背景:临床实践指南(CPG)的采用不一致,尽管它们有可能改善医疗保健质量和患者预后。一些准则编制者通过开发工具来鼓励更快地采用新准则来解决这个问题。这篇综述的重点是指南生产者开发和传播的工具的有效性,以改善其CPG的吸收。
目的:评估指南编制者开发和传播的实施工具的有效性,伴随或跟随CPG的发布,促进摄取。次要目标是确定哪些准则实施方法最有效。
方法:我们搜索了CochraneEffectivePracticeandOrganisationofCare(EPOC)GroupSpecialisedRegister,Cochrane中央对照试验登记册(CENTRAL);NHS经济评估数据库,HTA数据库;MEDLINE和MEDLINE过程中和其他非索引引文;Embase;PsycINFO;CINAHL;论文和论文,ProQuest;论文索引;科学引文索引扩展,ISIWebofKnowledge;会议论文集引文索引-科学,ISI知识网;健康管理信息联盟(HMIC),和NHS证据截至2016年2月。我们还搜索了试验登记簿,纳入研究的参考列表和相关网站。
方法:我们纳入了随机对照试验(RCT)和集群RCT,控制前后研究(CBA)和中断时间序列(ITS)研究,评估公认的指南生产者开发的指南实施工具的效果,以提高他们自己的指南的吸收。该指南可以针对任何临床领域。
方法:两位综述作者使用Cochrane“偏倚风险”标准独立提取数据并评估每个纳入研究的偏倚风险。我们使用GRADE工作组建议的方法对证据的信心进行了分级。目标临床条件和使用的实施工具太不均匀,无法结合数据进行荟萃分析。我们报告了遵守指南的主要结果的中位数绝对风险差异(ARD)和四分位数间距(IQR)。
结果:我们包括在荷兰进行的四个集群RCT,法国,美国和加拿大。这些研究评估了国家指南生产者为实施其CPG而开发的工具的效果。实施工具评估了目标医疗保健专业人员;没有目标医疗保健组织或患者。一项研究使用了两个针对障碍的短期教育讲习班。在三项研究中,干预措施包括提供纸质教育材料,订购表单或提醒,或者两者兼而有之。临床状况,医疗保健专业人员的类型,CPG针对的行为在不同的研究中有所不同。纳入研究的四项研究中有两项报告了医疗保健专业人员遵守指南的数据。由指南的生产者开发的指南工具可能会导致对指南的依从性增加;平均为期四周的随访(中度确定性证据)中的ARD(IQR)中位数为0.135(两项研究分别为0.115和0.159),这表明干预组中对指南的依从性中位数提高了13.5%.为医疗保健专业人员提供改善指南实施的工具可能会导致医疗服务成本的差异很小或没有差异。
结论:由公认的指南生产者开发的实施工具可能会提高医疗保健专业人员对非特异性下腰痛管理和甲状腺功能检查的指南依从性。关于实施这些干预措施的相对成本的数据有限。没有研究评估针对护理组织的干预措施的有效性(例如,基准工具、成本计算模板,等。),或大众媒体干预。我们无法就我们的第二个目标得出任何结论,实施工具的相对有效性,由于研究数量少,干预措施之间的异质性,以及所针对的临床状况。
BACKGROUND: The uptake of clinical practice
guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new
guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs.
OBJECTIVE: To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective.
METHODS: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites.
METHODS: We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own
guidelines. The
guideline could target any clinical area.
METHODS: Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane \'Risk of bias\' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to
guidelines.
RESULTS: We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals\' adherence to
guidelines. A
guideline tool developed by the producers of a
guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service.
CONCLUSIONS: Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals\' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.