Effectiveness and efficiency of guideline dissemination and implementation strategies
Effectiveness and efficiency of guideline dissemination and implementation strategies
复制标题
DOI：
10.3310/hta8060
复制
发表时间：
2004-02-01
影响因子：
3.6
通讯作者：
Donaldson, C
中科院分区：
文献类型：
--
作者：
Grimshaw, JM;Thomas, RE;Donaldson, C
目的：对不同指南制定、传播和实施策略的有效性和成本进行系统回顾。评估这些策略对资源的影响。制定一个框架，以决定何时有效地制定和引入临床指南。数据来源：MEDLINE， Healthstar， Cochrane对照试验注册，EMBASE， SIGLE和Cochrane有效实践和护理组织（EPOC）组的专业注册。回顾方法：基于主要终点或几个报告终点的中位数测量，为每个研究比较推导出二元过程变量的单一估计。对不同类型的干预进行了单独的分析比较。该研究还探讨了多方面干预的效果是否随着干预成分的增加而增加。报告经济数据的研究也得到了严格的评价。对来自初级和二级保健的关键信息提供者进行了一项调查，以估计指南传播和实施策略在英国的可行性和可能的资源需求。结果：总共有235项研究报告309项比较符合纳入标准；其中73%的比较评估了多方面干预措施，尽管特定多方面干预措施的最大重复次数为11次比较。总的来说，大多数报告二分类过程数据的比较观察到护理的改善；然而，在干预措施内部和不同干预措施之间观察到的效果存在相当大的差异。通常评价的单一干预措施是提醒、传播教育材料以及审计和反馈。涉及教育外展的多方面干预有23项比较。大多数干预措施观察到护理的适度改善。没有发现成分干预的数量与多方面干预的效果之间的关系。只有29.4%的比较报告了任何经济数据。大多数研究只报告了治疗费用；只有25项研究报告了指南制定或指南传播和实施成本的数据。大多数研究使用过程测量作为其主要终点，尽管事实上只有三个指导方针是明确基于证据的（并且可能不是有效的）。关键信息提供者调查的答复者很少确定现有的预算，以支持指南的传播和实施战略。总的来说，答复者认为，在现有资源范围内，一般只有分发教材和举行短期（午餐时间）教育会议是可行的。结论：在不同情况下，指导方针的传播和实施策略可能是有效的，支持决策的证据基础并不完善。决策者需要对如何最好地利用他们所拥有的有限资源进行临床治理和相关活动以最大限度地提高人口效益进行相当的判断。他们需要考虑临床有效性活动的潜在临床领域，引入指南所需的可能效益和成本，以及提供者行为发生任何变化可能带来的效益和成本。需要进一步的研究：发展和验证卫生专业人员和组织行为以及行为改变的连贯理论框架，以便更好地为研究和服务环境中干预措施的选择提供信息，并在存在不同障碍和影响调节因素的情况下估计传播和实施战略的效率。
Objectives: To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.Data sources: MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care ( EPOC) group.Review methods: Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care.Results: In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based ( and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short ( lunchtime) educational meetings were generally feasible within current resources.Conclusions: There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.