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Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review
BACKGROUND: The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. METHODS: We s...
Autores principales: | , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BMJ Publishing Group
2018
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855256/ https://www.ncbi.nlm.nih.gov/pubmed/29511005 http://dx.doi.org/10.1136/bmjopen-2017-017765 |
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author | Shanbhag, Deepti Graham, Ian D Harlos, Karen Haynes, R. Brian Gabizon, Itzhak Connolly, Stuart J Van Spall, Harriette Gillian Christine |
author_facet | Shanbhag, Deepti Graham, Ian D Harlos, Karen Haynes, R. Brian Gabizon, Itzhak Connolly, Stuart J Van Spall, Harriette Gillian Christine |
author_sort | Shanbhag, Deepti |
collection | PubMed |
description | BACKGROUND: The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. METHODS: We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. RESULTS: We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. CONCLUSION: Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. |
format | Online Article Text |
id | pubmed-5855256 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | BMJ Publishing Group |
record_format | MEDLINE/PubMed |
spelling | pubmed-58552562018-03-19 Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review Shanbhag, Deepti Graham, Ian D Harlos, Karen Haynes, R. Brian Gabizon, Itzhak Connolly, Stuart J Van Spall, Harriette Gillian Christine BMJ Open Health Services Research BACKGROUND: The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. METHODS: We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. RESULTS: We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. CONCLUSION: Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. BMJ Publishing Group 2018-03-06 /pmc/articles/PMC5855256/ /pubmed/29511005 http://dx.doi.org/10.1136/bmjopen-2017-017765 Text en © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ |
spellingShingle | Health Services Research Shanbhag, Deepti Graham, Ian D Harlos, Karen Haynes, R. Brian Gabizon, Itzhak Connolly, Stuart J Van Spall, Harriette Gillian Christine Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review |
title | Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review |
title_full | Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review |
title_fullStr | Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review |
title_full_unstemmed | Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review |
title_short | Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review |
title_sort | effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review |
topic | Health Services Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855256/ https://www.ncbi.nlm.nih.gov/pubmed/29511005 http://dx.doi.org/10.1136/bmjopen-2017-017765 |
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