Toward evidence-based quality improvement - Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998
Toward evidence-based quality improvement - Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998
复制标题
DOI：
10.1111/j.1525-1497.2006.00357.x
复制
发表时间：
2006-02-01
影响因子：
5.7
通讯作者：
Vale, L
中科院分区：
文献类型：
--
作者：
Grimshaw, J;Eccles, M;Vale, L
目标：确定不同指南传播和实施策略的有效性和成本。数据来源：MEDLINE（1966 年至 1998 年）、HEALTHSTAR（1975 年至 1998 年）、Cochrane 对照试验登记册（第 4 版 1998 年）、EMBASE（1980 年至 1998 年）、SIGLE（1980 年至 1988 年）和专门登记册审查方法：纳入标准：随机对照试验、对照临床试验、研究前后对照以及中断时间序列评估针对具有医学资格的卫生保健专业人员的指南传播和实施策略，这些专业人员报告了提供者行为和/或患者结果的客观测量。两名评审员独立提取有关研究方法质量、研究环境特征、参与者、目标行为的数据。和干预措施。我们对每项研究比较的二分过程变量（例如，接受适当治疗的患者比例）进行了单一估计，并报告了研究组和其他质量标准观察到的效应大小的中位数和范围。 结果：我们纳入了来自 235 项研究的 309 项比较。研究的总体质量很差。 73% 的比较评估了多方面的干预措施。总体而言，大多数比较（86.6%）观察到护理方面的改善；例如，各种干预措施的绩效绝对改善中位数范围为：14个提醒整群随机比较中的14.1%，教育材料传播的4个整群随机比较中的8.1%，审核和反馈的5个整群随机比较中的7.0%，以及涉及教育外展的多方面干预措施的13个整群随机比较中的6.0%。我们发现成分数量与多方面干预措施的效果之间没有关系。只有 29.4% 的比较报告了任何经济数据。结论：当前的指南传播和实施策略可以在严格的评估研究背景下改善护理。然而，没有不完善的证据基础来支持关于在不同情况下哪些指南传播和实施策略可能有效的决策。决策者需要对如何最好地利用有限的资源进行质量改进活动进行大量判断。
OBJECTIVES: To determine effectiveness and costs of different guideline dissemination and implementation strategies.DATA SOURCES: MEDLINE (1966 to 1998), HEALTHSTAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group.REVIEW METHODS: INCLUSION CRITERIA: Randomized -controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors. and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria.RESULTS: We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multifaceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1 % in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data.CONCLUSIONS: Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, 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 judgment about how best to use the limited resources they have for quality improvement activities.