Strategies for the implementation of clinical practice guidelines in public health: an overview of systematic reviews

Abstract

Background As a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination. Methods This overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA). Results This overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways—single intervention, educational meeting—single intervention, organizational culture, and audit and feedback—both strategies implemented in combination with others—were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term. Conclusion This overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.

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“…The dissemination of key messages could profit from digital resources (i.e., social media and mobile phones), as well as the traditional outlets available locally, including community health workers. Guidelines can be effective communication tools [ 39 ], but they need to be inclusive and follow implementation science principles, and their use should be carefully explained [ 40 ].…”

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“…A variety of different implementation strategies exist [ 6 , 7 ]. There is probably no superior strategy fitting to all situations [ 4 , 11 , 34 ].…”

“…The setting is the physical location, in which the intervention and its implementation interact with the context. A variety of different implementation strategies exist [6,7]. There is probably no superior strategy fitting to all situations [4,11,34].…”

“…Guidelines are nowadays a standard of evidence-based medicine [1][2][3]. However, the implementation in clinical practice remains in many cases insufficient [4][5][6][7]. While the development of clinical practice guidelines has been standardized and improved over the last years, the implementation to improve clinical practice remains challenging [8,9].…”

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“…[20] There is a significant body of literature on BPGs in the direct practice domain addressing a broad range of foci, including the evidence base of BPGs, implementation and integration, and quality and impact evaluation. [21][22][23][24][25][26][27] The implementation of RNAO's BPGs in hospitals and primary care centers in Canada and internationally has been the subject of numerous scholarly works, including research papers. [28][29][30][31][32][33] Kingsnorth and colleagues' evaluation of a multifaceted implementation strategy to support the adoption of an RNAO BPG on the assessment and management of acute pain in a pediatric rehabilitation and complex continuing care hospital found significant improvements in nurses' knowledge, attitudes, and behaviours related to optimal pain care for children with disabilities.…”