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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...

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Autores principales: Shanbhag, Deepti, Graham, Ian D, Harlos, Karen, Haynes, R. Brian, Gabizon, Itzhak, Connolly, Stuart J, Van Spall, Harriette Gillian Christine
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2018
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.
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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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