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BMC Medical Informatics and Decision Making
Published in: BMC Medical Informatics and Decision Making 1/2008

Open Access 01-12-2008 | Research article

Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review

Authors: Anneke L Francke, Marieke C Smit, Anke JE de Veer, Patriek Mistiaen

Published in: BMC Medical Informatics and Decision Making | Issue 1/2008

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Abstract

Background

Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect the implementation of guidelines, and secondly, to provide insight into the "state-of-the-art" regarding research within this field.

Methods

A search of five literature databases and one website was performed to find relevant existing systematic reviews or meta-reviews. Subsequently, a two-step inclusion process was conducted: (1) screening on the basis of references and abstracts and (2) screening based on full-text papers. After that, relevant data from the included reviews were extracted and the methodological quality of the reviews was assessed by using the Quality Assessment Checklist for Reviews.

Results

Twelve systematic reviews met our inclusion criteria. No previous systematic meta-reviews meeting all our inclusion criteria were found. Two of the twelve reviews scored high on the checklist used, indicating only "minimal" or "minor flaws". The other ten reviews scored in the lowest of middle ranges, indicating "extensive" or "major" flaws.
A substantial proportion (although not all) of the reviews indicates that effective strategies often have multiple components and that the use of one single strategy, such as reminders only or an educational intervention, is less effective.
Besides, characteristics of the guidelines themselves affect actual use. For instance, guidelines that are easy to understand, can easily be tried out, and do not require specific resources, have a greater chance of implementation.
In addition, characteristics of professionals – e.g., awareness of the existence of the guideline and familiarity with its content – likewise affect implementation.
Furthermore, patient characteristics appear to exert influence: for instance, co-morbidity reduces the chance that guidelines are followed.
Finally, environmental characteristics may influence guideline implementation. For example, a lack of support from peers or superiors, as well as insufficient staff and time, appear to be the main impediments.

Conclusion

Existing reviews describe various factors that influence whether guidelines are actually used. However, the evidence base is still thin, and future sound research – for instance comparing combinations of implementation strategies versus single strategies – is needed.
Appendix
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Literature
1.
2.
WHO World Health Organization: Global programme on evidence for health policy. Guidelines for WHO Guidelines. 2003, Geneva: WHO World Health Organization
3.
Schunemann HJ, Fretheim A, Oxman AD: Improving the use of research evidence in guideline development: 1. Guidelines for guidelines. Health Res Policy Syst. 2006, 4: 13-CrossRefPubMedPubMedCentral
4.
Grol R, Grimshaw J: From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003, 362: 1225-1230.CrossRefPubMed
5.
Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J: Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999, 318: 527-530.CrossRefPubMedPubMedCentral
6.
Casparie AF, Theuvenet WJ, Klazinga NS, Timmermans AE: Richtlijnontwikkeling als onderdeel van het kwaliteitsysteem [Development of guidelines as part of the quality system]. Evidence-based richtlijnontwikkeling [Evidence-based guideline development]. Edited by: van Everdingen JJE, Burgers JS, Assendelft WJJ, Swinkels JA, van Barneveld TA, van de Klundert JLM. 2004, Houten: Bohn Stafleu Van Loghum
7.
8.
Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J: Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999, 318: 527-530.CrossRefPubMedPubMedCentral
9.
Espeland A, Baerheim A: Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers – a qualitative study. BMC Health Serv Res. 2003, 3: 8-CrossRefPubMedPubMedCentral
10.
Azevedo JM, Germano CD: Potential of the Executive Order Increasing the Participation of Asian Americans and Pacific Islanders in Federal Programs. Asian Am Pac Isl J Health. 1999, 7: 47-56.PubMed
11.
Fretheim A, Schunemann HJ, Oxman AD: Improving the use of research evidence in guideline development: 15. Disseminating and implementing guidelines. Health Res Policy Syst. 2006, 4: 27-CrossRefPubMedPubMedCentral
12.
Burgers JS, Grol RP, Zaat JO, Spies TH, Bij van der AK, Mokkink HG: Characteristics of effective clinical guidelines for general practice. Br J Gen Pract. 2003, 53: 15-19.PubMedPubMedCentral
13.
Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H: Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ. 1998, 317: 858-861.CrossRefPubMedPubMedCentral
14.
Bauer MS: A review of quantitative studies of adherence to mental health clinical practice guidelines. Harv Rev Psychiatry. 2002, 10: 138-153.CrossRefPubMed
15.
Black N, Murphy M, Lamping D, McKee M, Sanderson C, Askham J: Consensus development methods: a review of best practice in creating clinical guidelines. J Health Serv Res Policy. 1999, 4: 236-248.PubMed
16.
Lomas J: Words without action? The production, dissemination, and impact of consensus recommendations. Annu Rev Public Health. 1991, 12: 41-65.CrossRefPubMed
17.
Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J: Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998, 2: i-88.PubMed
18.
Oxman AD, Lavis JN, Fretheim A: Use of evidence in WHO recommendations. World Hosp Health Serv. 2007, 43: 14-20.PubMed
19.
Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L: Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001, 39: II2-45.CrossRefPubMed
20.
NHS Centre for Reviews and Dissemination: Getting evidence into practice. Effective Health Care Bulletin. 1999, 5: 1-16.
21.
Oxman AD, Thomson MA, Davis DA, Haynes RB: No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995, 153: 1423-1431.PubMedPubMedCentral
22.
Solberg LI: Guideline implementation: what the literature doesn't tell us. Jt Comm J Qual Improv. 2000, 26: 525-537.PubMed
23.
Wensing M, Weijden van der T, Grol R: Implementing guidelines and innovations in general practice: which interventions are effective?. Br J Gen Pract. 1998, 48: 991-997.PubMedPubMedCentral
24.
Boyd EA, Bero LA: Improving the use of research evidence in guideline development: 4. Managing conflicts of interests. Health Res Policy Syst. 2006, 4: 16-CrossRefPubMedPubMedCentral
25.
Edejer TT: Improving the use of research evidence in guideline development: 11. Incorporating considerations of cost-effectiveness, affordability and resource implications. Health Res Policy Syst. 2006, 4: 23-CrossRefPubMedPubMedCentral
26.
Fretheim A, Schunemann HJ, Oxman AD: Improving the use of research evidence in guideline development: 5. Group processes. Health Res Policy Syst. 2006, 4: 17-CrossRefPubMedPubMedCentral
27.
Fretheim A, Schunemann HJ, Oxman AD: Improving the use of research evidence in guideline development: 3. Group composition and consultation process. Health Res Policy Syst. 2006, 4: 15-CrossRefPubMedPubMedCentral
28.
Oxman AD, Fretheim A, Schunemann HJ: Improving the use of research evidence in guideline development: introduction. Health Res Policy Syst. 2006, 4: 12-CrossRefPubMedPubMedCentral
29.
Oxman AD, Schunemann HJ, Fretheim A: Improving the use of research evidence in guideline development: 8. Synthesis and presentation of evidence. Health Res Policy Syst. 2006, 4: 20-CrossRefPubMedPubMedCentral
30.
Oxman AD, Schunemann HJ, Fretheim A: Improving the use of research evidence in guideline development: 2. Priority setting. Health Res Policy Syst. 2006, 4: 14-CrossRefPubMedPubMedCentral
31.
Oxman AD, Schunemann HJ, Fretheim A: Improving the use of research evidence in guideline development: 7. Deciding what evidence to include. Health Res Policy Syst. 2006, 4: 19-CrossRefPubMedPubMedCentral
32.
Oxman AD, Schunemann HJ, Fretheim A: Improving the use of research evidence in guideline development: 12. Incorporating considerations of equity. Health Res Policy Syst. 2006, 4: 24-CrossRefPubMedPubMedCentral
33.
Oxman AD, Schunemann HJ, Fretheim A: Improving the use of research evidence in guideline development: 14. Reporting guidelines. Health Res Policy Syst. 2006, 4: 26-CrossRefPubMedPubMedCentral
34.
Oxman AD, Schunemann HJ, Fretheim A: Improving the use of research evidence in guideline development: 16. Evaluation. Health Res Policy Syst. 2006, 4: 28-CrossRefPubMedPubMedCentral
35.
Schunemann HJ, Fretheim A, Oxman AD: Improving the use of research evidence in guideline development: 10. Integrating values and consumer involvement. Health Res Policy Syst. 2006, 4: 22-CrossRefPubMedPubMedCentral
36.
Schunemann HJ, Fretheim A, Oxman AD: Improving the use of research evidence in guideline development: 13. Applicability, transferability and adaptation. Health Res Policy Syst. 2006, 4: 25-CrossRefPubMedPubMedCentral
37.
Schunemann HJ, Fretheim A, Oxman AD: Improving the use of research evidence in guideline development: 9. Grading evidence and recommendations. Health Res Policy Syst. 2006, 4: 21-CrossRefPubMedPubMedCentral
38.
Schunemann HJ, Oxman AD, Fretheim A: Improving the use of research evidence in guideline development: 6. Determining which outcomes are important. Health Res Policy Syst. 2006, 4: 18-CrossRefPubMedPubMedCentral
39.
Richens Y, Rycroft-Malone J, Morrell C: Getting guidelines into practice: a literature review. Nurs Stand. 2004, 18 (50): 33-40.CrossRef
40.
Cheater FM, Closs SJ: The effectiveness of methods of dissemination and implementation of clinical guidelines for nursing practice: a selective review. Clinical Effectiveness in Nursing. 1997, 1: 4-15.CrossRef
41.
Grimshaw J, Eccles M, Thomas R, Maclennan G, Ramsay C, Fraser C: Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med. 2006, 21 (Suppl 2): S14-S20.PubMedPubMedCentral
42.
Grimshaw JM, Thomas RE, Maclennan G, Fraser C, Ramsay CR, Vale L: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004, 8: iii-72.CrossRefPubMed
43.
Oxman AD, Guyatt GH, Singer J, Goldsmith CH, Hutchison BG, Milner RA: Agreement among reviewers of review articles. J Clin Epidemiol. 1991, 44: 91-98.CrossRefPubMed
44.
Oxman AD, Guyatt GH: Validation of an index of the quality of review articles. J Clin Epidemiol. 1991, 44: 1271-1278.CrossRefPubMed
45.
Mistiaen P, Francke AL, Poot E: Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review. BMC Health Serv Res. 2007, 7: 47-CrossRefPubMedPubMedCentral
46.
Ospina MB, Kelly K, Klassen TP, Rowe BH: Overview of reports on the quality of systematic reviews and meta-analysis in the biomedical literature [conference abstract]. Canadian Journal of Emergency Medicine. 2005, 7: 176-
47.
Katrak P, Bialocerkowski AE, Massy-Westropp N, Kumar S, Grimmer KA: A systematic review of the content of critical appraisal tools. BMC Med Res Methodol. 2004, 4: 22-CrossRefPubMedPubMedCentral
48.
Shea B, Dubé C, Moher D: Assessing the quality of reports of systematic reviews: the QUORUM statement compared to other tools. Systematic reviews in health care: meta-analysis in context. Edited by: Egger M, Smith GD, Altman DG. 2001, London: BMJ Publishing Group, 122-139.CrossRef
49.
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA: Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999, 282: 1458-1465.CrossRefPubMed
50.
Simpson SH, Marrie TJ, Majumdar SR: Do guidelines guide pneumonia practice? A systematic review of interventions and barriers to best practice in the management of community-acquired pneumonia. Respir Care Clin N Am. 2005, 11: 1-13.CrossRefPubMed
51.
Sachs M: [Successful strategies and methods of nursing standards implementation]. Pflege. 2006, 19: 33-44.CrossRefPubMed
52.
Saillour-Glenisson F, Michel P: [Individual and collective facilitators of and barriers to the use of clinical practice guidelines by physicians: a literature review]. Rev Epidemiol Sante Publique. 2003, 51: 65-80.PubMed
53.
Grilli R, Lomas J: Evaluating the message: the relationship between compliance rate and the subject of a practice guideline. Med Care. 1994, 32: 202-213.CrossRefPubMed
54.
Gross PA, Pujat D: Implementing practice guidelines for appropriate antimicrobial usage: a systematic review. Med Care. 2001, 39: II55-II69.PubMed
55.
Tooher R, Middleton P, Babidge W: Implementation of pressure ulcer guidelines: what constitutes a successful strategy?. J Wound Care. 2003, 12: 373-2.CrossRefPubMed
56.
Thomas L, Cullum N, McColl E, Rousseau N, Soutter J, Steen N: Guidelines in professions allied to medicine. Cochrane Database Syst Rev. 1999, CD000349-2
57.
Davis DA, Taylor-Vaisey A: Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997, 157: 408-416.PubMedPubMedCentral
58.
Davies J, Freemantle N, Grimshaw J, Hurwitz B, Long A, Russell IT: Implementing clinical practice guidelines: Can guidelines be used to improve clinical practice?. Effective Health Care Bulletin. 1994, 1: 1-12.
59.
The Agree Collaboration: Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. 2008
60.
Tinetti ME, Bogardus ST, Agostini JV: Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004, 351: 2870-2874.CrossRefPubMed
61.
Durso SC: Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA. 2006, 295: 1935-1940.CrossRefPubMed
62.
Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L: Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001, 39: II2-45.CrossRefPubMed
63.
Chaillet N, Dube E, Dugas M, Audibert F, Tourigny C, Fraser WD: Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol. 2006, 108: 1234-1245.CrossRefPubMed
64.
Weinmann S, Koesters M, Becker T: Effects of implementation of psychiatric guidelines on provider performance and patient outcome: systematic review. Acta Psychiatr Scand. 2007, 115: 420-433.CrossRefPubMed
Metadata
Title
Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review
Authors
Anneke L Francke
Marieke C Smit
Anke JE de Veer
Patriek Mistiaen
Publication date
01-12-2008
Publisher
BioMed Central
Published in
BMC Medical Informatics and Decision Making / Issue 1/2008
Electronic ISSN: 1472-6947
DOI
https://doi.org/10.1186/1472-6947-8-38

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