Grimshaw Jeremy, Eccles Martin, Thomas Ruth, MacLennan Graeme, Ramsay Craig, Fraser Cynthia, Vale Luke
Clinical Epidemiology Program, Ottawa Health Research Institute, University of Ottawa, Ottawa, ON, Canada.
J Gen Intern Med. 2006 Feb;21 Suppl 2(Suppl 2):S14-20. doi: 10.1111/j.1525-1497.2006.00357.x.
To determine effectiveness and costs of different guideline dissemination and implementation strategies.
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.
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.
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.
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.
确定不同指南传播与实施策略的有效性及成本。
医学期刊数据库（1966年至1998年）、健康之星数据库（1975年至1998年）、Cochrane对照试验注册库（第4版，1998年）、荷兰医学文摘数据库（1980年至1998年）、灰色文献数据库（1980年至1988年）以及Cochrane有效实践与医疗照护组织小组的专业注册库。
随机对照试验、对照临床试验、前后对照研究以及中断时间序列研究，这些研究评估针对具备医学资质的医疗保健专业人员的指南传播与实施策略，并报告了关于医疗服务提供者行为和/或患者结局的客观测量指标。两名评审员独立提取关于研究方法质量、研究背景特征、参与者、目标行为及干预措施的数据。我们针对每项研究比较得出二分法过程变量（如接受适当治疗的患者比例）的单一估计值，并报告研究组观察到的效应大小的中位数及范围以及其他质量标准。
我们纳入了来自235项研究的309项比较。研究的整体质量较差。73%的比较评估了多方面干预措施。总体而言，大多数比较（86.6%）观察到了医疗服务的改善；例如，各项干预措施中表现的中位数绝对改善幅度在14项提醒措施的整群随机比较中为14.1%，在4项教育材料传播的整群随机比较中为8.1%，在5项审核与反馈的整群随机比较中为7.0%，在1项涉及教育外展的多方面干预措施的13项整群随机比较中为6.0%。我们发现多方面干预措施的组成部分数量与效果之间没有关系。只有29.4%的比较报告了任何经济数据。
在严格的评估研究背景下，当前的指南传播与实施策略能够带来医疗服务的改善。然而，支持在不同情况下确定哪些指南传播与实施策略可能有效的证据基础并不完善。决策者在如何最佳利用其用于质量改进活动的有限资源方面需要运用相当多的判断力。
