Success in implementing a hospital-wide evidence-based clinical pathways system for the management of cardiac patients: the ACAP program experience

Trends in guideline implementation: a scoping systematic review

BACKGROUND

There is currently no reliable way to choose strategies that are appropriate for implementing guidelines facing different barriers. This study examined trends in guideline implementation by topic over a 10-year period to explore whether and how strategies may be suitable for addressing differing barriers.

METHODS

A scoping systematic review was performed. MEDLINE and EMBASE were searched from 2004 to 2013 for studies that evaluated the implementation of guidelines on arthritis, diabetes, colorectal cancer and heart failure. Data on study characteristics, reason for implementation (new guideline or quality improvement), implementation strategy used, rationale for selecting that strategy and reported impact were extracted and summarized. Interventions were mapped against a published taxonomy of guideline implementation strategies.

RESULTS

The search resulted in 1,709 articles; 156 were retrieved and 127 were excluded largely because they did not evaluate guideline implementation, leaving 32 eligible for review (4 arthritis, 3 colorectal cancer, 21 diabetes, 4 heart failure). Six of 7 randomized trials and 8 of 25 observational studies had a low risk of bias. Most studies promoted guideline use for quality improvement (78.0%). Few studies rationalized strategy choice (18.8%). Most employed multiple approaches and strategies, most often educational meetings and print material for professionals or patients. Few studies employed organizational, financial or regulatory approaches. Strategies employed that were unique to the published taxonomy included professional (print material, tailoring guidelines, self-audit training or material) and patient strategies (education, counselling, group interaction, print material, reminders). Most studies achieved positive impact (87.5%). This did not appear to be associated with guideline topic, use of theory or barrier assessment, or number or type of implementation approaches and strategies.

CONCLUSIONS

While few studies were eligible, limiting insight on how to choose implementation strategies that address guideline-specific barriers, this review identified other important findings. Education for professionals or patients and print material were the most commonly employed strategies for translating guidelines to practice. Mapping of strategies onto the published taxonomy identified gaps in guideline implementation that represent opportunities for future research and expanded the taxonomy.

Deviations from guideline-based therapy for febrile neutropenia in cancer patients and their effect on outcomes

IMPORTANCE

Although febrile neutropenia (FN) is a major source of morbidity and mortality for patients with solid tumors, little is known about the use of guideline-based care.

OBJECTIVES

To examine compliance with guideline-based recommendations for FN treatment, explore the factors that influence adherence to consensus guidelines, and analyze how the use of guideline-based care affects the outcomes.

DESIGN

The Perspective database was used to examine the treatment of cancer patients with FN from January 1, 2000, through March 31, 2010. To capture initial decision making, we examined treatment within 48 hours of hospital admission. We determined use of guideline-based antibiotics and nonguideline-based treatments, vancomycin, and granulocyte colony-stimulating factors (GCSF). Hierarchical models were developed to examine the factors associated with treatment. Patients were stratified into low- and high-risk groups, and the effect of the initial treatment on outcome (nonroutine hospital discharge and death) was examined.

SETTING AND PARTICIPANTS

Twenty-five thousand two hundred thirty-one patients with solid tumors hospitalized for neutropenia.

MAIN OUTCOME MEASURE

Use of guideline-based antibiotics, vancomycin, and GCSF and their affect on outcome.

RESULTS

Among 25 231 patients admitted with FN, guideline-based antibiotics were administered to 79%, vancomycin to 37%, and GCSF to 63%. Patients treated at high FN-volume hospitals (odds ratio [OR], 1.56; 95% CI, 1.34-1.81) by high FN-volume physicians (OR, 1.19; 95% CI, 1.03-1.38) and patients managed by hospitalists (OR, 1.49; 95% CI, 1.18-1.88) were more likely to receive guideline-based antibiotics (P < .05). Vancomycin use increased from 17% in 2000 to 55% in 2010, while GCSF use only decreased from 73% to 55%. Among low-risk patients with FN, prompt initiation of guideline-based antibiotics decreased discharge to a nursing facility (OR, 0.77; 95% CI, 0.65-0.92) and death (OR, 0.63; 95% CI, 0.42-0.95).

CONCLUSIONS AND RELEVANCE

While use of guideline-based antibiotics is high, use of the nonguideline-based treatments, vancomycin, and GCSF is also high. Physician and hospital factors are the strongest predictors of both guideline- and nonguideline-based treatment.