Toward evidence-based quality improvement
Purchase on Springer.com
$39.95 / €34.95 / £29.95*
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.
OBJECTIVES: To determine effectiveness and costs of different guideline dissemination and implementation strategies.
DATA SOURCES: MEDLINE (1966 to 1998), HEALTH-STAR (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.
REVIEW METHODS: 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 multi-faceted 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.
- Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assessment. 2004;8:1–72. Available at: http://www.hta.nhsweb.nhs.uk. Accessed August 5, 2004.
- Grimshaw JM, Shirran L, Thomas RE, et al. Changing provider behaviour: an overview of systematic reviews of interventions. Med Care. 2001;39(suppl 2):II-2–II-45.
- Bushman BJ. Vote counting methods in meta-analysis. In: Cooper H, Hedges L, eds. The Handbook of Research Synthesis. New York: Russell Sage Foundation; 1994.
- Grimshaw J, McAuley L, Bero L, et al. Systematic reviews of the effectiveness of quality improvement strategies and programs. Qual Safety Health Care. 2003;12:293–303. CrossRef
- Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Appendices. Health Technol Assessment. 2004;8:73–309. Available at: http://www.hta.nhsweb.nhs.uk. Accessed August 5, 2004.
- Drummond MF, Jefferson TO, for the BMJ working party on guidelines of authors and peer-reviewers of economic submissions to the British Medical Journal. Guidelines for authors and peer-reviewers of economic submissions to the British Medical Journal. BMJ. 1996;313:275–83.
- Ramsay C, Matowe L, Grilli R, Grimshaw J, Thomas R. Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behaviour change strategies. Int J Technol Assessment Health Care. 2003;19:613–23.
- Jamtvedt G, Young JM, Kristoffersen DT, Thomson O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. The Cochrane Database of Systematic Reviews, 2003, Art. No.: CD000259. DOI: 10.1002/14651858.CD000259.
- Shojania KG, Ranji SR, Shaw LK, et al. Diabetes Mellitus Care. Vol. 2 of Shojania KG, McDonald KM, Wachter RM, Owens DK. Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9 (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-Based Practice Center). AHRQ Publication No. 04-0051-2. Rockville, MD: Agency for Healthcare Research and Quality; September 2004.
- Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educational materials to improve the behaviour of health care professionals and patient outcome (Cochrane Review). In: The Cochrane Library, Issue 4, 1996 Oxford: Update software
- Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–5. CrossRef
- Wensing M, Van der Weijden T, Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? J Gen Practice. 1998;48:991–7.
- Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N. Changing the behaviour of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol. 2005;58:107–12. CrossRef
- Toward evidence-based quality improvement
Journal of General Internal Medicine
Volume 21, Issue 2 Supplement, pp S14-S20
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- practice guideline
- systematic review
- implementation research
- Industry Sectors
- Author Affiliations
- 1. Ottawa Health Research Institute, University of Ottawa, Ottawa, ON, Canada
- 3. University of Newcastle upon Tyne, Newcastle upon Tyne, UK
- 4. University of Aberdeen, Aberdeen, UK