Effective Strategies for Implementing Clinical Guidelines;

a systematic review

A presentation of graduate research for the students, faculty and guests of Regis University December 01, 2007

“Clinical practice guidelines are systematically developed

statements to assist practitioner and patient decisions about appropriate health care for

specific clinical circumstances” (Institute of Medicine,

1990)

Importance

Reduce variation in clinical practices

Improve quality outcomes

Improve cost effectiveness

Criticisms

‘Cookbook Medicine’Not ReliableNot relevant to the presenting condition(s)Liability

A changing environment

• Increased emphasis on clinical quality

• Patient safety

• Cost effectiveness

• Transparency

• Payment structures (pay-for-performance)

Research Objective

Identify the most effective strategies ofimplementing clinical guidelines through an evidence based approach

Validate physician trustGuide health policyPresent opportunities to promote cost effective improvements in patient care

Methods

Endorsed by the Cochrane Effective Practice and Organization of Care (EPOC)

• Systematic review methodology has the ability to manage potentially unmanageable amounts of information (Torgeson, 2003)

Using qualitative research in systematic reviews

When is not appropriate to use meta-analysis?• Broad review question• Diverse studies (mixing apples with oranges)

Guidance on the Conduct of Narrative Synthesis in Systematic Reviews;

qualitative research methods from the Institute for health research at Lancaster University, London.

Steps for Conducting Narrative Synthesis

• Mapping

• Specify the Review Question

• Identify studies for inclusion

• Data Extraction and quality appraisal

• Synthesis

• Reporting conclusions

Inclusion Criteria using PICO

1) Study meets 4 PICO

2) Study meets 3 PICO

3) Study meets 2 PICO

4) Study meets 1 PICO

5) Study meets 0 PICO

Identify studies for inclusion

Data extraction and quality appraisal

EPPI centre approach

Trustworthiness Appropriateness Relevance Overall Weight A) HIGH

B) MEDIUM

C) LOW

Search Strategy

• Database search; EBSCOhost

• Full-texts published 1990-2007

• (clinical guidelines OR clinical practice guidelines OR evidence based guidelines) and (implement OR disseminate OR integrate) and/or (quality improvement OR process improvement)

Yield

• First search yielded 2727 abstracts for review

• Second screening evaluated 129 articles • Appraisal identified 56 articles for critical

review by first and second reviewer agreement

• Final appraisal identified 33 articles for synthesis

a r t i c l e p d f # Population (setting)

Intervention (Implementation factors present)

Comaprisons (pre/post design)

Outcomes (identified supported)

A Trustworthiness

B Appropriateness

C Relevance

D Overall weight comments

1211980.pdfHospitals yes yes yes 1 b high medium medium medium research does not provide conlcusive evidence to support review question

2444820.pdfclinicical alliance yes no yes 2 b medium medium medium medium clinical focus, lacks appropriateness to answer review question

3009671.pdfPeds Clinics yes yes yes 1 b high mdium high medium controled study, lacks strong approprateness of review question, topical relevance high

3740011.pdfclinicians yes no yes 2 c medium low medium low qualitative desing of guidleine use, lacks significance to review question, offers theoretical and evidenced based topical relevance

3970231.pdfGP yes yes Yes 1 a high high high high controlled study with strong appropriateness to review question

3970284.pdfPCP/GP yes yes yes 2 b medium medium low medium qualitative aevaluation of use of guidelines lacks relevance to review question,

3972072.pdfHospitals Hungry yes yes yes 1 a high medium high high trustworthy study methods, strong topical relevance, lacks some key componants of review question, but offers strong appropriateness to the relevance of the review question

4460579.pdfSingle practice yes yes yes 1 a medium high high high not scholorly, strong appropriateness to review quesiton, strong relevance

4997435.pdfNursing no no yes 3 c medium low low low research based opinion

5172083.pdfno no no no 5 c low low low low commercial proposoal

5184270.pdfGP Austraila no yes no 3 c medium low low low lacks appropriateness to answer review question

5184435.pdfPractice no no no 4 c low low low low lacks appropriateness to answer review question

5186676[1].pdfFP Canada yes yes yes 1 b high medium medium medium qualitative evaluation with componants appropriate to answer review question

5277923.pdfUrban GP yes yes yes 1 b high medium medium medium qaulitative desing, lacks appropriateness to asnwering review question

5302024.pdfHospital yes yes yes 1 b high medium low medium trustworthy research, lacks appropriateness to answering review question

5333208.pdfhospital units yes no yes 2 c medium low medium low lacks approrpiateness to answer review question

5383238.pdfpractices yes yes yes 1 a high high high high trustoworthy research design, appropriate to answering review question

53832385520966.pdfAlliances yes no yes 2 c low low medium low consensus, lacks appropriateness to answer review question

5608247.pdfclinics yes yes yes 1 a high medium high high qualitaive research design, lacks appropriateness to review question, offers strong relevance to review question

5661963[1].pdfno no no no 5 c low low low low has no appropriateness to asnwering review question

5801733[1].pdfclinics Finland yes yes yes 1 b medium medium low medium qualitative desing lacking in appropriateness to answering review question

5861964.pdfhospital units yes yes yes 1 b medium medium medium medium qaulitative research desing, moderate approriateness and relevence toanswer review queistion

5928424.pdfSNF 10 yes yes yes 1 a high high high high experimental design, strong appropriateness to asnwer review quation

6071232.pdfhospital yes no yes 2 c low low medium low non research, lacks approrpiateness to review question, offers moderade relevance to review question

6433398.pdfHealth Trusts yes yes yes 1 b medium medium high medium trustworthy research design, moderate appropriateness with high relevacne to review question

6494343.pdfCommunity RN yes yes yes 1 b medium high high high action research with appropriateness to review question, strong relevance to answer review question

6697833[1].pdfno no no no 5 c low low low low no relevance or appropriateness to review question

6712275[1].pdfBirth Center yes no yes 2 b medium medium medium medium moderate appropriatness to answer review question identified

6725285[1].pdfnone yes no yes 3 c low low medium low opinion based, moderate relevance to answering review question

6756415.pdfno no no no 5 b low medium high medium opinion based, with a strong relevance to answering review question

6756432.pdfhospital China yes yes yes 1 a high high high hgih trustworthy research desing, supports appropriateness to answer review question

6756432[1].pdf6822903[1].pdfhospital yes yes yes 1 b low medium high medium lacks research design, has componants of appropriateness to review question, high releveance to review question

6823752.pdfhospital yes no yes 2 b medium medium emdium medium lacks research design, has noted appropriateness and relevance to answer review question

6879242.pdfperinatal unit yes no yes 2 b medium medium low medium lacks research design, moderate appropriateness

6879246.pdfneonate unit yes no yes 2 b medium medium low medium lacks research design

6906180.pdfHMO clinics yes no yes 2 a high high medium high trustworthy qualitative design, strong appropriateness to review question

6910687.pdfhospital yes yes yes 1 a high high high high mixed method reserch, appropriateness and relevance to review question

6985898[1].pdfhospitals 4 yes yes yes 1 c high low low low controled study, lacks appropriateness to review question

6987359.pdfhospital yes yes yes 1 a high medium high high controlled study, has appropriateness and relevance to answer review question

7254449.pdforganization group hospitals yes no yes 2 a high high high high trusworthy study desing, strong appropriateness and relevance to review question

7296678.pdfhospital yes no yes 2 a high medium high high trustworthy study design, has componants of approrpirateness to review question, strong relevance to review question

7296678[1].pdf

Synthesis

• Thematic Analysis GroupingGrouping by common metaphors, concepts and themes

differentiated by effective vs. non-effective strategy

• Reciprocal TranslationExplores relationships within and between studies

Meta-ethnography approach to derive a constant comparison of themes to deduce primary conclusions

Reference

Common themes, concepts, metaphors. Effective implementation

Common themes, concepts, metaphors. Not Effective implementation Population Method

unit of measure

Hetlivek et al. 1999 1-a-1

computer decision support, no physician or organizational impetus, no use of supplementary materials for implementation measures discrepancy with guidelines

physician clinic

quantitative experimental

comparative discrepancy

Coquard at al. 2002. 1-a-10

Physician consensus, organized process, Physician (opinion leaders) led, existing computerized guidance, comparative measure hospital

experimental case control

comparative tx compliance

Brown et al. 2004. 1-a-13

organized process, existing computer EMR, reminders, prompts, chart posts, auto personalized referral letter,

hospital and physician clinic

case study evaluation

comparative icd audit

Wright & Maydom, 2004 1-a-16

existing computer system, prompts, reminder, auto print guide,

case study prgm evaluation

comparative tx icd-9

Clarke et al. 2005 1-a-17

independent CADS built into existing hospitals system, required additional nurse and physician processing, print out guides for disease

regional hospitals

case study prgm evaluation use of system

Rudisill et al. 2006 1-a-24

med order existing computer order entry, pocket cards, required physician training, pharmacists led, gatekeeper (organizational impetus) hospital

case study program evaluation

comparative order to cpg

Feldstein et al. 2006 2-a-6

existing computer EMR, personalized email to physician links to established pt EMR, system query, sends reminders and follow-up on established intervals

HMO organization

experimental case control control group, intervention group

comparative icd-9, tx

Pasztelyi & Schuler, 2000 1-a-24

printed guideline and established protocols, mailed with current physician comparison feed-back, Intent was to motivate physician behavior with use of peer comparison, no training, no supplemental guidance, no physician or organizational impetus.

physician groups

qualitative post dissemination survey comparative

Marshall et al. 2001 1-a-4

Benchmark, organizational impetus, Team champion facilitator, clinical appraisal feed-back, peer comparison feed-back, process organized, physician accountability, flexibility for individualized center use.

physician clinics

case control with survey follow-up

comparison with cpg benchmark

Lee et al. 2002. 1-a-7

forced organizational led, senior staff responsibility, educational lecture no dissemination. No supportive tools or supplemental guides. hospital

single case study

adherence to to guidelines

Miller et al. 1999 1-a-8

organized process, phased, QI impetus, change agent( champion led) regular audit and feedback, small session training, supplemental guides ( laminated cards, fact sheets, pamphlets, standing orders, care plan, pathways) hospital

case study program evaluation

comparative audit

Results non-effective

• Implementation strategy was passive • Guidelines are not generally accepted

• Guidelines are to long or complex • Implementation lacks accountability and

ownerships • Implementation process was unorganized or

required competing organizational values

Results Effective • Implementation is effective when applied to

structured quality improvements• Implementation is effective when guidelines are

are used as a benchmark or other comparative measure

• Regular feedback is critical to successful implementation

• Assistive supports in real-time help facilitate implementation

• Organizational setting must be supportive

Conceptual findings

• Quality Improvement facilitates social influencing behavior by acting as its vehicle

• Feedback and use of other comparative measures promotes group and individual competition & facilitating social influence through perceived intention.

• Knowledge translation; The use of assistive supports in real time that promote guidelines implementation presents a social influence at the level of interpersonal cognitive processing

• Organizational cultures are a construct to social influence where the organizations social structure has the most ability to influence either positively or negatively to the desired implementation.

Conclusion

Evidence Based Protocols for implementing clinical guidelines

Future Research

Limitations

Acknowledgements

Special thanks to Cassidy Smith from the Colorado Clinical Guidelines Collaborative

Jennie Popay and the teams for the providing the methods group Guidance on the conduct of Narrative Synthesis

My friends family and colleagues for their patients and support in helping me make this happen

THE END