Effectiveness and efficiency of guideline dissemination and implementation strategies

Abstract

Objectives: A systematic review of the effectiveness and costs of different guideline development, dissemination, and implementation strategies wasundertaken. The resource implications of these strategies was estimated, and a framework for deciding when it is efficient to develop and introduce clinical guidelines was developed.

Objectives: A systematic review of the effectiveness and costs of different guideline development, dissemination, and implementation strategies was undertaken. The resource implications of these strategies was estimated, and a framework for deciding when it is efficient to develop and introduce clinical guidelines was developed.

Methods: MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE, and the specialized register of the Cochrane Effective Practice and Organization of Care (EPOC) group were used as data sources. 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 United Kingdom 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 studies, 73 percent of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was eleven 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 twenty-three 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 percent of comparisons reported any economic data. The majority of studies only reported costs of treatment; only twenty-five 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 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 judgment about how best to use the limited resources they have for clinical governance and related activities to maximize 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 behavior. Further research is required to develop and validate a coherent theoretical framework of health professional and organizational behavior and behavior 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.