnostik und der Therapie von Suchterkrankungen verbessert. Ziel: Das aktuellste, internationale Wissen über evidenzbasierte Interventionen für alkohol- und tabakbezogenen Störungen soll zusammengefasst, Empfehlungen für die Praxis sollen abgeleitet und abgestimmt werden. Methode: Um Leitlinien der methodischen Qualität S3 im Rahmen der Arbeitsgemeinschaft Wissenschaftlich Medizinischer Fachgesellschaften (AWMF) zu entwickeln, erfolgt 1.) eine systematische Recherche, Auswahl und methodische Bewertung der internationalen Literatur, 2.) eine strukturierte Konsensfindung und 3.) die interdisziplinäre und repräsentative Beteiligung von über 50 Fachgesellschaften, Berufs-, Betroffenen- und Angehörigenverbänden sowie 70 Fachexperten. Ergebnisse: Die Fertigstellung der beiden S3-Leitlinien „Alkohol“ und „Tabak“ ist für das Jahr 2013 geplant. Danach sollen weitere substanzspezifische Leitlinien entwickelt werden. Alle Leitlinien sollen in regelmäßigem Abstand überarbeitet werden, um die Aktualität der klinischen Empfehlungen zu garantieren. Schlussfolgerungen: Die S3-Leitlinien sollen Therapeuten, Betroffenen und Angehörigen eine Entscheidungshilfe bei der Behandlung von Abhängigkeitserkrankungen zur Verfügung stellen.

The Physicians' Practice Assessment Questionnaire on asthma and COPD

We describe a new tool, the Physicians' Practice Assessment Questionnaire (PPAQ), designed for the global self-assessment of implementation of asthma and COPD guidelines, as determined by the percentage of patients in whom physicians estimate that they implement guidelines key recommendations. Some of its properties were assessed by a group of 47 general practitioners (GPs), and test-retest data were obtained in repeating the questionnaire at a 5-week interval without intervention in a sub-group of 28 practitioners. Answers to the various questions were globally reproducible. The lowest scores (recommendations implemented in less than 50% of their patients) were: 1) for both asthma and COPD: referral for patient education, provision of a written action plan and regular assessment of inhaler technique, 2) for asthma: referral to a specialist for difficult to control asthma or uncertain diagnosis, and 3) for COPD: assessment of lung function and disability according to specific criteria and referral to a rehabilitation program. The analysis showed sufficient internal consistency for both questionnaires (Cronbach alphas 0.7617 for asthma and 0.8317 for COPD). Pearson's correlations indicated good test-retest (r = 0.6421, p = 0.0002 for asthma; r = 0.6801, p < 0.0001 for COPD). In conclusion, the PPAQ is a new tool to assess implementation of asthma and COPD guidelines; it has the potential to identify care gaps that can be specifically targeted for intervention.

Reducing hospital‐acquired infections through knowledge‐sharing in work teams

Purpose

The purpose of this study is to analyze the use of a team‐based organizational structure for the purpose of improving the quality of the services provided by the health care system. More specifically, the research aims to investigate the efficiency of a cross‐functional team‐based structure in regard to improving knowledge‐sharing and hereby reducing hospital‐acquired infections (i.e. health‐care associated infections) caused by insufficient hand hygiene.

Design/methodology/approach

The findings are drawn from interviews, observations, and desk research conducted in a large Danish university hospital. The paper has applied a case study methodology using grounded theory and has approached the analysis by employing a holistic view.

Findings

The paper identifies the necessity for educating the hygiene teams in regard to team processes. Professional knowledge of proper hygiene behavior is to be combined with knowledge of procurement, processes of change, and teamwork in such a manner that the members of the hygiene teams can implement these tools effectively.

Research limitations/implications

The study is based on a small sample. The context and process imposed constraints and the findings are context specific; this has implications for the application of the findings to other settings.

Practical implications

Knowledge about proper hand washing is not enhanced through written policies and procedures.

Originality/value

The paper offers insight into means of enhancing hygiene standards by the integration of organizational processes and change with knowledge and knowledge transfer within a hospital.

Integrated audit as a means to implement unit protocols: a randomized and controlled study

RATIONALE

Great emphasis is placed on the need to base assistance activities on efficacy evidence. Nevertheless, it is demonstrated that the mere knowledge of scientific recommendations is not sufficient to determine changes in practice. Many elements can influence the operators' behaviour, so that comprehensive strategies are needed to change wrong or not evidence-based practices.

OBJECTIVES

The aim was to compare the efficacy of two protocol implementation strategies: clinical-organizational integrated audits with feedback and presence of facilitators in the departments versus standard observation.

METHODS

Cluster-randomized, controlled and open trial methods were used. Implementation was investigated for protocols regarding the prevention of pressure lesions and the management of peripheral and central venous catheters. For both protocols, a checklist with the indicators needed for the evaluation was created. The study was divided into five time points. For the initial and final investigation, evaluators filled-in the checklists for both study groups; for the three intermediate investigations, the checklists were self-filled by the operators of the control group, while the operators of the experimental group received the intervention.

RESULTS

For almost all indicators, the data show an increment in the adoption of correct practices. Nevertheless, the last investigation shows a significant (P < 0.05) difference between the two groups in favour of the experimental group: 12 process indicators versus one for catheter management protocol and seven versus one for protocol on pressure lesions.

CONCLUSIONS

The main strong point of the study lies in carrying out an intervention aimed at improving the operators' adoption of two protocols as a whole, rather than of single procedures. The audit intervention allowed to highlight some more subjective criticalities important in determining the success or failure of the implementation of effective practices.

Implementation of guideline-based care for depression in primary care

Evidence-based clinical practice guidelines for treating depression in primary care settings were developed, in part, to ensure that health services are provided in a consistent, high-quality, and cost-effective manner. Yet for a variety of reasons, guideline-based primary care for depression remains the exception rather than the rule. This work provides a brief review of effective strategies used to customize and then deliver evidence-based treatment for depression in primary care settings; describes two representative case studies that illustrate locally customized collaborative care strategies for treatment delivery; and concludes with principles and implications for policy and practice based on our practical experiences.

Prevention of perioperative venous thromboembolism and coronary events: differential responsiveness to an intervention program to improve guidelines adherence

INTRODUCTION

Prevention of venous thromboembolism and coronary events (with beta-blockers) during and after surgery is at the top of a list of safety practices for hospitalized patients, recommended by the Agency for Health Care Research and Quality (AHRQ). We wished to determine and improve adherence to clinical guidelines for these topics in our institution. PATIENTS, MATERIAL, AND METHODS: A prospective survey was conducted over several weeks on operated patients in a 1200-beds medical center (a teaching, community and referral hospital in Jerusalem, Israel). Eligibility for and actual administration of prophylactic treatment with anticoagulant and beta-blockers were determined. Following an intervention program, which included staff meetings, development of local protocols, and academic detailing by a nurse, the survey was repeated.

RESULTS

In general, adherence to recommended anticoagulation prophylaxis was low, found in only 29% [95% confidence interval (CI) = 23-36] of eligible patients. After the intervention, adequate anticoagulation increased to 50% (95% CI = 40-59) of eligible patients (P < 0.001). Initiation of beta-blockers in preventing perioperative cardiac events was very low (0%, 95% CI = 0-5%) and did not increase after intervention.

CONCLUSIONS

Adherence to guidelines for prevention of surgical complications was found to be low in our institution. A multifaceted intervention significantly increased use of prophylaxis for venous thromboembolism but not for coronary events. This differential response suggests that the success of a quality improvement project strongly depends on topic content and its phase of acceptance.

Outcome and quality of life in medicine: a conceptual framework to put quality of life research into practice

It is rather counterproductive to get caught up in never ending discussions on what quality of life (QOL) is and whether it can be assessed. This article is based on the idea that it is much more important to improve the conceptual frameworks that allow the use of the QOL concept in clinical practice. Survival of the QOL concept within the medical community will depend on its contributions to a better understanding of patients and to improving patient care. It is important to accept that QOL should not be viewed in isolation but in synopsis, with other psychologic concepts and clinical data. We propose a profile format that presents QOL data in a way that is easily accessible for clinicians, allowing action to be taken immediately. QOL profiles are never a substitute but a starting point for a patient-doctor interaction. A profile driven interaction has the potential to be structured, efficient, and leading to action.

The promises and pitfalls of evidence-based medicine

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. While advocates welcome the stronger scientific foundation of such guidelines, critics fear that they will lead to "cookbook medicine." Studies show, however, that few guidelines lead to consistent changes in provider behavior. The hopes, fears, and mixed record of EBM are rooted in the traditional professional perspective of the clinician as sole decisionmaker. Multifaceted implementation strategies that take the collaborative nature of medical work into consideration promise more effective changes in clinical practice.

Beiträge der Sozialpsychologie zur Analyse und Lösung von Problemen im deutschen Gesundheitssystem

Zusammenfassung: Ausgangspunkt dieser Darstellung ist die aktuelle Entwicklung in der Gesundheitsversorgung in Deutschland. Zur Debatte stehen tief greifende Änderungen im Versorgungssystem. Leitlinien, die medizinische Behandlungen nach dem neuesten Stand des Wissens festschreiben, werden als wichtiges Mittel zur Lösung vieler Probleme gesehen. Die Entwicklung von Leitlinien hat in den letzten Jahren große Fortschritte gemacht, und der Grund dafür, so das hier propagierte Argument, liegt in der Berücksichtigung von Prinzipien der Gruppenpsychologie. Ebenso wird aufgezeigt, warum die Akzeptanz und Implementierung von Leitlinien Schwierigkeiten bereitet, nämlich wegen der Vernachlässigung von motivationalen Faktoren. Die Sozialpsychologie hält einen wertvollen methodischen und konzeptuellen Schatz zur Analyse und Lösung im Gesundheitsbereich bereit. Die mangelnde Kenntnis dieses Umstandes ist nicht zuletzt einem schlechten Marketing der Sozialpsychologie zuzuschreiben.

Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation

OBJECTIVE

A gap exists between the information contained in published clinical practice guidelines and the knowledge and information that are necessary to implement them. This work describes a process to systematize and make explicit the translation of document-based knowledge into workflow-integrated clinical decision support systems.

DESIGN

This approach uses the Guideline Elements Model (GEM) to represent the guideline knowledge. Implementation requires a number of steps to translate the knowledge contained in guideline text into a computable format and to integrate the information into clinical workflow. The steps include: (1) selection of a guideline and specific recommendations for implementation, (2) markup of the guideline text, (3) atomization, (4) deabstraction and (5) disambiguation of recommendation concepts, (6) verification of rule set completeness, (7) addition of explanations, (8) building executable statements, (9) specification of origins of decision variables and insertions of recommended actions, (10) definition of action types and selection of associated beneficial services, (11) choice of interface components, and (12) creation of requirement specification.

RESULTS

The authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute's guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system.

CONCLUSION

Using the guideline document as a knowledge source promotes authentic translation of domain knowledge and reduces the overall complexity of the implementation task. From this framework, we believe that a better understanding of activities involved in guideline implementation will emerge.

Qualitätsmanagement der postoperativen Schmerztherapie

BACKGROUND

A main target of surgical treatment is to minimize postoperative pain. The aim of this study was to evaluate the benefit of quality management on postoperative pain and to improve pain therapy.

METHODS

In a prospective study, postoperative pain was recorded in a total of 700 patients in a general and visceral surgical ward in 2000, 2001, and 2002. Pain was measured on a ten-point visual analogue scale (0 no pain, 10 most severe pain).

RESULTS

Applying the principles of quality management (plan, do, check, act), we analyzed the reasons for high pain scores in detail. After study of the results in 2000, additional recommendations and guidelines for perioperative pain therapy were provided to all the physicians, and the mean visual analogue pain scores decreased by 15% in 2001 and more than 30% in 2002. At baseline, 12% of patients had pain above the threshold of 3 at rest and 5 in motion. These scores could be reduced to 6% and 3% in the two successive years, respectively.

CONCLUSION

A simple pain management system in a general surgical ward led to considerable improvement in postoperative pain scores as assessed by visual analogue scale.

Quality of Evidence

BACKGROUND

In 1998, the Committee on Health Care Quality in America was created and given the charge of devising a strategy to achieve substantial improvement in the quality of health care for all Americans. One strategy to move the quality agenda forward is the use of evidence by both providers of health care and consumers of health care. One feature of this agenda, evidence-based practice, refers to a hierarchy of evidence ranging from individual randomized, controlled trials to expert opinion.

OBJECTIVES

The purposes of this article are to describe the evidence base in nursing, discuss the quality and strength of nursing's evidence, illustrate the application of the Quality Health Outcomes Model, and present recommendations for practice, research, and policy to increase nursing's contribution to quality health care.

RESULTS AND RECOMMENDATIONS

Nurses everywhere must use innovative solutions to operationalize the "evidence" in evidence-based nursing. The Quality Health Outcomes Model (QHOM) provides a useful way of advancing research and evidence about the quality of health care in America. In concert with the conceptual framework for the National Health Care Quality Report, the QHOM provides a map for identifying evidence gaps and research questions arising from the model and conceptual framework, as well as evidence synthesis (integrating methodologic quality) driven by theoretical understanding.

Antibiograms: Hospitals, Part 1 Pharmaceutical Care in Japan Practice Guideline Implementation

To help readers monitor the most important developments in specialized areas of pharmacy practice in organized health systems, Hospital Pharmacy commissions Basic Bibliographies by guest editors, who have expertise in their respective fields. These guest editors survey the relevant literature and rank approximately 15 to 20 references that represent the most significant research and practice contributions in their areas. The more fundamental are listed first so that persons with limited time can select reading appropriate to their needs. A cumulative index to Basic Bibliography topics will be published semiannually in June and December.

Do local opinion leaders augment hospital quality improvement efforts? A randomized trial to promote adherence to unstable angina guidelines

BACKGROUND

The influence of an opinion leader intervention on adherence to Unstable Angina (UA) guidelines compared with a traditional quality improvement model was investigated.

RESEARCH DESIGN

A group-randomized controlled trial with 2210 patients from 21 hospitals was designed. There were three intervention arms: (1) no intervention (NI); (2) a traditional Health Care Quality Improvement Program (HCQIP); and (3) a physician opinion leader in addition to the HCQIP model (OL). Quality indicators included: electrocardiogram within 20 minutes, antiplatelet therapy within 24 hours and at discharge, and heparin and beta-blockers during hospitalization. Hospitals could determine the specific indicators they wished to target. Potential cases of UA were identified from Medicare claims data. UA confirmation was determined by a clinical algorithm based on data abstracted from medical records. Data analyses included both hospital level analysis (analysis of variance) and patient level analysis (generalized linear models).

RESULTS

The only statistically significant postintervention difference in percentage compliant was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital level (P = 0.01) and patient level analyses (P <0.05) compared with the HCQIP and NI groups. When analyses were confined to hospitals that targeted specific indicators, compared with the HCQIP hospitals, the OL hospitals showed significantly greater change in percentage compliant postintervention in both antiplatelet therapy during the first 24 hours (20.2% vs. -3.9%, P = 0.02) and heparin (31.0% vs.9.1%, P = 0.05).

CONCLUSIONS

The influence of physician opinion leaders was unequivocally positive for only one of five quality indicators. To maximize adherence to best practices through physician opinion leaders, more research on how these physicians influence health care delivery in their organizations will be required.