ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group
ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group
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DOI：
10.1016/j.jacc.2016.11.004
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发表时间：
2017-02-28
影响因子：
24
通讯作者：
Wells, Barbara L.
中科院分区：
文献类型：
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作者：
Chan, Wiley V.;Pearson, Thomas A.;Wells, Barbara L.
2008年，美国国家心脏、肺和血液研究所召集了一个实施科学工作组，以评估有效实施临床实践指南的循证策略。这是一个更大的努力，以更新现有的临床实践指南的胆固醇，血压和超重/obesity. CITTIVES审查证据，从已发表的实施科学文献，并确定有效的或有前途的战略，以提高采用和实施的临床实践指南。方法：本系统评价围绕4个关键问题进行，每个关键问题关注4种干预策略的采用和有效性：（1）提醒，（2）教育外展访问，（3）审计和反馈，（4）提供者激励。对系统性审查的Rx for Change数据库进行了范围审查，以确定针对供应商的有希望的指南实施干预措施。为每个问题预先制定了入选和排除标准，最初检索了2012年之前的已发表文献，然后更新了2015年之前的补充检索。两个独立的审查员筛选返回的引文，以确定相关的审查和评价的质量，每个包括review.Results审计和反馈和教育外展访问普遍有效地改善护理过程（15 21审查和12 13审查，分别）和临床结果（7 12审查和3 5审查，分别）。提供者激励措施在改善护理过程（4篇综述中的3篇）和临床结局（3篇综述平均分布在一般有效、混合和一般无效之间）方面表现出混合有效性。提示在改善护理结局过程方面表现出混合有效性（27项综述，11项混合结果和3项一般无效结果），并且对于临床结局通常无效（18项综述，6项混合结果和9项一般无效结果）。教育外展访问（2/2次审查）、提醒（3/4次审查）和提供者激励（1/1次审查）通常对降低成本有效。教育外联访问（1/1审查）和提供者激励措施（1/1审查）通常也对成本效益结果有效。临床医生采用或遵守指南的障碍包括时间限制（8篇综述/综述）;有限的人力资源（2篇综述）;时间（5篇综述/综述）;临床医生怀疑（5篇综述/综述）;临床医生对指南的了解（4篇综述/综述）;临床医生年龄较大（1篇综述）。促进因素包括指南特征，如格式、资源和最终用户参与（6次审查/概述）;让利益攸关方参与（5次审查/概述）;领导支助（5次审查/概述）;执行范围（5次审查/概述）;组织文化，如多学科团队和低基线遵守情况（9个评论/综述）;和电子指南系统（3个评论）。结论审计和反馈和教育外展访问的策略，一般有效地改善护理过程和临床结果。提醒和提供者激励措施的效果好坏参半，或者总体上无效。由于证据有限，无法就成本效益得出一般性结论。实施干预措施的有效性证据存在重大差距，特别是在临床结果、成本效益和影响成功实施的背景问题方面。
BACKGROUND In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity.OBJECTIVES Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review.RESULTS Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews).CONCLUSION The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.