Shanbhag Deepti, Graham Ian D, Harlos Karen, Haynes R Brian, Gabizon Itzhak, Connolly Stuart J, Van Spall Harriette Gillian Christine
Bachelor of Health Sciences Program, McMaster University, Hamilton, Ontario, Canada.
School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
BMJ Open. 2018 Mar 6;8(3):e017765. doi: 10.1136/bmjopen-2017-017765.
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.
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.
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.
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.
改善心力衰竭（HF）预后的指南建议的采纳情况仍未达到最佳水平。我们回顾了提高医生对这些建议依从性的实施干预措施，并确定了与实施成功相关的背景因素。
我们检索了1990年1月至2017年11月的数据库，以查找测试改善I类HF指南采纳情况的干预措施的研究。我们使用Cochrane有效实践与护理组织及流程重新设计框架进行数据提取。主要结局包括：接受指南推荐的药物治疗、自我护理教育、左心室功能评估和/或心内装置的符合条件患者的比例。如有可用，我们报告临床结局。
我们纳入了38项研究。提供者层面的干预措施（n = 13项研究）包括审核与反馈、提醒和教育。组织层面的干预措施（n = 18项）包括病历系统变更、多学科团队、临床路径和连续护理。系统层面的干预措施（n = 3项）包括提供者/机构激励措施。四项研究评估了多层面干预措施。由于统计/概念异质性，我们无法进行荟萃分析。32项研究报告至少一项主要结局有显著改善。临床路径、多学科团队和多层面干预措施在提高医生对指南的采纳率方面最具持续性成功。在随机对照试验（RCT）（n = 10）中，药剂师和护士主导的干预措施改善了目标剂量处方。11项研究报告了临床结局；三项研究报告有显著改善，包括一项临床路径、一个多学科团队和一项多层面干预措施。对障碍的基线评估、工作人员培训、迭代干预措施开发、领导承诺以及政策/财务激励与干预效果相关。大多数研究（n = 20）存在中等偏倚风险；九项RCT的偏倚风险较低。
我们的研究受到原始研究质量和异质性的限制。临床路径、多学科团队和多层面干预措施在提高指南采纳率方面似乎最具一致性。然而，过程结局的改善很少伴随着临床结局的改善。我们的工作强调需要改进研究方法，以可靠地评估实施干预措施的有效性。
