ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group

Abstract

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.

Characteristics and Treatments of Patients Enrolled in the CHAMP‐HF Registry Compared With Patients Enrolled in the PARADIGM‐HF Trial

“…However, this pattern of adoption is not unique to sacubitril/valsartan, as described in a prior Institute of Medicine report noting an average of 17 years for new knowledge generated by randomized clinical trials to be incorporated into practice 12. The slow early adoption of sacubitril/valsartan underscores the need for robust evidence on best implementation strategies, as noted in a recent special report by the National Heart, Lung, and Blood Institute Implementation Science Work Group 13. This is being addressed in an ongoing cluster randomized trial of quality improvement strategies for patients hospitalized with HFrEF, CONNECT‐HF (Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure; NCT03035474).…”

Differences in implementation strategies of the European Resuscitation Council Guidelines 2015 in Danish hospitals – a nationwide study

“…Examples of active implementation methods that have been shown to be effective are interactive workshops, educational outreach, and audit and feedback. 11 , 12 , 17 – 21 A few Danish hospitals did plan to use active methods in the form of, eg, skill stations and workshops, but it is unknown if this has resulted in faster implementation of the guidelines compared with the hospitals not using active methods. Multifaceted strategies have also been implied to have a larger effect than single intervention strategies.…”

A Roadmap on the Prevention of Cardiovascular Disease Among People Living With Diabetes

“…A unique opportunity for this Roadmap is to highlight the crucial role that CVD plays in type 2 diabetes mellitus and the potential lives saved from effective preventive strategies. The use of strategies such as audit and feedback as well as educational outreach visits for health providers can be instrumental for sustained guideline adherence and Roadmap implementation [129].…”