How can we improve guideline use? A conceptual framework of implementability

Stimulating implementation of clinical practice guidelines in hospital care from a central guideline organization perspective: A systematic review

BACKGROUND

The uptake of guidelines in care is inconsistent. This review focuses on guideline implementation strategies used by guideline organizations (governmental agencies, scientific/professional societies and other umbrella organizations), experienced implementation barriers and facilitators and impact of their implementation efforts.

METHODS

We searched PUBMED, EMBASE and CINAHL and conducted snowballing. Eligibility criteria included guidelines focused on hospital care and OECD countries. Study quality was assessed using the Mixed Methods Appraisal Tool. We used framework analysis, narrative synthesis and summary statistics.

RESULTS

Twenty-six articles were included. Sixty-two implementation strategies were reported, used in different combinations and ranged between 1 and 16 strategies per initiative. Most frequently reported strategies were educational session(s) and implementation supporting materials. The most commonly reported barrier and facilitator were respectively insufficient healthcare professionals' time and resources; and guideline's credibility, evidence base and relevance. Eighty-five percent of initiatives that measured impact achieved improvements in adoption, knowledge, behavior and/or clinical outcomes. No clear optimal approach for improving guideline uptake and impact was found. However, we found indications that employing multiple active implementation strategies and involving external organizations and hospital staff were associated with improvements.

CONCLUSION

Guideline organizations employ diverse implementation strategies and encounter multiple barriers and facilitators. Our study uncovered potential effective implementation practices. However, further research is needed on effective tailoring of implementation approaches to increase uptake and impact of guidelines.

Key factors in complex public health interventions to address vaccine hesitancy using a multidisciplinary approach: the VAX-TRUST project

The VAX-TRUST project addresses vaccine hesitancy in seven European countries with a systematic and evidence-based approach. Interventions, targeting healthcare professionals, draw from behavioural and social theories. A checklist, inspired by the TIDieR (Template for Intervention Description and Replication), ensures a detailed description of actions, transparency and replicability. The intervention development process begins with collaborative meetings and systematic revisions, concluding with external evaluations for replicability in diverse public health contexts. This study aims to provide valuable insights for future complex interventions in public health, based on lessons learnt to reduce the risk of vaccine-preventable diseases. The analysis of educational interventions within the VAX-TRUST project has led to the definition of precise guidelines to ensure their replicability and adaptation to various contexts, attempting to establish a universally applicable approach. Active participant engagement and consideration of local social dynamics, beyond information transmission, have emerged as key factors to improve intervention effectiveness. Various educational tools and collaboration with academic institutions have contributed to strengthening credibility.

Axial spondyloarthritis guidelines - aiming for maximum impact

PURPOSE OF REVIEW

This review discusses international clinical practice guidelines (CPGs) for axial spondyloarthritis (axSpA) focusing on methodology, guideline quality, and implementation.

RECENT FINDINGS

The Assessment of SpondyloArthritis International Society/European Alliance of Associations for Rheumatology (ASAS/EULAR) and Pan-American League of Associations for Rheumatology (PANLAR) recently published axSpA CPGs and updates of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) and Asia-Pacific League of Associations for Rheumatology (APLAR) CPGs are expected. GRADE has emerged as the dominant framework for CPG development and has been used by three of the four international axSpA guidelines. Notable differences exist among these guidelines in the way that the recommendations are presented. Two of the four acknowledge the need for implementation strategies, but little detail about this is provided. The few studies that have evaluated the implementation of axSpA CPGs have identified poor adherence to recommendations on physical therapy/exercise and disease activity monitoring. Implementation science has identified many barriers and facilitators affecting guideline uptake, including those related to healthcare professionals and to the guidelines themselves. Creation of a tailored implementation plan simultaneously with the CPG is recommended.

SUMMARY

While methodological rigor in the creation of evidence-based recommendations is the focus of CPG development, recommendations must be presented in a user-friendly format that makes them easy to apply. 'Living guidelines' could facilitate keeping content up to date. Implementation is critical for the success of a CPG and should be emphasized in future axSpA guideline updates. Further research is needed to better understand the factors impacting the successful implementation of axSpA CPGs.

Characteristics and quality of clinical practice guidelines for diabetic kidney disease: a systematic review

OBJECTIVE

To assess the quality of Clinical practice guidelines (CPGs) in the context of diabetic kidney disease (DKD) and determine whether any factors affect the quality.

METHODS

We searched eight databases along with five international and national organizations to develop or archive guidelines from their inception to July 2023, with an additional search of medlive.cn. And the authoritative organizations related to nephrology. CPGs and consensus statements created using direct differential diagnosis or therapy for DKD were included without language restrictions. Their quality was evaluated by four reviewers using the Appraisal of Guidelines for Research and Evaluation Ⅱ (AGREE Ⅱ) instrument. Along with the item and domain scores, the guideline was also allocated an overall quality score, which ranged from 1 (lowest possible quality) to 7 (highest possible quality). Moreover, an overall recommendation for use was also assigned ("recommended", "recommended with modifications" or "not recommended").

RESULTS

A total of 16 CPGs were included, of which 14 were from Asia and the remaining two from Europe. These two CPGs were updated in the third version. Six CPGs were recommended for use because their primary domains scored in the medium or high category. Furthermore, five CPGs were recommended with modifications as the stakeholder involvement, applicability, and editorial independence domains were evaluated as low categories. In all domains, the lowest average score was for rigour of development (33%), followed by application (36%), and stakeholder involvement (51%). The highest average score was for scope and purpose (79%), followed by clarity of presentation (75%). None of the CPGs considered the patient's viewpoint, and six of 16 CPGs did not use any grading system to translate the evidence into recommendations. Additionally, only three of 16 CPGs shared search strategy, and eight of 16 CPGs did not declare a funding source.

CONCLUSIONS

According to the AGREE II evaluation, more than one in four CPGs for DKD had poor methodological quality. Enhanced efforts are needed to advance the rigour of development, application, and editorial independence of DKD guideline panels for most guidelines. Stakeholders, CPG developers, and CPG users should consider methodological quality while choosing CPGs, and interpret and implement their issued suggestions.

Leveraging Artificial Intelligence for Expediting Implementation Efforts

Expedited implementation of evidence into practice and policymaking is critical to ensure the delivery of effective care and improve health-care outcomes. Implementation science deals with the designing of methods and strategies for increasing and facilitating the uptake of evidence into practice and policymaking. Nevertheless, the process of designing and selecting methods and strategies for implementing evidence is complicated because of the complexity of health-care settings where implementation is desired. Artificial intelligence (AI) has revolutionized a range of fields, including genomics, education, drug trials, research, and health care. This commentary discusses how AI can be leveraged to expedite implementation science efforts for transforming health-care practice. Four key aspects of AI use in implementation science are highlighted: (a) AI for implementation planning (e.g., needs assessment, predictive analytics, and data management), (b) AI for developing implementation tools and guidelines, (c) AI for designing and applying implementation strategies, and (d) AI for monitoring and evaluating implementation outcomes. Use of AI along the implementation continuum from planning to delivery and evaluation can enable more precise and accurate implementation of evidence into practice.

Clinical practice guideline-inconsistent management of fever and neutropenia in pediatric oncology: A Children's Oncology Group study

BACKGROUND

The primary objective was to measure the proportion of episodes where care delivery was inconsistent with selected recommendations of a clinical practice guideline (CPG) on fever and neutropenia (FN) management. The influence of site size on CPG-inconsistent care delivery, and association between patient outcomes and CPG-inconsistent care were described.

METHODS

This retrospective, multicenter study included patients less than 21 years old with cancer who were at high risk of poor FN outcomes and were previously enrolled to a Children's Oncology Group (COG) study at participating National Cancer Institute Community Oncology Research Program (NCORP) institutions from January 2014 through December 2015. Patients were randomly selected for chart review by participating sites from a COG-generated list. Care delivered in each episode was adjudicated (CPG-consistent or CPG-inconsistent) against each of five selected recommendations.

RESULTS

A total of 107 patients from 22 sites, representing 157 FN episodes, were included. The most common CPG-inconsistent care delivered was omission of pulmonary computerized tomography in patients with persistent FN (60.3%). Of 74 episodes where assessment of four (episodes without persistent FN) or five (episodes with persistent FN) recommendations was possible, CPG-inconsistent care was delivered with respect to at least one recommendation in 63 (85%) episodes. Site size was not associated with CPG-inconsistent care delivery. No statistically significant association between CPG-inconsistent care and fever recurrence was observed.

CONCLUSIONS

In this cohort of pediatric patients at high risk of poor FN outcomes, CPG-inconsistent care was common. Opportunities to optimize resource stewardship by boosting supportive care CPG implementation are highlighted.

Behavioral Interventions on Surgeons' Preoperative Decision-Making: A Scoping Review and Critical Analysis

INTRODUCTION

Consensus is lacking regarding the optimal strategy to influence surgeons' behaviors to reduce low-value surgical care. Comprehensively describing the existing body of literature that seeks to intervene on surgeons' preoperative decision-making may aid in structuring future behavior change strategies.

METHODS

We performed a scoping review using four databases (Medical Literature Analysis and Retrieval System Online, Embase, Web of Science, and Cumulated Index to Nursing and Allied Health Literature) for articles that tested the effect of behavioral-based interventions on any aspect of surgeons' decision-making in the preoperative setting. Abstracted data were characterized by summative descriptions and analyzed using the Tailored Implementation for Chronic Disease framework, mapping aspects of deimplementation strategies in the studies onto the determinant(s) that they altered. Data abstraction and mapping tools were piloted and iteratively revised before two researchers independently assessing studies and categorizing determinants, and then meeting to discuss their decisions.

RESULTS

There were 1460 articles identified from the initial search, with 17 full text articles ultimately included in the scoping review. Eight studies relied on a multidisciplinary preoperative conference to accomplish their aims, while five were multifaceted in their approach to deimplementation, and four studies used only a clinical decision support tool to accomplish their aims. Mapping determinants addressed in these studies onto the Tailored Implementation for Chronic Disease framework demonstrated that most strategies attempted to close knowledge gaps, leverage communication between providers, and broadcast institutional prioritization of change.

CONCLUSIONS

There is a small but growing field of implementation and deimplementation strategies in preoperative surgical decision-making, and different approaches may be equally effective in varied clinical contexts. Deliberate measurement and comparison of outcomes, as well as selection of control groups, are areas for improvement in future work.

Citizen science to improve patient and public involvement in GUideline Implementation in oral health and DEntistry (the GUIDE platform)

BACKGROUND

Citizen science is a way to democratise science by involving groups of citizens in the research process. Clinical guidelines are used to improve practice, but their implementation can be limited. Involving patients and the public can enhance guideline implementation, but there is uncertainty about the best approaches to achieve this. Citizen science is a potential way to involve patients and the public in improving clinical guideline implementation. We aimed to explore the application of citizen science methods to involve patients and the public in the dissemination and implementation of clinical guidelines in oral health and dentistry.

METHODS

We developed GUIDE (GUideline Implementation in oral health and DEntistry), a citizen science online platform, using a participatory approach with researchers, oral health professionals, guideline developers and citizens. Recruitment was conducted exclusively online. The platform focused on prespecified challenges related to oral health assessment guidelines, and asked citizens to generate ideas, as well as vote and comment on other citizens' ideas to improve those challenges. Citizens also shared their views via surveys and two online synchronous group meetings. Data were collected on participant's demographics, platform engagement and experience of taking part. The most promising idea category was identified by an advisory group based on engagement, feasibility and relevance. We presented quantitative data using descriptive statistics and analysed qualitative data using inductive and deductive thematic analysis.

RESULTS

The platform was open for 6 months and we recruited 189 citizens, from which over 90 citizens actively engaged with the platform. Most citizens were over 34 years (64%), female (58%) and had a university degree (50%). They generated 128 ideas, 146 comments and 248 votes. The challenge that led to most engagement was related to prevention and oral health self-care. To take this challenge forward, citizens generated a further 36 ideas to improve a pre-existing National Health Service oral care prevention leaflet. Citizens discussed motivations to take part in the platform (understanding, values, self-care), reasons to stay engaged (communication and feedback, outputs and impact, and relevance of topics discussed) and suggestions to improve future platforms.

CONCLUSION

Citizen science is an effective approach to generate and prioritise ideas from a group of citizens to improve oral health and dental services. Prevention and oral health self-care were of particular interest to citizens. More research is needed to ensure recruitment of a diverse group of citizens and to improve retention in citizen science projects.

PATIENT OR PUBLIC CONTRIBUTION

This project was inherently conducted with the input of public partners (citizen scientists) in all key aspects of its conduct and interpretation. In addition, two public partners were part of the research team and contributed to the design of the project, as well as key decisions related to its conduct, analysis, interpretation and dissemination and are co-authors of this manuscript.

Assessing the impact of an evidence- and consensus-based guideline for controlling SARS-CoV-2 transmission in German schools on decision-making processes: a multi-component qualitative analysis

INTRODUCTION

During the COVID-19 pandemic, decision-making on measures to reduce or prevent transmission of SARS-CoV-2 in schools was rendered difficult by a rapidly evolving and uncertain evidence base regarding their effectiveness and unintended consequences. To support decision-makers, an interdisciplinary panel of scientific experts, public health and school authorities as well as those directly affected by school measures, was convened in an unprecedented effort to develop an evidence- and consensus-based public health guideline for German schools. This study sought to assess whether and how this guideline impacted decision-making processes.

METHODS

This study comprised three components: (1) we sent inquiries according to the Freedom of Information Acts of each Federal State to ministries of education, family, and health. (2) We conducted semi-structured interviews with individuals involved in decision-making regarding school measures in two Federal States, and (3) we undertook semi-structured interviews with members of the guideline panel. The content of response letters in component 1 was analysed descriptively; data for components 2 and 3 were analysed using deductive-inductive thematic qualitative content analysis according to Kuckartz.

RESULTS

Responses to the Freedom of Information Act inquiries showed that the guideline was recognised as a relevant source of information by ministries of education in nine out of 16 Federal States and used as a reference to check existing directives for school measures in five Federal States. All participants (20 interviews) emphasised the value of the guideline given its evidence- and consensus-based development process but also noted limitations in its usability and usefulness, e.g., lack of context-specificity. It was consulted by participants who advised policy-makers (5 interviews) alongside other sources of evidence. Overall, perceptions regarding the guideline's impact were mixed.

CONCLUSIONS

Our findings suggest that the guideline was relatively well-known in Federal States' decision-making bodies and that it was considered alongside other forms of evidence in some of these. We suggest that further research to evaluate the impact of public health guidelines on (political) decision-making is warranted. Guideline development processes may need to be adapted to account for the realities of decision-making during public health emergencies and beyond.

Prioritization of clinical questions for the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis

AIM

Living guidelines aim to reduce delays in translating new knowledge into practice by updating individual recommendations as soon as relevant new evidence emerges. We surveyed members of the Australian Rheumatology Association (ARA) to develop a list of priority questions for the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis (ALG) and to explore clinicians' use of clinical practice guidelines.

METHODS

An electronic survey of ARA members was performed in two phases. The first survey contained questions about current guideline use and beliefs and invited participants to submit at least three questions relevant to the management of rheumatoid arthritis (RA). In the second round, participants selected 10 questions they considered to be the highest priority from the collated list and ranked them in priority order. The sum of ranks was used to generate a final priority list.

RESULTS

There were 115 (21%) and 78 (14%) responses to the first and second survey rounds respectively. 87% of respondents use existing rheumatology guidelines in their usual practice, primarily EULAR guidelines. Most respondents favored the development of Australian rheumatology guidelines. In total, 34 potential recommendation topics were identified and ranked in order of priority.

CONCLUSION

A list of 34 clinical questions about RA management, ranked in order of importance by clinicians, has informed the development of the ALG. Similar prioritization exercises in other contexts may permit guidelines to be tailored to the needs of guideline users in their specific context, which may facilitate international collaboration and promote efficient translation of evidence to practice.

Physical activity in people diagnosed with cancer: a rapid review of recommendations and critical appraisal of international guidelines

PURPOSE

There are numerous guidelines that recommend physical activity (PA) in people diagnosed with cancer, but the quality of these guidelines is unknown. The aim of this study was to identify existing PA guidelines for cancer survivors, describe the recommendations, and assess their methodology quality.

METHODS

A rapid review of the literature was conducted in PubMed and EMBASE, supplemented by a search of the grey literature. The methodological quality of the guidelines was assessed using the AGREE II checklist. A descriptive synthesis of the recommendations from guidelines judged to be of good quality has been performed.

RESULTS

A total of nine guidelines published between 2006 and 2019 were included. Of nine guidelines, five achieved a high enough AGREE II score and were judged to be of good quality for use in clinical practice. We found that the recommendations from the five guidelines converged on the prescription of supervised PA (aerobic and resistance exercise) of at least 75 min per week of high intensity or 150 min per week of moderate intensity, spread over two to five sessions per week, equating to a PA dose between 8.70 and 17.5 MET.h/week. The recommendations were applicable to address the most common side effects of cancer and its treatment, namely fatigue, lymphedema, anxiety, depressive symptoms, health-related quality of life (QoL), survival, and physical function. However, no guideline recommends PA to improve other cancer-related outcomes, such as cognitive impairment, falls, sexual function, and peripheral neuropathy frequently experienced by cancer survivors. No guideline also referred to work outcomes (i.e., work ability, return to work, etc.).

CONCLUSION

Most PA guidelines for cancer survivors are of good quality. However, specific PA guidelines are needed for a given cancer site (e.g., location, stage), at a particular phase of the cancer trajectory, and for specific outcomes including return to work (RTW) in order to tailor PA to each cancer survivor.

Development of an Administration Guideline of Oral Medicines to Patients with Dysphagia

Background and Objectives: There is increasing evidence that patients with dysphagia often have limited access to suitable oral dosage forms, especially when administered via an enteral feeding tube (FT). In addition, there is a lack of clear and readily available information from drug manufacturers on how to administer medications to patients with dysphagia. This study aimed to develop a practical guide for healthcare professionals to increase the safe and effective administration of oral medications to patients with dysphagia. Materials and Methods: The data were collected from existing English databases and handbooks available to develop an easy-to-use tabular guideline presenting all relevant information using keywords and short expressions. The working group differentiated 514 formulation types, and the information was collected and added to the guideline separately. In addition, the instructions for the patients taking the medicines orally or via FT were described separately. Results: The guideline consisted of 24 keywords or short expressions developed by the working group and described the instructions to use them. The guideline contained 343 active pharmaceutical ingredients and 19 fixed-dose combinations. Conclusions: Knowledge about proper medication preparation and administration for patients with swallowing difficulties is limited but essential. It is crucial to encourage drug manufacturers to provide this information as a standard to ensure the safe and effective use of medications for all patient groups.

The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature

OBJECTIVES

To identify barriers and facilitators of clinical practice guidelines (CPGs) implementation, and map those factors to the theoretical domains framework (TDF) and behavior change wheel (BCW).

METHODS

We conducted an umbrella review of systematic reviews. PubMed, Embase, and the Cochrane Library were searched. Two investigators independently screened the studies, extracted the data, and assessed the methodological quality. The identified barriers and facilitators of CPG implementation were categorized and mapped to the TDF domains and BCW components.

RESULTS

Thirty-seven studies were included, and 193 barriers and 140 facilitators were identified. Intrinsic aspects (35 barriers and 28 facilitators) mainly included the CPGs' impracticality, complexity, and inaccessibility. Extrinsic aspects (158 barriers and 113 facilitators) mainly included lack of resources, training, funding, or awareness of CPG content in barriers; audits and feedback; strong leadership and management support; and educating and training about CPGs in facilitators. Environmental context and resources (n = 97, 19.48%) were the most reported barriers in TDF domains. Physical opportunity and social opportunity were the most frequently mentioned models in BCW.

CONCLUSION

Multiple barriers and facilitators for healthcare CPG implementation are identified, with further links to TDF and BCW. Future knowledge translation strategies should be developed accordingly in specified health care settings.

A scoping review of implementation science theories, models, and frameworks - an appraisal of purpose, characteristics, usability, applicability, and testability

BACKGROUND

A proliferation of theories, models, and frameworks (TMFs) have been developed in the implementation science field to facilitate the implementation process. The basic features of these TMFs have been identified by several reviews. However, systematic appraisals on the quality of these TMFs are inadequate. To fill this gap, this study aimed to assess the usability, applicability, and testability of the current TMFs in a structured way.

METHODS

A scoping review method was employed. Electronic databases were searched to locate English and Chinese articles published between January 2000 and April 2022. Search terms were specific to implementation science. Additionally, hand searches were administered to identify articles from related reviews. Purpose and characteristics such as the type of TMF, analytical level, and observation unit were extracted. Structured appraisal criteria were adapted from Birken et al.'s Theory Comparison and Selection Tool (T-CaST) to conduct an in-depth analysis of the TMFs' usability, applicability, and testability.

RESULTS

A total of 143 TMFs were included in this analysis. Among them, the most common purpose was to identify barriers and facilitators. Most TMFs applied the descriptive method to summarize the included constructs or the prescriptive method to propose courses of implementation actions. TMFs were mainly mid-range theories built on existing conceptual frameworks or demonstrated grand theories. The usability of the TMFs needs to be improved in terms of the provision of conceptually matched strategies to barriers and facilitators and instructions on the TMFs usage. Regarding the applicability, little attention was paid to the constructs of macro-level context, stages of scale-up and sustainability, and implementation outcomes like feasibility, cost, and penetration. Also, fewer TMFs could propose recommended research and measurement methods to apply the TMFs. Lastly, explicit hypotheses or propositions were lacking in most of the TMFs, and empirical evidence was lacking to support the claimed mechanisms between framework elements in testability.

CONCLUSIONS

Common limitations were found in the usability, application, and testability of the current TMFs. The findings of this review could provide insights for developers of TMFs for future theoretical advancements.

Development and validation of core entrustable professional activities for abdominal radiology

OBJECTIVES

To develop and validate European entrustable professional activities (EPAs) for sub-specialised hepatobiliary and gastrointestinal (HB/GI) diagnostic imaging.

MATERIALS AND METHODS

Both European Society of Radiology and national curricula in HB/GI diagnostic radiology were thoroughly reviewed, resulting in preliminary EPAs drafted by a pilot group of expert radiologists in 2 different countries. Each EPA was fully described with 7 components (Specification/limitations; Potential risks of failing; Relevant domains of competence; Required experience, knowledge, skills, attitude and behaviour; Assessment information sources to assess progress and ground a summative entrustment decision; Entrustment for which level of supervision is to be reached; and Expiration date). The modified Delphi method with 3 Delphi rounds was chosen for validation. Content validity index (CVI) and median values were used for validation.

RESULTS

There were 15 preliminary EPAs, some of them divided according to 2 levels: resident and fellow level. The 37 members of the Delphi group were based in 2 different European countries with a background experience of 10 represented countries. Subsequent to the first Delphi round, 6 EPAs were accepted (CVI ≥ 0.8, median ≥ 4), 6 needed major revisions (CVI 0.7-0.79, median ≥ 4), 3 were rejected (CVI < 0.7) and 1 was added. After the second Delphi round, both the 6 revised EPAs and the additional one met the validation criteria (CVI ≥ 0.8, median ≥ 4). Finally, 13 EPAs were validated during the 3rd Delphi round with an agreement percentage of 95-100%.

CONCLUSION

This study creates and validates EPAs for sub-specialised HB/GI diagnostic imaging.

CRITICAL RELEVANCE STATEMENT

Thirteen EPAs for sub-specialised hepatobiliary and gastrointestinal diagnostic imaging were created with a strong methodology, and as a first example set in sub-specialised diagnostic imaging, they provide a template for others to be created.

KEY POINTS

• The competence-based teaching in medical studies has recently been reintroduced through EPAs. • Thirteen EPAs have been developed for hepatobiliary and gastrointestinal sub-specialised diagnostic imaging. • These EPAs were validated using a Delphi modified method and provide a template for other to be created.

Barriers, facilitators and implementation strategies for guideline-adherence in physiotherapy: a scoping review protocol

INTRODUCTION

Guideline-adherent physiotherapy can improve patient outcomes and reduce costs in the healthcare system. However, although there are numerous guidelines for physiotherapy practice, services are not consistently based on clinical practice guidelines. While various systematic and scoping reviews have highlighted barriers, facilitators and implementation strategies for guideline-adherent practice in other health professions, this scoping review aims to explore the barriers and facilitators for guideline-adherent physiotherapy and summarises the strategies used to implement such practice.

METHODS AND ANALYSIS

This scoping review will be based on Arksey and O'Malley's scoping review methodology and the methodological guidance for conducting scoping reviews published by Joanna Briggs Institute. Relevant publications will be first searched from the beginning of June 2023 on the MEDLINE and CINAHL databases before we expand the search to other databases such as EMBASE, the Cochrane Library and PEDro at the end of June 2023. Two reviewers will independently screen the titles and abstracts of all retrieved citations for inclusion against the eligibility criteria before conducting an independent full-text screening. The criteria will be tested on a sample of abstracts before beginning the abstract review to ensure that they are robust enough to capture any articles that may relate. The extracted data will finally be collated and charted to summarise key findings regarding our research question.

ETHICS AND DISSEMINATION

This scoping review will provide an extensive overview of the barriers, facilitators and implementation strategies for guideline-adherent physiotherapy. As scoping reviews are a form of secondary data analysis, ethical review is not required. Results will be disseminated through a peer-reviewed publication and stakeholder meetings.

TRIAL REGISTRATION NUMBER

This scoping review has been registered on 3 April 2023 on the Open Science Framework under https://doi.org/10.17605/OSF.IO/SEUW6.

Complementary and alternative medicine mention and recommendations in inflammatory bowel disease guidelines: systematic review and assessment using AGREE II

BACKGROUND

Many patients with inflammatory bowel disease (IBD) use complementary and alternative medicine (CAM) for disease management. There is, however, a communication gap between patients and healthcare professionals regarding CAM use, where patients are hesitant to disclose CAM use to providers. The purpose of this study was to identify the quantity and assess the quality of CAM recommendations in IBD clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

METHODS

MEDLINE, EMBASE, and CINAHL were systematically searched from 2011 to 2022 to find CPGs for the treatment and/or management of IBD. The Guidelines International Network (GIN) and National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs were assessed using the AGREE II instrument.

RESULTS

Nineteen CPGs made CAM recommendations for IBD and were included in this review. Average scaled domain percentages of CPGs were as follows (overall CPG, CAM section): scope and purpose (91.5%, 91.5%), clarity of presentation (90.3%, 64.0%), editorial independence (57.0%, 57.0%), stakeholder involvement (56.7%, 27.8%), rigour of development (54.7%, 45.9%), and applicability (14.6%, 2.1%).

CONCLUSIONS

The majority of CPGs with CAM recommendations were of low quality and their CAM sections scored substantially lower relative to other therapies in the overall CPG. In future updates, CPGs with low scaled-domain percentages could be improved in accordance with AGREE II and other guideline development resources. Further research investigating how CAM therapies can best be incorporated into IBD CPGs is warranted.

Recommendations for the management of opioid-induced constipation - how to improve usability in clinical practice

INTRODUCTION

Opioid-induced constipation remains undertreated despite effective and safe treatment options exists. Previous guidelines have only been partially effective in improving management, possibly due to their complexity, and studies suggest that a simple setup of concise and behaviorally-orientated steps improves usability.

AREAS COVERED

This article introduces the concept of opioid-induced constipation and provides an overview of existing guidelines in this field. We also propose simplified recommendations for managing opioid-induced constipation, derived from a synthesis of current guidelines and the principles of optimal guideline design theory.

EXPERT OPINION

Despite standard treatment with laxatives and fluid intake in patients with opioid-induced constipation, escalation of treatment is often needed where μ-opioid receptor antagonists or newer medications such as lubiprostone, linaclotide, or prucalopride are used. Previous guidelines have not been used sufficiently and thus management of the condition is often insufficient. We therefore propose simplified recommendations to management, which we believe can come into broader use. It was validated in primary care for credibility, clarity, relevance, usability, and overall benefit. We believe that this initiative can lead to better management of the substantial proportion of patients suffering from side effects of opioids.

Dissemination and implementation of clinical practice guidelines: a longitudinal, mixed-methods evaluation of the Canadian Task Force on Preventive Health Care's knowledge translation efforts

BACKGROUND

The Canadian Task Force on Preventive Health Care (task force) develops evidence-based preventive health care guidelines and knowledge translation (KT) tools to facilitate guideline dissemination and implementation. We aimed to determine practitioners' awareness of task force guidelines and KT tools and explore barriers and facilitators to their use.

METHODS

The task force's KT team completed annual evaluations using surveys and interviews with primary care providers in Canada from 2014 to 2020, to assess practitioners' awareness and determinants of use of task force guidelines and tools. We transcribed interviews verbatim and double-coded them using a framework analysis approach.

RESULTS

A total of 1284 primary care practitioners completed surveys and 183 participated in interviews. On average, 79.9% of participants were aware of the task force's 7 cancer screening guidelines, 36.2% were aware of the other 6 screening guidelines and 18.6% were aware of the 3 lifestyle or prevention guidelines. Participants identified 13 barriers and 7 facilitators to guideline and KT tool implementation; these were consistent over time. Participants identified strategies at the public and patient, provider and health systems levels to improve uptake of guidelines.

INTERPRETATION

Canadian primary care practitioners were more aware of task force cancer screening guidelines than its other preventive health guidelines. Over the 6-year period, participants consistently reported barriers to guideline uptake, including misalignment with patient preferences and other provincial or specialty guideline organizations. Further evaluations will assess tailored strategies to address the barriers identified.

Adoption of IWGDF guidance on prevention and management of foot problems in diabetes for local use in Iran by ADAPTE methodology: a step toward best practice

Purpose

Adoption of international working group on the diabetic foot (IWGDF) guidance on prevention and management of foot problems in patients with diabetes was the study aim.

Methods

The ADAPTE process consisted of three main phases of set-up, adoption, and finalization with overall 24 steps was used. In set- up phase, organizing committee by a multidisciplinary approach was established. In adoption phase, comprehensive search in databases and guideline resources was done. According to the inclusion criteria, the 2015IWGDF guidance was selected for adoption process. Quality, currency, content and consistency of the guidance were assessed. Also, consensus on different level of agreement for each recommendation were reported. On finalization phase, the adopted version was reviewed by the guidance developer and the final guidance for local use in Iran was disseminated.

Results

The 2015 IWGDF guidance with 77 recommendations was adopted after screening of 1760 documents retrieved from Jan. 2006 to Nov. 2016. An organizing committee was established according to a multidisciplinary approach including 73 members with endocrinology, orthopedic & vascular surgery, dermatology, infectious diseases, physical medicine and rehabilitation specialties, general practitioners and nurses. This guidance obtained a good quality in all six domains of AGREE II instrument (Score ≥ 80%), good currency, content, and consistency. Also, during the third round of Delphi, the consensus on the agreement level of each recommendation were greater than 80% and 77 recommendations of the original guidance were kept in the adopted version.

Conclusion

The 2015 IWGDF guidance with 77 recommendations adopted for local use in different health care settings of Iran.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01121-0.

Physical Activity Preferences of People Living with Brain Injury: Formative Qualitative Research to Develop a Discrete Choice Experiment

BACKGROUND AND OBJECTIVE

The World Health Organization physical activity guidelines for people living with disability do not consider the needs of people living with moderate-to-severe traumatic brain injury. This paper describes the qualitative co-development of a discrete choice experiment survey to inform the adaption of these guidelines by identifying the physical activity preferences of people living with moderate-to-severe traumatic brain injury in Australia.

METHODS

The research team comprised researchers, people with lived experience of traumatic brain injury and health professionals with expertise in traumatic brain injury. We followed a four-stage process: (1) identification of key constructs and initial expression of attributes, (2) critique and refinement of attributes, (3) prioritisation of attributes and refinement of levels and (4) testing and refining language, format and comprehensibility. Data collection included deliberative dialogue, focus groups and think-aloud interviews with 22 purposively sampled people living with moderate-to-severe traumatic brain injury. Strategies were used to support inclusive participation. Analysis employed qualitative description and framework methods.

RESULTS

This formative process resulted in discarding, merging, renaming and reconceptualising attributes and levels. Attributes were reduced from an initial list of 17 to six: (1) Type of activity, (2) Out-of-pocket cost, (3) Travel time, (4) Who with, (5) Facilitated by and (6) Accessibility of setting. Confusing terminology and cumbersome features of the survey instrument were also revised. Challenges included purposive recruitment, reducing diverse stakeholder views to a few attributes, finding the right language and navigating the complexity of discrete choice experiment scenarios.

CONCLUSIONS

This formative co-development process significantly improved the relevance and comprehensibility of the discrete choice experiment survey tool. This process may be applicable in other discrete choice experiment studies.

Creating implementable clinical practice guidelines: the 2020 Focused Updates to the National Heart, Lung, and Blood Institute's Asthma Management Guidelines

BACKGROUND

The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group provides the first new clinical practice recommendations from the National Heart, Lung, and Blood Institute (NHLBI) since the previous 2007 asthma management guidelines. Guideline implementability was a high priority for the expert panel, and many approaches were undertaken to enhance the implementability of this clinical guideline update. Within the report, specific implementation guidance sections provide expanded summaries for each recommendation to quickly assist users. The implementation guidance incorporates findings from NHLBI-sponsored focus groups conducted with people who have asthma, caregivers, and health care providers. The findings were used to identify the types of information and tools that individuals with asthma, their caregivers, and their health care providers would find most helpful; ensure that the new asthma guidelines reflect the voices of individuals with asthma and their caregivers; and identify potential barriers to uptake by individuals with asthma and their caregivers. The expert panel used a GRADE-based approach to develop evidence-to-decision tables that provided a framework for assessing the evidence and consideration of a range of contextual factors that influenced the recommendations such as desirable and undesirable effects, certainty of evidence, values, balance of effects, acceptability, feasibility, and equity. To facilitate uptake in clinical care workflow, selected recommendations were converted into structured, computer-based clinical decision support artifacts, and the new recommendations were integrated into existing treatment tables used in the 2007 asthma management guidelines, with which many users are familiar. A comprehensive approach to improve guidelines dissemination and implementation included scientific publications, patient materials, media activities, stakeholder engagement, and professional education.

CONCLUSION

We developed evidence-based clinical practice guideline updates for asthma management focused on six topic areas. The guideline development processes and implementation and dissemination activities undertaken sought to enhance implementability by focusing on intrinsic factors as described by Kastner, Gagliardi, and others to produce usable, adoptable, and adaptable guidelines. Enhanced collaboration during guideline development between authors, informaticists, and implementation scientists may facilitate the development of tools that support the application of recommendations to further improve implementability.

Perceived readiness for diabetes and cardiovascular care delivery in Mangochi, Malawi: multicentre study from healthcare providers' perspectives

BACKGROUND

Despite the expected prevalence rise of 98.1% for diabetes between 2010 and 2030 in sub-Saharan Africa (SSA) and the anticipated rise of both diabetes and cardiovascular diseases (CVDs) in Malawi from their current figures ( 5.6 and 8.9%; respectively), data on the readiness of health facilities to provide diabetes and cardiovascular diseases in Mangochi district is not available. Therefore, this study aimed to assess the readiness of health facilities to provide services for diabetes and cardiovascular diseases.

METHODS

An exploratory study was conducted from July to early September 2021 in 34 health facilities in Mangochi, Malawi. Forty-two participants were purposefully selected. They included medical officers, clinical officers, medical assistants, and registered nurses. The study used semi-structured interviews (for qualitative data) with a checklist (for quantitative data) to provide information about the readiness of services (such as guidelines and trained staff, drugs, diagnosis capacity and equipment, essential medicines, community services, and education/counseling).The thematic content analysis and basic descriptive statistics were carried out.

RESULTS

The following main theme emerged from the qualitative part: low use of diabetes-cardiovascular disease (CVD) services. This was due to: health facility factors (shortage of drugs and supplies, poor knowledge, few numbers and lack of training of providers, and absent copies of guidelines), patients factors (poor health-seeking behaviour, lack of education and counseling for many), and community factors (very limited community services for diabetes and CVDs, lack of transport policy and high transportation costs). Data from the checklists revealed low readiness scores across domains (below the 75% target) in diabetes and cardiovascular diseases: trained staff and guidelines (26.5% vs. 32.4%); diagnosis capacity and equipment (63.7% vs. 66.2%); essential medicines (33.5% vs. 41.9%), and community services, and education and counseling (37.5% vs. 42.5%).

CONCLUSION

There were several noticeable shortfalls identified in the readiness of health facilities to provide diabetes and cardiovascular disease services in Mangochi health facilities. Any future intervention in diabetes-cardiovascular disease care in these areas must include these elements in its basic package.

How to improve the dissemination of clinical practice guidelines in the Brazilian Unified Health System? Report of a pilot project

In Brazil, there have been some initiatives to improve the development of Ministry of Health clinical protocols and therapeutic guidelines (PCDTs in Portuguese, and clinical practice guidelines-CPGs, in English) and their implementation so that best practices can be disseminated and adopted at multiple levels of health systems. One of the initiatives was to conduct a pilot project to improve the format of these CPGs. The objective of this article is to present the processes and results of the pilot project, including the development of a new standardized format for CPGs to promote national dissemination and uptake. The pilot project was designed in three phases: identification and selection of strategies to effectively implement clinical practice guidelines, definition of the ideal characteristics for the format of CPGs, and development and implementation of the new format. Initially, an overview of systematic reviews was conducted to map the global evidence on the effectiveness of dissemination and implementation strategies of CPGs. Among the most effective interventions, a low-cost strategy was selected to improve the format of CPGs, namely a full format and a short format. The two formats were evaluated for usefulness and acceptability by professionals who use or develop CPGs, and after several reiterations, the formats were finalized, considering the progression of care (from diagnosis of the disease to treatment, including specific technologies indicated in each stage of the disease). Related to the technical aspects, the visual presentation of the CPGs was improved, ensuring that key information was easily identified for decision-making by end users. The initial phase of implementation involved 33 clinical conditions, equating to approximately 20% of published CPGs. It is anticipated that disseminating the CPGs in the new formats will promote the accessibility of information and implementation of standardized CPGs by health professionals in the public health sector (servicing more than 210 million Brazilians). Further research should be considered to determine the impact of the use of the new CPGs formats, contributing to the knowledge base related to the implementation of guidelines in Brazil and internationally.

Clinical practice guideline recommendation summaries for pediatric oncology health care professionals: A qualitative study

OBJECTIVE

To develop a summary format of clinical practice guideline (CPG) recommendations to improve understandability among health care professionals.

METHODS

We developed a summary format based on current research and used the "Think Aloud" technique in one-on-one cognitive interviews to iteratively improve it. Interviews of health care professionals from Children's Oncology Group-member, National Cancer Institute Community Oncology Research Program sites were conducted. After every five interviews (a round), responses were reviewed, and changes made to the format until it was well understood and no new, substantive suggestions for revision were raised. We took a directed (deductive) approach to content analysis of the interview notes to identify concerns related to recommendation summary usability, understandability, validity, applicability and visual appeal.

RESULTS

During seven rounds of interviews with 33 health care professionals, we identified important factors that influenced understandability. Participants found understanding weak recommendations more challenging than strong recommendations. Understanding was improved when the term 'conditional' recommendation was used instead of 'weak' recommendation. Participants found a Rationale section to be very helpful but desired more information when a recommendation entailed a practice change. In the final format, the recommendation strength is clearly indicated in the title, highlighted, and defined within a text box. The rationale for the recommendation is in a column on the left, with supporting evidence on the right. In a bulleted list, the Rationale section describes the benefits and harms and additional factors, such as implementation, that were considered by the CPG developers. Each bullet under the supporting evidence section indicates the level of evidence with an explanation and the supporting studies with hyperlinks when applicable.

CONCLUSIONS

A summary format to present strong and conditional recommendations was created through an iterative interview process. The format is straightforward, making it easy for organizations and CPG developers to use it to communicate recommendations clearly to intended users.

Standardized tools for assessing balance and mobility in stroke clinical practice guidelines worldwide: A scoping review

Background

Use of standardized tools to assess balance and mobility limitations is a recommended practice in stroke rehabilitation. The extent to which clinical practice guidelines (CPGs) for stroke rehabilitation recommend specific tools and provide resources to support their implementation is unknown.

Purpose

To identify and describe standardized, performance-based tools for assessing balance and/or mobility and describe postural control components challenged, the approach used to select tools, and resources provided for clinical implementation, in CPGs for stroke.

Methods

A scoping review was conducted. We included CPGs with recommendations on the delivery of stroke rehabilitation to address balance and mobility limitations. We searched seven electronic databases and grey literature. Pairs of reviewers reviewed abstracts and full texts in duplicate. We abstracted data about CPGs, standardized assessment tools, the approach for tool selection, and resources. Experts identified postural control components challenged by each tool.

Results

Of the 19 CPGs included in the review, 7 (37%) and 12 (63%) were from middle- and high-income countries, respectively. Ten CPGs (53%) recommended or suggested 27 unique tools. Across 10 CPGs, the most commonly cited tools were the Berg Balance Scale (BBS) (90%), 6-Minute Walk Test (6MWT) (80%), Timed Up and Go Test (80%) and 10-Meter Walk Test (70%). The tool most frequently cited in middle- and high-income countries was the BBS (3/3 CPGs), and 6MWT (7/7 CPGs), respectively. Across 27 tools, the three components of postural control most frequently challenged were underlying motor systems (100%), anticipatory postural control (96%), and dynamic stability (85%). Five CPGs provided information in varying detail on how tools were selected; only 1 CPG provided a level of recommendation. Seven CPGs provided resources to support clinical implementation; one CPG from a middle-income country included a resource available in a CPG from a high-income country.

Conclusion

CPGs for stroke rehabilitation do not consistently provide recommendations for standardized tools to assess balance and mobility or resources to facilitate clinical application. Reporting of processes for tool selection and recommendation is inadequate. Review findings can be used to inform global efforts to develop and translate recommendations and resources for using standardized tools to assess balance and mobility post-stroke.

Systematic Review Registration

https://osf.io/, identifier: 10.17605/OSF.IO/6RBDV.

Recommendations for Improving the Quality of Prehospital Evidence-Based Guidelines

Evidence-based guidelines that provide recommendations for clinical care or operations are increasingly being published to inform the EMS community. The quality of evidence evaluation and methodological rigor undertaken to develop and publish these recommendations vary. This can negatively affect dissemination, education, and implementation efforts. Guideline developers and end users could be better informed by efforts across medical specialties to improve the quality of guidelines, including the use of specific criteria that have been identified within the highest quality guidelines. In this special contribution, we aim to describe the current state of published guidelines available to the EMS community informed by two recent systematic reviews of existing prehospital evidenced based guidelines (EBGs). We further aim to provide a description of key elements of EBGs, methods that can be used to assess their quality, and concrete recommendations for guideline developers to improve the quality of evidence evaluation, guideline development, and reporting. Finally, we outline six key recommendations for improving prehospital EBGs, informed by systematic reviews of prehospital guidelines performed by the Prehospital Guidelines Consortium.

Acceptability Assessment in HIV Prevention and Treatment Intervention and Service Delivery Research: A Systematic Review and Qualitative Analysis

We reviewed the literature on the assessment of acceptability of HIV prevention and treatment interventions and service delivery strategies. Following PRISMA guidelines, we screened 601 studies published from 2015 to 2020 and included 217 in our review. Of 384 excluded studies, 21% were excluded because they relied on retention as the sole acceptability indicator. Of 217 included studies, only 16% were rated at our highest tier of methodological rigor. Operational definitions of acceptability varied widely and failed to comprehensively represent the suggested constructs in current acceptability frameworks. Overall, 25 studies used formal quantitative assessments (including four adapted measures used in prior studies) and six incorporated frameworks of acceptability. Findings suggest acceptability assessment in recent HIV intervention and service delivery research lacks harmonization and rigor. We offer guidelines for best practices and future research, which are timely and critical in this era of informed choice and novel options for HIV prevention and treatment.

Effective web-based clinical practice guidelines resources: recommendations from a mixed methods usability study

BACKGROUND

Clinical practice guidelines (CPG) are an important knowledge translation resource to help clinicians stay up to date about relevant clinical knowledge. Effective communication of guidelines, including format, facilitates its implementation. Despite the digitalization of healthcare, there is little literature to guide CPG website creation for effective dissemination and implementation. Our aim was to assess the effectiveness of the content and format of the Diabetes Canada CPG website, and use our results to inform recommendations for other CPG websites.

METHODS

Fourteen clinicians (family physicians, nurses, pharmacists, and dieticians) in diabetes care across Canada participated in this mixed-methods study (questionnaires, usability testing and interviews). Participants "thought-aloud" while completing eight usability tasks on the CPG website. Outcomes included task success rate, completion time, click per tasks, resource used, paths, search attempts and success rate, and error types. Participants were then interviewed.

RESULTS

The Diabetes Canada CPG website was found to be usable. Participants had a high task success rate of 79% for all tasks and used 144 (standard deviation (SD) = 152) seconds and 4.6 (SD = 3.9) clicks per task. Interactive tools were most frequently used compared to full guidelines and static tools. Misinterpretation accounted for 48% of usability errors. Participants overall found the website intuitive, with effective content and design elements.

CONCLUSION

Different versions of CPG information (e.g. interactive tools, quick reference guide, static tools) can help answer clinical questions more quickly. Effective web design should be assessed during CPG website creation for effective guideline dissemination and implementation.

Variation of caesarean section rates in Palestinian governmental hospitals

BACKGROUND

Globally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. We have rates as high as 35.8% in some governmental hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in governmental hospitals that use the same guidelines.

METHODS

A qualitative and quantitative research approach was used. In-depth interviews were conducted with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision-making. Each hospital's delivery records for one month were analyzed to determine the reason for each cesarean section.

RESULTS

The results indicated that each governmental hospital at the system level had a different policy on cesarean sections. The National Guidelines were found to be interpreted differently among hospitals. One obstetrician-gynecologist decided on a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and discussion of cases subjective to obstetrician-gynecologists interpretations.

CONCLUSION

Several institutional factors were identified to strengthen the implementation of the national obstetric guidelines. For example, encouraging collective decision-making between obstetrician-gynecologists and midwives, promoting the use of a second opinion, and mandatory training.

Trends in guideline implementation: an updated scoping review

Background

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

Methods

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

Results

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01223-6.

The effect of individualized iron supplementation on iron status in Dutch preterm infants born between 32 and 35 weeks of gestational age: evaluation of a local guideline

OBJECTIVE

Iron deficiency (ID) and iron deficiency anemia (IDA) in early life are associated with adverse effects. Preterm infants are at risk for developing ID(A). Considering that not every preterm infant develops ID(A) and the potential risk of iron overload, indiscriminate iron supplementation in late preterm infants is debatable. This study aimed to evaluate the effect of a locally implemented guideline regarding individualized iron supplementation on the prevalence of ID(A) at the postnatal age of 4-6 months in Dutch preterm infants born between 32 and 35 weeks of gestational age (GA).

METHODS

An observational study comparing the prevalence of ID(A) at the postnatal age of 4-6 months in Dutch preterm infants born between 32 and 35 weeks of GA before (i.e. PRE-guideline group) and after (i.e. POST-guideline group) implementation of the local guideline.

RESULTS

Out of 372 eligible preterm infants, 110 were included (i.e. 72 and 38 in the PRE- and POST-guideline group, respectively). ID- and IDA-prevalence rates at 4-6 months of age in the PRE-guideline group were 36.1% and 13.9%, respectively, and in the POST-guideline group, 21.1% and 7.9%, respectively, resulting in a significant decrease in ID-prevalence of 15% and IDA-prevalence of 6%. No indication of iron overload was found.

CONCLUSION

An individualized iron supplementation guideline for preterm infants born between 32 and 35 weeks GA reduces ID(A) at the postnatal age of 4-6 months without indication of iron overload.

Translating guidelines into practice via implementation science: an update in lipidology

PURPOSE OF REVIEW

Guidelines provide recommendations for clinicians based on the best available evidence and informed by clinical expertise. These recommendations often fail to be utilized by clinicians hindering the translation of evidence into practice. The purpose of this review is to describe novel ways in which implementation science has been used to improve translation of guidelines into clinical practice in the field of lipidology.

RECENT FINDINGS

We searched PubMed for articles related to guideline implementation in lipidology published in 2021 and 2022. Identified articles were categorized into three domains: first, poor uptake of guideline recommendations in practice; second, implementation science as a solution to improve care; and third, examples of how implementation science can be incorporated into guidelines.

SUMMARY

The field of lipidology has identified that many guideline recommendations fail to be translated into practice and has started to utilize methods from implementation science to assess ways to shrink this gap. Future work should focus on deploying tools from implementation science to address current gaps in guideline development. Such as, developing a systematic approach to restructure guideline recommendations so they are implementable in practice and aid in clinicians' ability to easily translate them into practice.

Implementing a complex hospital innovation: conceptual underpinnings, program design and implementation of a complex innovation in an international multi-site hospital trial

Background

Designing implementation programs that effectively integrate complex healthcare innovations into complex settings is a fundamental aspect of knowledge translation. We describe the development of a conceptually grounded implementation program for a complex healthcare innovation and its subsequent application in pediatric hospital settings.

Methods

We conducted multiple case observations of the application of the Phased Reciprocal Implementation Synergy Model (PRISM) framework in the design and operationalization of an implementation program for a complex hospital wide innovation in pediatric hospital settings.

Results

PRISM informed the design and delivery of 10 international hospital wide implementations of the complex innovation, BedsidePEWS. Implementation and innovation specific goals, overarching implementation program design principles, and a phased-based, customizable, and context responsive implementation program including innovation specific tools and evaluation plans emerged from the experience.

Conclusion

Theoretically grounded implementation approaches customized for organizational contexts are feasible for the adoption and integration of this complex hospital-wide innovation. Attention to the fitting of the innovation to local practices, setting, organizational culture and end-user preferences can be achieved while maintaining the integrity of the innovation.

An integrative review of the implementation of public health guidelines

Health guidelines are important tools to ensure that health practices are evidence-based. However, research on how these guidelines are implemented is scarce. This integrative review aimed to: identify the literature on evaluation of public health guidelines implementation to explore (a) the topics which public health guidelines being implemented and evaluated in their implementation process are targeting; (b) how public health guidelines are being translated into action and the potential barriers and facilitators to their implementation; and (c) which methods are being used to evaluate their implementation. A total of 2001 articles published since 2000 and related to both clinical and public health guidelines implementation was identified through searching four databases (PubMed, CINAHL, Web of Science, Scopus). After screening titles and abstracts, only 10 papers related to public health guidelines implementation, and after accessing full-text, 8 were included in the narrative synthesis. Data were extracted on: topic and context, implementation process, barriers and facilitators, and evaluation methods used, and were then synthesised in a narrative form using a thematic synthesis approach. Most of these studies focussed on individual behaviours and targeted specific settings. The evaluation of implementation processes included qualitative, quantitative and mixed-methods. The few articles retrieved suggest that evidence is still limited and highly context specific, and further research on translating public health guidelines into practice is needed.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

Assessment of Walking Speed and Distance Post-Stroke Increases After Providing a Theory-Based Toolkit

BACKGROUND AND PURPOSE

While underutilized, poststroke administration of the 10-m walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice. We aimed to evaluate provision of a toolkit designed to increase use of these tests by physical therapists (PTs).

METHODS

In a before-and-after study, 54 PTs and professional leaders in 9 hospitals were provided a toolkit and access to a clinical expert over a 5-month period. The toolkit comprised a guide, smartphone app, and video, and described how to set up walkways, implement learning sessions, administer walk tests, and interpret and apply test results clinically. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models.

RESULTS

Data from 347 and 375 pre- and postintervention hospital visits, respectively, were analyzed. Compared with preintervention, the odds of implementing the 10mWT were 12 times greater (odds ratio [OR] = 12.4, 95% confidence interval [CI] 5.8, 26.3), and of implementing the 6MWT were approximately 4 times greater (OR = 3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively).

DISCUSSION AND CONCLUSIONS

Providing a comprehensive toolkit to hospitals with professional leaders likely contributed to increasing 10mWT and 6MWT administration during inpatient and outpatient stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A390 ).

Facilitators, barriers and strategies for health-system guidance implementation: a critical interpretive synthesis protocol

Background

As systematically developed statements regarding possible courses of action, health system guidance (HSG) can assist with making decisions about addressing problems or achieving goals in health systems. However, there are conceptual and methodological challenges in HSG implementation due to the complexity of health-system policy-making, the diversity of available evidence and vast differences in contexts. To address these gaps, we aim to develop a theoretical framework for supporting HSG implementation as part of a broader effort to promote evidence-informed policy-making in health systems.

Methods

To develop a theoretical framework about facilitators, barriers and strategies for HSG implementation, we will apply a critical interpretive synthesis (CIS) approach to synthesize the findings from a range of relevant literature. We will search 11 electronic databases and seven organizational websites to identify relevant published and grey literature. We will check the references of included studies and contact experts to identify additional eligible papers. Finally, we will conduct purposively sampling of the literature to fill any identified conceptual gaps. We will use relevance and five quality criteria to assess included papers. A standardized form will be developed for extracting information. We will use an interpretive analytic approach to synthesize the findings, including a constant comparative method throughout the analysis. Two independent reviewers will conduct the literature screening and relevance assessment, and disagreements will be resolved through discussion. The principal investigator will conduct data extraction and synthesis, and a second reviewer will check the sample of extracted data for consistency and accuracy.

Discussion

A new theoretical framework about facilitators, barriers and strategies for HSG implementation will be developed using a CIS approach. The HSG implementation framework could be widely used for supporting the implementation of HSG covering varied topics and in different contexts (including low-, middle- and high-income countries). In later work, we will develop a tool for supporting HSG implementation based on the theoretical framework.

Registration PROSPERO CRD42020214072. Date of Registration: 14 December 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00908-0.

Strategies for developing evidence-based clinical practice guidelines to foster implementation into dental practice

BACKGROUND

Professional and other organizations, including oral health care organizations, have been developing evidence-based clinical practice guidelines (CPGs) to help providers incorporate the best available evidence into their clinical decision making. Although the rigor of guideline development has increased over time, ongoing challenges prevent the full adoption of CPGs into clinical practices that experience variability in provider expertise and opinion, patient flow pace, and use of electronic dental records. These challenges include lack of relevant evidence, failure to keep guidelines up to date, and failure to adopt strategies aimed at overcoming the barriers preventing implementation into clinical practice.

RESULTS

This article provides a brief overview of strategies that can be used to overcome common challenges to guideline adoption. Such strategies include creating evidence-based CPGs that use additional sources of evidence and methods to inform guideline development and accelerate the guideline updating and dissemination process (that is, evidence directly from clinical practice, big data, patients' values and preferences, and living guidelines) and applying implementation strategies that have been documented as improving translation of CPGs into routine clinical practice (that is, guideline implementability, implementation science, and computable guidelines).

PRACTICAL IMPLICATIONS

Adopting newer strategies for developing and translating evidence into practice could lead to improvements in patient care and population health.

Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review

Background

WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship.

Methods

We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.

Results

The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines.

Conclusions

The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00899-y.

Clinician and early childhood educator knowledge and advice given to parents regarding physical activity, screen time and sleep. An observational study

BACKGROUND

Global guidelines regarding infant physical activity, screen time and sleep were released by the World Health Organisation in 2019. Clinician and Early Childhood Educator's knowledge and advice given to parents regarding this content is unknown. The aims of this study were to determine the advice given to parents regarding infant care. This will enable a baseline from which future interventions and multidisciplinary professional development can be compared and reviewed.

METHODS

80 Clinicians (Medical, Nursing, Allied Health) and Early Childhood Educators from a local health district in NSW Australia completed an online survey. Medical records (N = 272) were also reviewed to determine if the documentation included advice in accordance with guidelines.

FINDINGS

Staff were aware that infant guidelines contributes to positive health outcomes (all >85%). Nursing entered the most information into the medical record with >80% of files containing general advice about infant physical activity and sleep. Only 30% of entries contained evidence of guideline specific information. Minimal entries from all clinicians contained information about screen time (2%).

DISCUSSION

The majority of clinicians and Early Childhood Educators were aware of the content of the guidelines and the advice they report to provide is consistent. Medical record documentation regarding the specificity of advice provided is lacking.

APPLICATION TO PRACTICE

This study provides a baseline from which professional development interventions aimed at increasing compliance to infant guidelines can be compared.

The Guideline Language and Format Instrument (GLAFI): development process and international needs assessment survey

Background

Successful guideline implementation depends both on factors extrinsic to guidelines and their intrinsic features. In the Guideline Implementability for Decision Excellence Model (GUIDE-M), “communicating” content (language and format) is one of three core determinants of intrinsic implementability, but is seldom addressed. Our aims were to develop a tool that could be used by guideline developers to optimize language and format during development; identify gaps in this type of guidance in existing resources; and evaluate the perceived need for and usefulness of such a tool among guideline developers.

Methods

Our mixed-methods design consisted of (1) content development (selection and organization of evidence-based constructs from the GUIDE-M into a prototype Guideline Language and Format Instrument (GLAFI), followed by face validation with guideline developers); (2) document analysis (duplicate) of seven existing guideline tools to measure coverage of GLAFI items and identify new items; and (3) an international survey of guideline developers (corresponding authors of recent Canadian Medical Association or Guidelines International Network database guidelines) to measure perceived importance of language and format, quality of existing resources, and usefulness of a language and format tool.

Results

GLAFI items were organized into 4 language and 4 format subdomains. In face validation with guideline developers (17 clinicians, 1 methodologist), all agreed that the tool would improve guideline implementability and 93% indicated a desire for regular use. In the existing guideline tool document analysis, only 14/44 (31.8%) GLAFI items were operationalized in at least one tool. We received survey responses from 148/674 (22.0%) contacted guideline authors representing 45 organizations (9 countries). Language was rated as “extremely important” or “important” in determining uptake by 94% of respondents, and format by 84%. Correspondingly, 72% and 70% indicated that their organization would likely use such a tool.

Conclusions

Optimal language and format are fundamental to guideline implementability but often overlooked. The GLAFI tool operationalizes evidence-based constructs, most of which are absent in existing guideline tools. Guideline developers perceive these concepts to be important and express a willingness to use such a tool. The GLAFI should be further tested and refined with guideline developers and its impact on end-users measured.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01219-2.

Effectiveness of a guideline implementation tool for supporting management of mental health complications after mild traumatic brain injury in primary care: protocol for a randomised controlled trial

INTRODUCTION

Mental health problems frequently interfere with recovery from mild traumatic brain injury (mTBI) but are under-recognised and undertreated. Consistent implementation of clinical practice guidelines for proactive detection and treatment of mental health complications after mTBI will require evidence-based knowledge translation strategies. This study aims to determine if a guideline implementation tool can reduce the risk of mental health complications following mTBI. If effective, our guideline implementation tool could be readily scaled up and/or adapted to other healthcare settings.

METHODS AND ANALYSIS

We will conduct a triple-blind cluster randomised trial to evaluate a clinical practice guideline implementation tool designed to support proactive management of mental health complications after mTBI in primary care. We will recruit 535 adults (aged 18-69 years) with mTBI from six emergency departments and two urgent care centres in the Greater Vancouver Area, Canada. Upon enrolment at 2 weeks post-injury, they will complete mental health symptom screening tools and designate a general practitioner (GP) or primary care clinic where they plan to seek follow-up care. Primary care clinics will be randomised into one of two arms. In the guideline implementation tool arm, GPs will receive actionable mental health screening test results tailored to their patient and their patients will receive written education about mental health problems after mTBI and treatment options. In the usual care control arm, GPs and their patients will receive generic information about mTBI. Patient participants will complete outcome measures remotely at 2, 12 and 26 weeks post-injury. The primary outcome is rate of new or worsened mood, anxiety or trauma-related disorder on the Mini International Neuropsychiatric Interview at 26 weeks.

ETHICS AND DISSEMINATION

Study procedures were approved by the University of British Columbia's research ethics board (H20-00562). The primary report for the trial results will be published in a peer-reviewed journal. Our knowledge user team members (patients, GPs, policymakers) will co-create a plan for public dissemination.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04704037).

Systematic development of quality indicators for skin cancer management in primary care: a mixed-methods study protocol

INTRODUCTION

Australia has the highest incidence of skin cancer in the world, with two out of three Australians expected to be diagnosed with skin cancer in their lifetime. Such incidence necessitates large-scale, effective skin cancer management practices. General practitioners (in mainstream practice and in skin cancer clinics) play an important role in skin cancer care provision, making decisions based on relevant evidence-based guidelines, protocols, experience and training. Diversity in these decision-making practices can result in unwarranted variation. Quality indicators are frequently implemented in healthcare contexts to measure performance quality at the level of the clinician and healthcare practice and mitigate unwarranted variation. Such measurements can facilitate performance comparisons between peers and a standard benchmark, often resulting in improved processes and outcomes. A standardised set of quality indicators is yet to be developed in the context of primary care skin cancer management.

AIMS

This research aims to identify, develop and generate expert consensus on a core set of quality indicators for skin cancer management in primary care.

METHODS

This mixed-methods study involves (1) a scoping review of the available evidence on quality indicators in skin cancer management in primary care, (2) identification and development of a core set of quality indicators through interviews/qualitative proforma surveys with participants, and (3) a focus group involving discussion of quality indicators according to Nominal Group Technique. Qualitative and quantitative data will be collected and analysed using thematic and descriptive statistical analytical methods.

ETHICS AND DISSEMINATION

Approval was granted by the university's Research Ethics Committee (HREC no. 520211051532420). Results from this study will be widely disseminated in publications, study presentations, educational events and reports.

Unwarranted variation in radiation therapy fractionation

The adoption of hypofractionation across multiple tumour sites has been slow despite robust evidence. There is considerable unwarranted variation in practice, both within and between jurisdictions. This has been attributed to inconsistencies in guidelines, physician preference, lack of technology and differing financial incentives. Unwarranted variation in the use of hypofractionation has a tremendous effect on cost to both patients and the healthcare system. This places an unnecessary burden on patients and poorly utilises scarce healthcare resources. A collaborative effort from clinicians, patients, healthcare providers and policymakers is needed to reduce unwarranted variation in practice. This will improve quality of care both for patients and at broader healthcare system level.

An extension of the RIGHT statement for introductions and interpretations of clinical practice guidelines: RIGHT for INT

OBJECTIVE

The purpose of the extension of the RIGHT Statement for INTroductions and INTerpretations of Clinical Practice Guidelines (RIGHT for INT) is to promote the development of comprehensive and clear articles that introduce and interpret clinical practice guidelines.

METHODS

The RIGHT for INT checklist was developed following methods recommended by the EQUATOR Network. The development process included three stages. In the first stage, a multidisciplinary team of experts was recruited by email and WeChat and further divided into three groups (a steering group, a consensus group, and a secretariat group); in the second stage, the initial items were collected by literature review and brainstorming; and in the third stage, the final items were formed through a Delphi survey and expert consultation.

RESULTS

A total of 40 initial items were collected through literature review and brainstorming. A final checklist of 27 items was formed after the Delphi survey and expert consultation. The RIGHT for INT checklist contains items on the following 10 topics: title, abstract, background of guideline interpretation, background of guideline development, guideline development methodology, recommendations, strengths, and limitations, implications for local guidelines and clinical research, dissemination and implementation, and reporting quality.

CONCLUSION

The RIGHT for INT checklist provides guidance for guideline interpreters on how to introduce and interpret clinical practice guidelines in a scientific and comprehensive manner.

Awareness and agreement with neurofibromatosis care guidelines among U.S. neurofibromatosis specialists

Introduction

The neurofibromatoses (NF) are a group of rare, genetic diseases sharing a predisposition to develop multiple benign nervous system tumors. Given the wide range of NF symptoms and medical specialties involved in NF care, we sought to evaluate the level of awareness of, and agreement with, published NF clinical guidelines among NF specialists in the United States.

Methods

An anonymous, cross-sectional, online survey was distributed to U.S.-based NF clinicians. Respondents self-reported demographics, practice characteristics, awareness of seven NF guideline publications, and level of agreement with up to 40 individual recommendations using a 5-point Likert scale. We calculated the proportion of recommendations that each clinician rated “strongly agree”, and assessed for differences in guideline awareness and agreement by respondent characteristics.

Results

Sixty-three clinicians (49% female; 80% academic practice) across > 8 medical specialties completed the survey. Awareness of each guideline publication ranged from 53%-79% of respondents; specialists had higher awareness of publications endorsed by their medical professional organization (p < 0.05). The proportion of respondents who “strongly agree” with individual recommendations ranged from 17%-83%; for 16 guidelines, less than 50% of respondents “strongly agree”. There were no significant differences in overall agreement with recommendations based on clinicians’ gender, race, specialty, years in practice, practice type (academic/private practice/other), practice location (urban/suburban/rural), or involvement in NF research (p > 0.05 for all).

Conclusions

We identified wide variability in both awareness of, and agreement with, published NF care guidelines among NF experts. Future quality improvement efforts should focus on evidence-based, consensus-driven methods to update and disseminate guidelines across this multi-specialty group of providers. Patients and caregivers should also be consulted to proactively anticipate barriers to accessing and implementing guideline-driven care. These recommendations for improving guideline knowledge and adoption may also be useful for other rare diseases requiring multi-specialty care coordination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02196-x.

Implementability of healthcare interventions: an overview of reviews and development of a conceptual framework

Background

Implementation research may play an important role in reducing research waste by identifying strategies that support translation of evidence into practice. Implementation of healthcare interventions is influenced by multiple factors including the organisational context, implementation strategies and features of the intervention as perceived by people delivering and receiving the intervention. Recently, concepts relating to perceived features of interventions have been gaining traction in published literature, namely, acceptability, fidelity, feasibility, scalability and sustainability. These concepts may influence uptake of healthcare interventions, yet there seems to be little consensus about their nature and impact. The aim of this paper is to develop a testable conceptual framework of implementability of healthcare interventions that includes these five concepts.

Methods

A multifaceted approach was used to develop and refine a conceptual framework of implementability of healthcare interventions. An overview of reviews identified reviews published between January 2000 and March 2021 that focused on at least one of the five concepts in relation to a healthcare intervention. These findings informed the development of a preliminary framework of implementability of healthcare interventions which was presented to a panel of experts. A nominal group process was used to critique, refine and agree on a final framework.

Results

A total of 252 publications were included in the overview of reviews. Of these, 32% were found to be feasible, 4% reported sustainable changes in practice and 9% were scaled up to other populations and/or settings. The expert panel proposed that scalability and sustainability of a healthcare intervention are dependent on its acceptability, fidelity and feasibility. Furthermore, acceptability, fidelity and feasibility require re-evaluation over time and as the intervention is developed and then implemented in different settings or with different populations. The final agreed framework of implementability provides the basis for a chronological, iterative approach to planning for wide-scale, long-term implementation of healthcare interventions.

Conclusions

We recommend that researchers consider the factors acceptability, fidelity and feasibility (proposed to influence sustainability and scalability) during the preliminary phases of intervention development, evaluation and implementation, and iteratively check these factors in different settings and over time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01171-7.

Clinical decision support in primary care for better diagnosis and management of retinal disease

Misdiagnosis of retinal disease is a common problem in primary care that can lead to irreversible vision loss and false-positive referrals, resulting in inappropriate use of health services. Clinical decision support systems describe tools that leverage information technology to provide timely recommendations that assist clinicians in the decisions they make about the care of a patient. They, therefore, have the potential to reduce the rate of misdiagnosis by promoting evidence-based medicine and more effective and efficient healthcare. This narrative review aims to support primary care practitioners in better understanding the current and emerging capacity of clinical decision support systems in eye care. Different types of clinical decision support systems are discussed, using current examples and evidence from the available literature to demonstrate how they may improve diagnostic effectiveness and aid the management of retinal disease. Comments are made on the future directions of clinical decision support in primary eye care and the potential applications of artificial intelligence.

Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines

BACKGROUND

Females with persistent pelvic pain (PPP) report great variability in treatments they are recommended despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. A clear consensus for the best practice care for PPP is required.

OBJECTIVE

Identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality.

SEARCH STRATEGY

MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection, and relevant guideline databases were searched from their inception to June 2021.

SELECTION CRITERIA

Included CPGs were those for the management of urogynaecological conditions in adult females published in English, of any publication date, and endorsed by a professional organisation or society.

DATA COLLECTION AND ANALYSIS

We screened 1,379 records and included 20 CPGs. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs.

MAIN RESULTS

CPGs for seven conditions provided 281 individual recommendations. On quality appraisal, guidelines on average scored 'excellent' for the domains 'scope and purpose' (80.6%, SD=13.3) and 'clarity and presentation' (74.4%, SD=12.0); for other domains, average scores were satisfactory or poor. Four guidelines (Endometriosis, NICE, RANZCOG, ESHRE; PCOS, Teede et al. 2018) were deemed recommended for use. Recommendations were most frequent for pharmaceutical and surgical interventions. Recommendations were variable for psychological, physiotherapy, and other conservative interventions.

CONCLUSIONS

The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical, and other biomedical interventions.