Article type
Year
Abstract
Introduction/Objective: This study analyzes the findings from AHCPR-sponsored investigations of guideline dissemination and implementation, compares these findings to published reviews of the effectiveness of guidelines and other interventions to improve clinical practice, and highlights the implications for promoting the use of evidence-based information in improving the quality of health care.
Methods: An evaluation synthesis of 68 grants and contracts, funded by the U.S. Agency for Health Care Policy & Research since 1989, that investigate aspects of guideline dissemination and implementation.
Results: Awareness and acceptance of evidence-based clinical information or recommendations is necessary but not sufficient to cause changes in clinician behavior. Acceptance by clinicians of recommendations for practice change is heavily influenced by the perceived credibility of the source of the recommendations. Obstacles to acceptance and use of guidelines are diverse, vary with the nature of the desired behavior change, and affect which dissemination and implementation strategies are effective. Efforts to implement guidelines are hampered by ambiguity or lack of specificity in clinical recommendations, or the inconsistency of the recommendations compared with existing practice patterns or health care policies. To increase clinician acceptance and to enhance applicability to specific provider organizations, clinical settings and patient populations, guidelines and recommendations are frequently adapted by local provider institutions. Adaptation may include adoption of only selected recommendations from the guideline, efforts to increase the specificity or clarity of guideline recommendations, or development of institution-specific implementation tools to facilitate adherence to the guideline, such as clinical paths, laminated pocket guides, or adaptation to the structure of the medical record. It is often difficult to demonstrate a causal relationship between specific dissemination or implementation strategies and observed changes in clinical practice or outcomes. When interventions are sub-optimal, effects are often modest and short-lived.
Discussion: The consistent need for local adaptation raises important issues concerning the appropriate format and dissemination vehicle for evidence-based clinical findings and recommendations developed at the national level. Effective dissemination and implementation strategies must be tailored to specific organizational and practice environments and designed to overcome specific obstacles. Success often requires the introduction of multiple and sustained interventions such as use of opinion leaders and key physicians advocates to introduce proposed changes, introduction of implementation tools or system level changes to facilitate adoption of guideline recommendations, and ongoing feedback to clinicians about performance relative to the guideline recommendations, and ongoing feedback to clinicians about performance relative to the guideline recommendations. Additional research examining the impact of multiple interventions, scaled to the magnitude of obstacles to change, is needed.
Methods: An evaluation synthesis of 68 grants and contracts, funded by the U.S. Agency for Health Care Policy & Research since 1989, that investigate aspects of guideline dissemination and implementation.
Results: Awareness and acceptance of evidence-based clinical information or recommendations is necessary but not sufficient to cause changes in clinician behavior. Acceptance by clinicians of recommendations for practice change is heavily influenced by the perceived credibility of the source of the recommendations. Obstacles to acceptance and use of guidelines are diverse, vary with the nature of the desired behavior change, and affect which dissemination and implementation strategies are effective. Efforts to implement guidelines are hampered by ambiguity or lack of specificity in clinical recommendations, or the inconsistency of the recommendations compared with existing practice patterns or health care policies. To increase clinician acceptance and to enhance applicability to specific provider organizations, clinical settings and patient populations, guidelines and recommendations are frequently adapted by local provider institutions. Adaptation may include adoption of only selected recommendations from the guideline, efforts to increase the specificity or clarity of guideline recommendations, or development of institution-specific implementation tools to facilitate adherence to the guideline, such as clinical paths, laminated pocket guides, or adaptation to the structure of the medical record. It is often difficult to demonstrate a causal relationship between specific dissemination or implementation strategies and observed changes in clinical practice or outcomes. When interventions are sub-optimal, effects are often modest and short-lived.
Discussion: The consistent need for local adaptation raises important issues concerning the appropriate format and dissemination vehicle for evidence-based clinical findings and recommendations developed at the national level. Effective dissemination and implementation strategies must be tailored to specific organizational and practice environments and designed to overcome specific obstacles. Success often requires the introduction of multiple and sustained interventions such as use of opinion leaders and key physicians advocates to introduce proposed changes, introduction of implementation tools or system level changes to facilitate adoption of guideline recommendations, and ongoing feedback to clinicians about performance relative to the guideline recommendations, and ongoing feedback to clinicians about performance relative to the guideline recommendations. Additional research examining the impact of multiple interventions, scaled to the magnitude of obstacles to change, is needed.