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Translating guidelines into practice

 

Clinical guidelines as a tool to improve the quality of health care have been evolving over the last decade. They are an important component of the movement to implement evidence-based practice. Guidelines are welcomed by funders of health care who see them as a means to eliminate unacceptable variations in practice. Guidelines are now becoming integrated into the thinking of many clinicians and professional clinical organisations.

But doubts remain about how best to promote their use. What is the best way to encourage health professionals to adopt new information and change their practice? These concerns prompted a systematic review of the theory about, the practical experience of using them, and the research evidence about the adoption of clinical guidelines.

Reference

DA Davis, Anne Taylor-Vaisey. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical, practice guidelines. Can Med Assoc J. 1997 157: 408-416.

How was the review tackled?

The team developed a search strategy involving three main steps. First, they reviewed theoretical models about how clinicians learn and how guidelines are produced. Second, they searched relevant databases for suitable papers etc. The search embraced sources linked to continuing medical education as well as other health care research material covering the period 1990 to 1996. It used a combination of MeSH headings and key words. Third, papers identified in the search were screened to identify randomised-controlled trials and to trials that objectively measured physicians performance or health care outcomes.

The results of the search were then examined against three key questions:

  1. Do clinical guidelines dissemination or implementation processes work?
  2. Which non-educational factors affect the adoption of guidelines?
  3. Which specific educational interventions facilitate the implementation of clinical guidelines?

Findings related to the latter questions were looked at as either review papers or specific educational strategies.

What did the review find?

Do clinical guidelines dissemination or implementation processes work?

The answer to this question was mixed. Some studies had shown significant improvements in outcomes, but the results were often weak or positive to a limited degree. Furthermore the more positive outcomes often reflected the intensity of the effort to implement them.

Which non-educational factors affect the adoption of guidelines?

The review identified several papers that explored the variables that impede of facilitate adoption of guidelines.

  1. Quality of the guidelines . How will it be received? An important factor is the merit of the guideline - is the practice being proposed demonstrably better than the old one? Research has also shown that guidelines that are relatively uncomplicated and which could be seen in operation and/or tested were more likely to be adopted.
  2. The characteristics of the health care professional . Are they likely to be receptive? Some studies suggest that younger clinicians may be more favourably inclined towards the concept of clinical guidelines. Other studies showed that clinicians might be concerned about the impact of clinical guidelines on their clinical autonomy and satisfaction with practice.
  3. Characteristics of the practice setting . Does the organisation support adoption of the guideline? Factors such as the efficiency of local systems and the attitudes of local peers appear to be determinants of clinician behaviour.
  4. Incentives . What is in it for the clinician? Several studies showed that financial reward may advance implementation.
  5. Regulation and/or accreditation by a licensing or professional regulatory body has been shown to encourage the uptake of guidelines.
  6. Patient interest and demand can also be influential. Do patients want the new practice?

Which specific educational interventions facilitate the implementation of clinical guidelines?

The review identified two types of material.

Review papers , which had looked at literature about educational approaches. These indicated that the interventions fall into three categories:

Weak interventions : ie didactic lecture-based continuing medical education (CME) and mailed, unsolicited material.

Moderately effective interventions : ie audit and feedback, especially if directed at specific clinicians and delivered by peers or opinion leaders.

Relatively strong intervention : ie reminder systems, academic detailing and multiple interventions when used together.

Results of trials of specific educational strategies .

The review identified trials of four traditional continuing medical education methods :

1. Educational materials - which had been shown to have some impact on the behaviour of GPs.

2. Formal CME conferences and workshops - which had shown that those involving small group work had some impact whereas traditional seminars had little effect.

3. Academic detailing - taking the message to clinicians 'on the shop floor' was shown to be effective.

4. Opinion leaders - educationally influential and respected clinicians - were shown to be effective.

The review identified three types of practice-based interventions :

1 Patient-based interventions , involving the creation of educational material for patients had been shown to be effective.

2 Audit and feedback , had been shown to have mixed effect although if carefully managed and made concurrently it could be effective.

3 Reminders , as material to reinforce the messages in clinical guidelines have been shown to be effective.

The review also identified studies involving multiple intervention strategies. This work involved two or more interventions linked together to achieve specific objectives, such as using mailing material to clinicians, follow-up telephone calls, presentations at meetings and follow-up meetings involving local specialists. A subsequent audit had shown that this programme had significant impact.

What has the review told us?

In the drive to improve the quality of health care, it can be argued that the creation of clinical guidelines is the relatively simple part of the task - the real challenge is to implement the guidelines. As the review says, the creation of guidelines without significant attention to their adoption is ' a sterile exercise, which is wasteful of intellectual and human resources '. This review has provided much ammunition to help those charged with the implementation of clinical guidelines.

A strategy for implementation is essential. It needs to take account of the nature of the guideline, the nature and beliefs of the clinicians to whom it is directed and the organisational context for the change. The strategy should have three stages. First , being clear about the need for change, second , making information available generally to as many health professionals as possible and third , reinforcing the need to change in the practice setting - get out, talk to and help those involved.