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Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998

Review

Affiliations

• ¹ Clinical Epidemiology Program, Ottawa Health Research Institute, University of Ottawa, Ottawa, ON, Canada. jgrimshaw@ohri.ca

• PMID: 16637955
• PMCID: PMC2557130
• DOI: 10.1111/j.1525-1497.2006.00357.x

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Review

Jeremy Grimshaw et al. J Gen Intern Med. 2006 Feb.

• ¹ Clinical Epidemiology Program, Ottawa Health Research Institute, University of Ottawa, Ottawa, ON, Canada. jgrimshaw@ohri.ca

• PMID: 16637955
• PMCID: PMC2557130
• DOI: 10.1111/j.1525-1497.2006.00357.x

Item in Clipboard

Objectives: To determine effectiveness and costs of different guideline dissemination and implementation strategies.

Data sources: MEDLINE (1966 to 1998), HEALTHSTAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group.

Inclusion criteria: Randomized-controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors, and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria.

Results: We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multifaceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1% in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data.

Conclusions: Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, 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 quality improvement activities.

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Flowchart of included studies

Flowchart of included studies

Flowchart of included studies

Effect sizes of multifaceted interventions…

Effect sizes of multifaceted interventions by number of component interventions

Effect sizes of multifaceted interventions by number of component interventions

• Effectiveness and efficiency of guideline dissemination and implementation strategies.

  Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L, Shirran L, Wensing M, Dijkstra R, Donaldson C. Grimshaw JM, et al. Health Technol Assess. 2004 Feb;8(6):iii-iv, 1-72. doi: 10.3310/hta8060. Health Technol Assess. 2004. PMID: 14960256 Review.

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  Soll RF, Ovelman C, McGuire W. Soll RF, et al. Early Hum Dev. 2020 Nov;150:105191. doi: 10.1016/j.earlhumdev.2020.105191. Epub 2020 Sep 12. Early Hum Dev. 2020. PMID: 33036834

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  Giguère A, Zomahoun HTV, Carmichael PH, Uwizeye CB, Légaré F, Grimshaw JM, Gagnon MP, Auguste DU, Massougbodji J. Giguère A, et al. Cochrane Database Syst Rev. 2020 Jul 31;8(8):CD004398. doi: 10.1002/14651858.CD004398.pub4. Cochrane Database Syst Rev. 2020. PMID: 32748975 Free PMC article.

• Printed educational materials: effects on professional practice and health care outcomes. Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F. Farmer AP, et al. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004398. doi: 10.1002/14651858.CD004398.pub2. Cochrane Database Syst Rev. 2008. PMID: 18646106 Updated. Review.
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  Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C. Akbari A, et al. Cochrane Database Syst Rev. 2008 Oct 8;2008(4):CD005471. doi: 10.1002/14651858.CD005471.pub2. Cochrane Database Syst Rev. 2008. PMID: 18843691 Free PMC article. Review.

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  Emond YE, Calsbeek H, Teerenstra S, Bloo GJ, Westert GP, Damen J, Wolff AP, Wollersheim HC. Emond YE, et al. Implement Sci. 2015 Jan 8;10:3. doi: 10.1186/s13012-014-0198-5. Implement Sci. 2015. PMID: 25567584 Free PMC article. Clinical Trial.

• Reducing work pressure and IT problems and facilitating IT integration and audit & feedback help adherence to perioperative safety guidelines: a survey among 95 perioperative professionals.

  Emond YEJJM, Wolff AP, Peters YAS, Bloo GJA, Westert GP, Damen J, Calsbeek H, Wollersheim HC. Emond YEJJM, et al. Implement Sci Commun. 2020 May 27;1:49. doi: 10.1186/s43058-020-00037-1. eCollection 2020. Implement Sci Commun. 2020. PMID: 32885205 Free PMC article.

• Evidence-based medicine in psychopharmacotherapy: possibilities, problems and limitations.

  Möller HJ, Maier W. Möller HJ, et al. Eur Arch Psychiatry Clin Neurosci. 2010 Feb;260(1):25-39. doi: 10.1007/s00406-009-0070-9. Eur Arch Psychiatry Clin Neurosci. 2010. PMID: 19838763

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