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CMAJ. Aug 15, 1997; 157(4): 408–416.
PMCID: PMC1227916

Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines

Abstract

OBJECTIVE: To recommend effective strategies for implementing clinical practice guidelines (CPGs). DATA SOURCES: The Research and Development Resource Base in Continuing Medical Education, maintained by the University of Toronto, was searched, as was MEDLINE from January 1990 to June 1996, inclusive, with the use of the MeSH heading "practice guidelines" and relevant text words. STUDY SELECTION: Studies of CPG implementation strategies and reviews of such studies were selected. Randomized controlled trials and trials that objectively measured physicians' performance or health care outcomes were emphasized. DATA EXTRACTION: Articles were reviewed to determine the effect of various factors on the adoption of guidelines. DATA SYNTHESIS: The articles showed that CPG dissemination or implementation processes have mixed results. Variables that affect the adoption of guidelines include qualities of the guidelines, characteristics of the health care professional, characteristics of the practice setting, incentives, regulation and patient factors. Specific strategies fell into 2 categories: primary strategies involving mailing or publication of the actual guidelines and secondary interventional strategies to reinforce the guidelines. The interventions were shown to be weak (didactic, traditional continuing medical education and mailings), moderately effective (audit and feedback, especially concurrent, targeted to specific providers and delivered by peers or opinion leaders) and relatively strong (reminder systems, academic detailing and multiple interventions). CONCLUSIONS: The evidence shows serious deficiencies in the adoption of CPGs in practice. Future implementation strategies must overcome this failure through an understanding of the forces and variables influencing practice and through the use of methods that are practice- and community-based rather than didactic.

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Selected References

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  • Oxman AD, Sackett DL, Guyatt GH. Users' guides to the medical literature. I. How to get started. The Evidence-Based Medicine Working Group. JAMA. 1993 Nov 3;270(17):2093–2095. [PubMed]
  • Guyatt GH, Sackett DL, Cook DJ. Users' guides to the medical literature. II. How to use an article about therapy or prevention. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 1993 Dec 1;270(21):2598–2601. [PubMed]
  • Jaeschke R, Guyatt G, Sackett DL. Users' guides to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 1994 Feb 2;271(5):389–391. [PubMed]
  • Levine M, Walter S, Lee H, Haines T, Holbrook A, Moyer V. Users' guides to the medical literature. IV. How to use an article about harm. Evidence-Based Medicine Working Group. JAMA. 1994 May 25;271(20):1615–1619. [PubMed]
  • Laupacis A, Wells G, Richardson WS, Tugwell P. Users' guides to the medical literature. V. How to use an article about prognosis. Evidence-Based Medicine Working Group. JAMA. 1994 Jul 20;272(3):234–237. [PubMed]
  • Carter AO, Battista RN, Hodge MJ, Lewis S, Basinski A, Davis D. Report on activities and attitudes of organizations active in the clinical practice guidelines field. CMAJ. 1995 Oct 1;153(7):901–907. [PMC free article] [PubMed]
  • Carter AO, Battista RN, Hodge MJ, Lewis S, Haynes RB. Proceedings of the 1994 Canadian Clinical Practice Guidelines Network Workshop. CMAJ. 1995 Dec 15;153(12):1715–1719. [PMC free article] [PubMed]
  • Lomas J. Diffusion, dissemination, and implementation: who should do what? Ann N Y Acad Sci. 1993 Dec 31;703:226–237. [PubMed]
  • Browman GP, Levine MN, Mohide EA, Hayward RS, Pritchard KI, Gafni A, Laupacis A. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol. 1995 Feb;13(2):502–512. [PubMed]
  • Rush AJ. Clinical practice guidelines. Good news, bad news, or no news? Arch Gen Psychiatry. 1993 Jun;50(6):483–490. [PubMed]
  • Kelly JT, Toepp MC. Practice parameters: development, evaluation, dissemination, and implementation. QRB Qual Rev Bull. 1992 Dec;18(12):405–409. [PubMed]
  • Brennan PJ, Abrutyn E. Developing policies and guidelines. Infect Control Hosp Epidemiol. 1995 Sep;16(9):512–517. [PubMed]
  • Hayward RS, Laupacis A. Initiating, conducting and maintaining guidelines development programs. CMAJ. 1993 Feb 15;148(4):507–512. [PMC free article] [PubMed]
  • Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993 Nov 27;342(8883):1317–1322. [PubMed]
  • Arroll B, Jenkins S, North D, Kearns R. Management of hypertension and the core services guidelines: results from interviews with 100 Auckland general practitioners. N Z Med J. 1995 Feb 22;108(994):55–57. [PubMed]
  • Stolar MW. Clinical management of the NIDDM patient. Impact of the American Diabetes Association practice guidelines, 1985-1993. Endocrine Fellows Foundation Study Group. Diabetes Care. 1995 May;18(5):701–707. [PubMed]
  • Rosser WW, Palmer WH. Dissemination of guidelines on cholesterol. Effect on patterns of practice of general practitioners and family physicians in Ontario. Ontario Task Force on the Use and Provision of Medical Services. Can Fam Physician. 1993 Feb;39:280–284. [PMC free article] [PubMed]
  • Rogers EM. Lessons for guidelines from the diffusion of innovations. Jt Comm J Qual Improv. 1995 Jul;21(7):324–328. [PubMed]
  • Grilli R, Lomas J. Evaluating the message: the relationship between compliance rate and the subject of a practice guideline. Med Care. 1994 Mar;32(3):202–213. [PubMed]
  • Weingarten S, Riedinger M, Conner L, Johnson B, Ellrodt AG. Reducing lengths of stay in the coronary care unit with a practice guideline for patients with congestive heart failure. Insights from a controlled clinical trial. Med Care. 1994 Dec;32(12):1232–1243. [PubMed]
  • Ferrier BM, Woodward CA, Cohen M, Williams AP. Clinical practice guidelines. New-to-practice family physicians' attitudes. Can Fam Physician. 1996 Mar;42:463–468. [PMC free article] [PubMed]
  • Tunis SR, Hayward RS, Wilson MC, Rubin HR, Bass EB, Johnston M, Steinberg EP. Internists' attitudes about clinical practice guidelines. Ann Intern Med. 1994 Jun 1;120(11):956–963. [PubMed]
  • Wachtel TJ, O'Sullivan P. Practice guidelines to reduce testing in the hospital. J Gen Intern Med. 1990 Jul-Aug;5(4):335–341. [PubMed]
  • Putnam RW, Curry L. Physicians' participation in establishing criteria for hypertension management in the office: will patient outcomes be improved? CMAJ. 1989 Apr 1;140(7):806–809. [PMC free article] [PubMed]
  • Stobberingh E, Janknegt R, Wijnands G. Antibiotic guidelines and antibiotic utilization in Dutch hospitals. J Antimicrob Chemother. 1993 Jul;32(1):153–161. [PubMed]
  • Albrecht KG, Lee PP. Conformance with preferred practice patterns in caring for patients with glaucoma. Ophthalmology. 1994 Oct;101(10):1668–1671. [PubMed]
  • Studnicki J, Schapira DV, Bradham DD, Clark RA, Jarrett A. Response to the National Cancer Institute Alert. The effect of practice guidelines on two hospitals in the same medical community. Cancer. 1993 Nov 15;72(10):2986–2992. [PubMed]
  • Ellrodt AG, Conner L, Riedinger M, Weingarten S. Measuring and improving physician compliance with clinical practice guidelines. A controlled interventional trial. Ann Intern Med. 1995 Feb 15;122(4):277–282. [PubMed]
  • Conroy M, Shannon W. Clinical guidelines: their implementation in general practice. Br J Gen Pract. 1995 Jul;45(396):371–375. [PMC free article] [PubMed]
  • Zweig FM, Witte HA. Assisting judges in screening medical practice guidelines for health care litigation. Jt Comm J Qual Improv. 1993 Aug;19(8):342–354. [PubMed]
  • Jutras D. Clinical practice guidelines as legal norms. CMAJ. 1993 Mar 15;148(6):905–908. [PMC free article] [PubMed]
  • Robinson MB. Evaluation of medical audit. J Epidemiol Community Health. 1994 Oct;48(5):435–440. [PMC free article] [PubMed]
  • Borowitz M, Sheldon T. Controlling health care: from economic incentives to micro-clinical regulation. Health Econ. 1993 Oct;2(3):201–204. [PubMed]
  • Sisk JE. Promises and hazards of strategies to implement change. Jt Comm J Qual Improv. 1995 Jul;21(7):357–360. [PubMed]
  • Sagert G, Austin TW, Bombassaro AM, Parbtani A. Conformity with guidelines for antimicrobial prophylaxis against bacterial endocarditis. Am J Hosp Pharm. 1994 Oct 1;51(19):2403–2408. [PubMed]
  • Petrazzuoli M, Rothe MJ, Grin-Jorgensen C, Ramsey WH, Grant-Kels JM. Monitoring patients taking methotrexate for hepatotoxicity. Does the standard of care match published guidelines? J Am Acad Dermatol. 1994 Dec;31(6):969–977. [PubMed]
  • Bertram DA, Brooks-Bertram PA. The evaluation of continuing medical education: a literature review. Health Educ Monogr. 1977 Winter;5(4):330–362. [PubMed]
  • Haynes RB, Davis DA, McKibbon A, Tugwell P. A critical appraisal of the efficacy of continuing medical education. JAMA. 1984 Jan 6;251(1):61–64. [PubMed]
  • Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992 Sep 2;268(9):1111–1117. [PubMed]
  • Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700–705. [PubMed]
  • Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995 Nov 15;153(10):1423–1431. [PMC free article] [PubMed]
  • Oakeshott P, Kerry SM, Williams JE. Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination. Br J Gen Pract. 1994 May;44(382):197–200. [PMC free article] [PubMed]
  • Karuza J, Calkins E, Feather J, Hershey CO, Katz L, Majeroni B. Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process. Arch Intern Med. 1995 Mar 27;155(6):625–632. [PubMed]
  • Browner WS, Baron RB, Solkowitz S, Adler LJ, Gullion DS. Physician management of hypercholesterolemia. A randomized trial of continuing medical education. West J Med. 1994 Dec;161(6):572–578. [PMC free article] [PubMed]
  • Nardella A, Pechet L, Snyder LM. Continuous improvement, quality control, and cost containment in clinical laboratory testing. Effects of establishing and implementing guidelines for preoperative tests. Arch Pathol Lab Med. 1995 Jun;119(6):518–522. [PubMed]
  • Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med. 1989 Nov 9;321(19):1306–1311. [PubMed]
  • McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH. Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial. JAMA. 1991 Jul 24;266(4):538–544. [PubMed]
  • Wilson DM, Taylor DW, Gilbert JR, Best JA, Lindsay EA, Willms DG, Singer J. A randomized trial of a family physician intervention for smoking cessation. JAMA. 1988 Sep 16;260(11):1570–1574. [PubMed]
  • Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5;273(13):1026–1031. [PubMed]
  • Johnson CC, Martin M. Effectiveness of a physician education program in reducing consumption of hospital resources in elective total hip replacement. South Med J. 1996 Mar;89(3):282–289. [PubMed]
  • Dartnell JG, Allen B, McGrath KM, Moulds RF. Prescriber guidelines improve initiation of anticoagulation. Med J Aust. 1995 Jan 16;162(2):70–73. [PubMed]
  • Emslie C, Grimshaw J, Templeton A. Do clinical guidelines improve general practice management and referral of infertile couples? BMJ. 1993 Jun 26;306(6894):1728–1731. [PMC free article] [PubMed]
  • Benninger MS, King F, Nichols RD. Management guidelines for improvement of otolaryngology referrals from primary care physicians. Otolaryngol Head Neck Surg. 1995 Oct;113(4):446–452. [PubMed]

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