Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

Symptom Screening for Hospitalized Pediatric Patients With Cancer: A Randomized Clinical Trial

Importance

Pediatric patients with cancer experience severely bothersome symptoms during treatment. It was hypothesized that symptom screening and provision of symptom reports to the health care team would reduce symptom burden in pediatric patients with cancer.

Objective

To determine if daily symptom screening and provision of symptom reports to the health care team was associated with lower total symptom burden as measured by the Symptom Screening in Pediatrics Tool (SSPedi) compared to usual care among pediatric patients with cancer admitted to a hospital or seen in a clinic daily for at least 5 days.

Design, Setting, and Participants

This randomized clinical trial enrolled participants from July 2018 to September 2023 from 8 Canadian tertiary care centers that diagnose and treat pediatric patients with cancer. Patients aged 8 to 18 years with cancer expected to be in a hospital or clinic daily for at least 5 consecutive days were eligible for inclusion. Participants were randomized to intervention (n = 176) vs control (n = 169) groups. Data were analyzed from November 2023 to December 2023.

Intervention

Intervention participants completed the SSPedi once daily for 5 days. Printed symptom reports were provided daily to the health care team, and email alerts were distributed for severely bothersome symptoms. Control participants received usual care.

Main Outcomes and Measures

The primary outcome was self-reported total SSPedi score on day 5. Secondary outcomes were individual SSPedi symptoms, pain, quality of life, symptom documentation, and intervention provision. The primary analysis compared the day 5 total SSPedi scores between randomized groups using a multiple linear regression model. For the secondary analysis comparing individual SSPedi symptom scores, the odds ratio for the intervention was estimated using a proportional odds model. Pain and quality of life were analyzed using the same approach as the primary outcome. Fisher exact test was used to compare symptom documentation, any intervention, and symptom-specific intervention between groups.

Results

A total of 345 participants were enrolled; median (range) participant age was 13.8 (8.0-18.8) years, and 150 participants (43.5%) were female. Day 5 SSPedi score was significantly better with symptom screening compared to usual care (adjusted mean difference, -2.5; 95% CI, -3.8 to -1.2). Symptom screening reduced the odds of higher individual symptom scores; 8 of 15 symptom reductions were statistically significant. There were no significant differences in pain or quality of life scores between groups. Five symptoms were documented or treated significantly more often with symptom screening than usual care.

Conclusions and Relevance

In this randomized clinical trial, among pediatric patients with cancer admitted to a hospital or seen in a clinic daily for at least 5 days, symptom screening with SSPedi improved total symptom scores compared to usual care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03593525.

Barriers to quality cancer care: a qualitative exploration of oncology case managers' experiences in facilitating guideline implementation in Taiwan

BACKGROUND

In cancer care, the use of clinical practice guidelines (CPGs) has been shown to improve the quality and effectiveness of medical services. To facilitate physicians' adherence to these guidelines, Taiwan established the position of oncology case manager (OCM) in 2010, one of whose responsibilities is to monitor physicians' compliance. However, there have been few explorations of their experiences and the barriers they face in facilitating guideline implementation.

OBJECTIVE

The aim of this study was to explore how OCMs carry out their roles in facilitating the implementation of CPGs in Taiwan and the challenges they encounter in this process.

METHODS

In this study, a qualitative interpretative phenomenological analysis (IPA) approach focusing on interpreting phenomena was adopted. The subjects were eight OCMs from the same hospital in Taiwan. Data collection primarily involved conducting interviews, supplemented by document analysis.

RESULTS

The analysis revealed the following challenges for OCMs in the process of facilitating guideline implementation: (1) Local production: Self-directed exploration leads to significant pressure. (2) Operational modes: Difficulties arise in the "low-ranking overseeing high-ranking" approach. (3) Accountability mechanisms: OCMs are saddled with the chore of managing evaluation.

CONCLUSION/PRACTICAL IMPLICATIONS

Guidelines are vital tools to ensure the quality of cancer care. However, based on the experiences of OCMs, shortcomings in institutional design, hierarchical organizational culture, misconceptions about the role of OCMs, and a lack of support from management have been identified as key obstacles in the implementation process. Suggestions of ways to address these challenges and promote successful guideline implementation are proposed.

Developing a Strategy to Increase Lung Cancer Screening in Areas of Need

Lung cancer screening (LCS) rates are low, and lung cancer mortality is high in the United States. This report describes a strategy that health systems can use to identify LCS areas of need and engage associated primary care providers and patients in screening. A research team from Jefferson Health (JH), a large, urban health system, used geocoded standardized lung cancer mortality rates (SMRs) to identify zip codes in Philadelphia where lung cancer mortality is high. In addition, health system electronic medical record data were used to identify primary care practices serving these areas. The study also developed an online program to train providers in shared decision making (SDM) about LCS. Finally, primary care leaders were interviewed to learn about training obstacles and opportunities. The JH research team identified 8 high-SMR zip codes and 8 practices with patients from those areas. Working with the American College of Chest Physicians and the National Lung Cancer Round Table, the authors developed a free, online, accredited course to train providers in patient education, values elicitation, and decision support for LCS. Interview analyses with practice leaders encouraged the health system to incentivize provider training and use of SDM tools in practice. Health systems can implement a systematic approach to identify LCS areas of need and train primary care providers to engage patients in SDM about LCS. Research is needed to implement such an approach and evaluate the program's impact on patient engagement, screening, and related outcomes among patients' diverse populations.

Assessing the feasibility of an integrated collection of education modules for fall and fracture prevention (iCARE) for healthcare providers in long term care: A longitudinal study

Falls and hip fractures are a major health concern among older adults in long term care (LTC) with almost 50% of residents experiencing a fall annually. Hip fractures are one of the most important and frequent fall-related injuries in LTC. There is moderate to strong certainty evidence that multifactorial interventions may reduce the risk of falls and fractures; however, there is little evidence to support its implementation. The purpose of this study was to determine the feasibility (recruitment rate and adaptations) with a subobjective to understand facilitators to and barriers of implementing the PREVENT (Person-centred Routine Fracture PreEVENTion) model in practice. The model includes a multifactorial intervention on diet, exercise, environmental adaptations, hip protectors, medications (including calcium and vitamin D), and medication reviews to treat residents at high risk of fracture. Our secondary outcomes were to determine if there was a change in knowledge uptake of the guidelines among healthcare providers and in the proportion of fracture prevention prescriptions post-intervention. We conducted a mixed-methods longitudinal cohort study in three LTC homes across southern Ontario. A local champion was selected to help guide the implementation of the model and promote best practices. We reported recruitment rates using descriptive statistics and challenges to implementation using content analysis. We reported changes in knowledge uptake and in the proportion of fracture prevention medications using the McNemar's test. We recruited three LTC homes and identified one local champion for each home. We required two months to identify and train the local champion over three, 1.5-hour train-the-trainer sessions, and the local champion required three months to deliver the intervention to a team of healthcare professionals. We identified several facilitators, barriers, and adaptations to PREVENT. Benefits of the model include easy access to the Fracture Risk Scale (FRS), clear and succinct educational material catered to each healthcare professional, and an accredited Continuing Medical Educational module for physicians and nurses. Challenges included misperceptions between the differences in fall and fracture prevention strategies, fear of perceived side effects associated with fracture prevention medications, and time barriers with completing the audit report. Our study found an increase knowledge uptake of the guidelines and an increase in the proportion of fracture prevention prescriptions post-intervention.

Implementing national care guidelines in local authorities in England and Wales: a theory-of-change

BACKGROUND

The delivery of high-quality services in chronically underfunded social or long-term care systems is a major challenge internationally. National guidelines, developed by the National Institute for Health and Care Excellence, set out how local authorities in England and Wales should fund and provide care based on best available evidence. Theoretical and participatory approaches can usefully inform the design and evaluation of implementation strategies for guidelines. The aim of the study is to develop a Theory-of-Change for how the implementation of these guidelines is expected to lead to impacts from a local authority perspective.

METHODS

As part of a comparative case study (The 'Valuing Care Guidelines' study; February 2022 to April 2024) with three local authority sites in England and Wales, we involved altogether 17 participants in two Theory-of-Change online workshops per site, each of 2 hours. Additional data gathered from the same participants as part of the overall study were used to conceptualise and enrich information from the workshops.

RESULTS

Participants described the Theory-of-Change map as follows: A wide range of activities (categorised in stages of 'pre-implementation', 'implementation', 'sustainment and scaling') and skills were required to implement guidelines, and achieve long-term organisational sustainability and service delivery outcomes, leading to final impacts for service users and carers. Participants described a co-creation implementation model, led by 'Implementation Support Practitioners', who utilised relational skills to achieve motivation, trust, and confidence at different organisational levels, addressing contextual barriers such as inadequate staffing, lack of resources and of organisational support systems. Consistent use of guidelines by frontline staff could only be achieved if the value of guideline implementation was promoted widely, and if consideration was given to the roles of stakeholders, such as the inspection body, local health care providers, users and carers.

CONCLUSIONS

Our study is the first to investigate the implementation of national social care guidelines by local authorities in England and Wales. It generates insights that can guide implementation practice as well as inform the evaluation of future implementation strategies.

Clinical Practice Guideline-Inconsistent Management of Fertility Preservation in Pediatric Cancer Patients in Community Settings: A Children's Oncology Group Study

Background: The primary objective was to measure adherence to clinical practice guideline (CPG) recommendations for fertility preservation (FP) in pediatric cancer patients treated in National Cancer Institute Community Oncology Research Program (NCORP) sites. Secondary objectives were to describe factors such as site size associated with CPG-inconsistent care delivery and cryopreservation completion. Methods: This retrospective, multicenter study included patients 15 to 21 years old with a first cancer diagnosis from January 2014 through December 2015 who were previously enrolled to a Children's Oncology Group (COG) study and received care at a participating NCORP site. Patients were randomly selected from a list generated by the COG for chart review by participating sites. Primary outcome was care delivery that was inconsistent with a strong CPG recommendation on FP, namely discussion and offering of FP options before cancer treatment initiation, as adjudicated centrally by a panel. Results: A total of 129 patients from 25 sites were included. Among these, 48% (62/129) received CPG-inconsistent care. Most CPG-inconsistent care was due to lack of FP discussion documentation (93.5%, 58/62). Small site size, treatment at a pediatric (vs mixed adult/pediatric) site, and female sex were associated with higher odds of CPG-inconsistent care delivery. Conclusions: Newly diagnosed pediatric cancer patients often received CPG-inconsistent care for FP, with disproportionate gaps noted for females, and those treated at smaller or pediatric NCORP sites. The primary reason for CPG-inconsistent care is lack of FP discussion from clinicians. Opportunities to improve FP CPG implementation are highlighted.

Iodinated contrast media waste management in hospitals in central Norway

INTRODUCTION

The demand for iodine has increased in the last years, among other factors due to increased medical use. There is no consensus regarding iodinated contrast media (ICM)'s damaging impact on the environment and therefore the producers encourage collecting and recycling ICM waste. The aim of the study was to investigate the ICM waste management in hospitals in Central Norway and to explore the radiographers' attitudes regarding ICM recycling and possible causes of suboptimal waste management.

METHODS

The link to the electronic survey was sent to all radiographers working with computed tomography within the Central Norway Regional Health Authority. Descriptive and inferential statistics were performed.

RESULTS

Results reported from 100 radiographers from eight hospitals show that ICM leftovers are recycled or reused in most cases (26% collect them for recycling and 38% use them for oral administration) while 25% send them to the pharmacy together with other pharmaceutical waste and 8% discard them in the sink or the garbage bin. 25% reported that they are not familiar with their department's procedures related to ICM waste. 84% were concerned about the consequences of ICM waste for the environment.

CONCLUSION

There were considerable differences in the management of ICM waste amongst the hospitals and also internally within the hospitals. Improper practices, likely caused by lack of disposal plans and/or suboptimal information flow, were reported to a low extent.

IMPLICATIONS FOR PRACTICE

Local ICM waste management guidelines which are easily available for radiographers may increase both reuse and recycle rates. Including ICM waste management in the educational curriculum for radiographers can provide early understanding of the rationale behind the procedures and their environmental impact.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022

BACKGROUND

Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes.

METHODS

We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes.

FINDINGS

Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions.

CONCLUSION

This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

Implementation Strategies to Promote Short-Course Radiation for Bone Metastases

Importance

For patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings.

Objective

To evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions).

Design, Setting, and Participants

This prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023.

Exposures

Three implementation strategies-(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)-were rolled out to physicians.

Main Outcomes and Measures

The primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy.

Results

Forty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly.

Conclusions and Relevance

In this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.

Developing a low back pain guideline implementation programme in collaboration with physiotherapists and chiropractors using the Behaviour Change Wheel: a theory-driven design study

BACKGROUND

Low back pain is still the leading cause of disability and societal burden, with 619 million prevalent cases worldwide in 2020. Most countries produce clinical guidelines to support healthcare professionals in evidence-based care regarding low back pain. However, several studies have identified relatively poor uptake of guidelines. Tailored strategies to facilitate the implementation of guidelines have been argued to increase uptake. This study aimed to develop a contextually tailored implementation programme to enhance evidence-based low back pain care among Danish physiotherapists and chiropractors in primary care.

METHODS

A theory-driven implementation programme development study was conducted using the Behaviour Change Wheel, with high healthcare professional involvement. Data collection included four workshops with seven physiotherapists and six chiropractors from primary care clinics. The development process consisted of [1] establishing a theoretical frame, [2] involving participants, [3] understanding the behaviour, [4] designing the implementation programme, and [5] final implementation programme.

RESULTS

The target behaviours selected (guideline recommendations) for the implementation programme were (i) screening of psychosocial risk factors and (ii) offering patient education. The barriers and facilitators for the selected behaviours were described and linked to intervention functions and behavioural techniques. Finally, the implementation programme comprised five strategies: webinars, e-learning videos, communication exercises, peer learning, and group dialogue meetings. In addition, the programme consisted of implementation support: champions, a physical material folder, a weekly email reminder, a specially designed website and a visit from an implementation consultant. An essential element of the overall programme was that it was designed as a step-by-step implementation process consisting of 16 h of education and training distributed over 16 weeks.

CONCLUSIONS

A programme for implementing low back pain guideline recommendations was developed based on behaviour change theory and four co-design workshops involving healthcare professionals to overcome the contextually identified barriers. A theory-driven approach involving healthcare professionals was useful in identifying relevant target behaviours and tailoring the programme to consider contextual barriers and facilitators for implementation. The effectiveness of the final implementation programme will be evaluated in the project's next phase.

TRIAL REGISTRATION

Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19.

The effectiveness of interventions to disseminate the results of non-commercial randomised clinical trials to healthcare professionals: a systematic review

BACKGROUND

It is unclear how to disseminate the results of randomised controlled trials effectively to health professionals and policymakers to improve treatment, care or prevention through changing policy and practice. This systematic review examined the effectiveness of different methods of dissemination of clinical research results to professional audiences.

METHODS

We systematically reviewed the published and grey literature from 2000 to 2022 for studies assessing different approaches for disseminating clinical study results to professional audiences (health professionals, policymakers and guideline developers). Two reviewers assessed potentially relevant full texts for inclusion. We grouped studies by intervention type, synthesising findings using effect direction plots. Outcomes were grouped into out-takes (e.g. awareness, knowledge, understanding), outcomes (e.g. attitude changes) and impact (changes in policy/practice). The quality of evidence was assessed using GRADE.

RESULTS

Our search identified 13,264 unique records, of which 416 full texts were assessed for eligibility. Of 60 studies that were identified as eligible for inclusion, 20 evaluated the effectiveness of interventions to disseminate clinical research results (13 RCTs, 2 observational studies, 3 pre- and post-intervention surveys and 2 cross-sectional surveys). Studies were grouped by intervention: 7 studies that involved face-to-face meetings between the target audience and trained educators were classified as 'outreach interventions'; 5 studies that provided a summary format for systematic review findings (e.g. summary of findings tables) were grouped together. There was high certainty evidence of a small beneficial impact of outreach interventions on health and moderate certainty evidence of impact on practice (mostly prescribing). There was no evidence of impact on policy and very low certainty around benefits on outcomes and out-takes. We found no consistent benefits of summary formats for systematic review results on outcomes or out-takes (moderate quality evidence). Other interventions with less evidence are reported in the Additional Materials.

CONCLUSIONS

Outreach interventions to disseminate clinical research results can lead to changes in practice and improvements in health. However, these interventions can be resource-intensive. Investment is vital to identify and implement effective and cost-effective ways to disseminate results, so that the potential benefits of trials to patients can be realised.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), CRD42019137364.

Anemia diagnosis and therapy in malignant diseases: implementation of guidelines-a representative study

PURPOSE

Anemia in cancer should be diagnosed and treated according to guideline recommendations. The implementation of ESMO and German guidelines and their effect on anemia correction was analyzed.

METHODS

This retrospective epidemiological study, representative for Germany, analyzed data on anemia management of cancer patients with anemia ≥ grade 2. The Guideline Adherence Score (GLAD) for diagnosis (GLAD-D) and therapy (GLAD-T) was defined as follows: 2 points for complete, 1 point for partial, 0 point for no adherence.

RESULTS

Data were analyzed for 1046 patients. Hb levels at diagnosis of anemia were 8-10 g/dL in 899 (85.9%) patients, 7-8 g/dL in 92 (8.7%), and < 7 g/dL (5.0%) in 52. Transferrin saturation was determined in 19% of patients. Four hundred fifty-six patients received RBC (43.6%), 198 (18.9%) iron replacement, 106 (10.1%) ESA, and 60 (5.7%) vitamin B12 replacement. 60.6% of patients receiving iron replacement were treated intravenously and 39.4% were treated orally. Two hundred eighty-eight (36.6%) of 785 patients receiving transfusions had no guideline-directed indication. GLAD-D was 2 in 310 patients (29.6%), 1 in 168 (16.1%), and 0 in 568 (54.3%). GLAD-T was 2 in 270 patients (25.8%), 1 in 320 patients (30.6%), and 0 in 456 patients (43.6%). Higher GLAD-D significantly correlated with higher GLAD-T (τB = 0.176, p < 0.001). GLAD-T 2 was significantly associated with greater Hb increase than GLAD-T 0/1 (p < 0.001) at 28 days (10.2 vs. 9.7 g/dL) and at 2 months (10.4 vs. 9.9 g/dL).

CONCLUSIONS

Anemia assessment is inadequate, transfusion rates too high, and iron and ESA therapy too infrequent.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05190263, date: 2022-01-13.

Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active-cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full-text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active-cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B-cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non-Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good-excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active-cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962).

What information sources do Dutch medical specialists use in medical decision-making: a qualitative interview study

OBJECTIVE

To explore what information sources medical specialists currently use to inform their medical decision-making.

DESIGN

Qualitative, semistructured interviews.

SETTING AND PARTICIPANTS

A total of 20 semistructured interviews were conducted with 10 surgeons and 10 internal medicine specialists who work in academic and/or regional hospitals in the Netherlands.

RESULTS

Medical specialists reported that they primarily rely on their general knowledge and experience, rather than actively using information sources. The sources they use to update their knowledge can be categorised into 'scientific publications', 'guidelines or protocols', and 'presentations and meetings'. When medical specialists feel their general knowledge and experience are insufficient, they use three different approaches to find answers in response to clinical questions: consulting a colleague, actively searching the literature and asking someone else to search the literature.

CONCLUSION

Medical specialists use information sources to update their general knowledge and to find answers to specific clinical questions when they feel their general knowledge and experience are insufficient. An important finding is that medical specialists prefer accessible information sources (eg, consulting colleagues) over existing evidence-based medicine tools.

Indicators to measure implementation and sustainability of nursing best practice guidelines: A mixed methods analysis

Background

The use of best practice guidelines (BPGs) has the potential to decrease the gap between best evidence and nursing and healthcare practices. We conducted an exploratory mixed method study to identify strategies, processes, and indicators relevant to the implementation and sustainability of two Registered Nurses' Association of Ontario (RNAO) BPGs at Best Practice Spotlight Organizations® (BPSOs).

Methods

Our study had four phases. In Phase 1, we triangulated two qualitative studies: a) secondary analysis of 126 narrative reports detailing implementation progress from 21 BPSOs spanning four sectors to identify strategies and processes used to support the implementation and sustainability of BPGs and b) interviews with 25 guideline implementers to identify additional strategies and processes. In Phase 2, we evaluated correlations between strategies and processes identified from the narrative reports and one process and one outcome indicator for each of the guideline. In Phase 3, the results from Phases 1 and 2 informed indicator development, led by an expert panel. In Phase 4, the indicators were assessed internally by RNAO staff and externally by Ontario Health Teams. A survey was used to validate proposed indicators to determine relevance, feasibility, readability, and usability with knowledge users and BPSO leaders.

Results

Triangulation of the two qualitative studies revealed 46 codes of implementation and sustainability of BPGs, classified into eight overarching themes: Stakeholder Engagement, Practice Interventions, Capacity Building, Evidence-Based Culture, Leadership, Evaluation & Monitoring, Communication, and Governance. A total of 28 structure, process, or outcome indicators were developed. End users and BPSO leaders were agreeable with the indicators according to the validation survey.

Conclusions

Many processes and strategies can influence the implementation and sustainability of BPGs at BPSOs. We have developed indicators that can help BPSOs promote evidence-informed practice implementation of BPGs.

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.

Characteristics and impact of interventions to support healthcare providers' compliance with guideline recommendations for breast cancer: a systematic literature review

BACKGROUND

Breast cancer clinical practice guidelines (CPGs) offer evidence-based recommendations to improve quality of healthcare for patients. Suboptimal compliance with breast cancer guideline recommendations remains frequent, and has been associated with a decreased survival. The aim of this systematic review was to characterize and determine the impact of available interventions to support healthcare providers' compliance with CPGs recommendations in breast cancer healthcare.

METHODS

We searched for systematic reviews and primary studies in PubMed and Embase (from inception to May 2021). We included experimental and observational studies reporting on the use of interventions to support compliance with breast cancer CPGs. Eligibility assessment, data extraction and critical appraisal was conducted by one reviewer, and cross-checked by a second reviewer. Using the same approach, we synthesized the characteristics and the effects of the interventions by type of intervention (according to the EPOC taxonomy), and applied the GRADE framework to assess the certainty of evidence.

RESULTS

We identified 35 primary studies reporting on 24 different interventions. Most frequently described interventions consisted in computerized decision support systems (12 studies); educational interventions (seven), audit and feedback (two), and multifaceted interventions (nine). There is low quality evidence that educational interventions targeted to healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified have not been evaluated with appropriate study designs for such purpose. There is very limited data on the costs of implementing these interventions.

CONCLUSIONS

Different types of interventions to support compliance with breast cancer CPGs recommendations are available, and most of them show positive effects. More robust trials are needed to strengthen the available evidence base concerning their efficacy. Gathering data on the costs of implementing the proposed interventions is needed to inform decisions about their widespread implementation.

TRIAL REGISTRATION

CRD42018092884 (PROSPERO).

The effectiveness of clinical guideline implementation strategies in oncology-a systematic review

IMPORTANCE

Guideline recommendations do not necessarily translate into changes in clinical practice behaviour or better patient outcomes.

OBJECTIVE

This systematic review aims to identify recent clinical guideline implementation strategies in oncology and to determine their effect primarily on patient-relevant outcomes and secondarily on healthcare professionals' adherence.

METHODS

A systematic search of five electronic databases (PubMed, Web of Science, GIN, CENTRAL, CINAHL) was conducted on 16 december 2022. Randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) assessing the effectiveness of guideline implementation strategies on patient-relevant outcomes (overall survival, quality of life, adverse events) and healthcare professionals' adherence outcomes (screening, referral, prescribing, attitudes, knowledge) in the oncological setting were targeted. The Cochrane risk-of-bias tool and the ROBINS-I tool were used for assessing the risk of bias. Certainty in the evidence was evaluated according to GRADE recommendations. This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number CRD42021268593.

FINDINGS

Of 1326 records identified, nine studies, five cluster RCTs and four controlled before-and after studies, were included in the narrative synthesis. All nine studies assess the effect of multi-component interventions in 3577 cancer patients and more than 450 oncologists, nurses and medical staff.

PATIENT-LEVEL

Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain.

PROVIDER-LEVEL

Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.

CONCLUSIONS AND RELEVANCE

Knowledge and skill accumulation through team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched guideline implementation strategies in oncology recently. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia

BACKGROUND

The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers.

METHODS

The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127).

RESULTS

Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body.

CONCLUSION

Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Assessing the impact of a national clinical guideline for the management of chronic pain on opioid prescribing rates: a controlled interrupted time series analysis

BACKGROUND

Opioids can be effective analgesics, but long-term use may be associated with harms. In 2013, the first national, comprehensive, evidence-based pain management guideline was published, from the Scottish Intercollegiate Guideline Network (SIGN 136: Management of Chronic Pain) with key recommendations on analgesic prescribing. This study aimed to examine the potential impact on national opioid prescribing rates in Scotland.

METHODS

Trends in national and regional community opioid prescribing data for Scotland were analysed from quarter one (Q1) 2005 to Q2 2020. Interrupted time series regression examined the association of SIGN 136 publication with prescribing rates for opioid-containing drugs. Gabapentinoid prescribing was used as a comparison drug.

RESULTS

After a positive prescribing trend pre-publication, the timing of SIGN 136 publication was associated with a negative change in the trend of opioid prescribing rates (-2.82 items per 1000 population per quarter [PTPPQ]; P < 0.01). By Q2 2020, the relative reduction in the opioid prescribing rate was -20.67% (95% CI: -23.61, -17.76). This persisted after correcting for gabapentinoid prescribing and was mainly driven by the reduction in weak opioids, whereas strong opioid prescribing rates continued to rise. Gabapentinoid prescribing showed a significant rise in level (8.00 items per 1000 population; P = 0.01) and trend (0.27 items PTPPQ; P = 0.01) following SIGN 136 publication.

CONCLUSIONS

The publication of SIGN 136 was associated with a reduction in opioid prescribing rates. This suggests that changes in clinical policy through evidence-based national clinical guidelines may affect community opioid prescribing, though this may be partially replaced by gabapentinoids, and other factors may also contribute.

'Well, in dentistry the dentist is always the boss': a multi-method exploration of which organisational characteristics of dental practices most influence the implementation of evidence-based guidance

OBJECTIVE

To investigate which organisational characteristics of primary care dental practices influence the implementation of evidence-based guidance.

DESIGN

A multimethod study set within primary care dentistry in Scotland comprising: (1) Semistructured interviews with dental teams to inform development of a self-report questionnaire exploring the translation of guidance in primary care dentistry and (2) A questionnaire-based survey and case studies exploring which organisational characteristics influence knowledge translation.

RESULTS

Interview data identified three themes: leadership, communication and context. Survey data revealed compliance with recommendations from three topics of dental guidance to be variable, with only 41% (emergency dental care), 19% (oral health assessment and review) and 4% (drug prescribing) of respondents reporting full compliance. Analysis revealed no significant relationship between practice characteristics and compliance with emergency dental care or drug prescribing recommendations. Positive associations were observed between compliance with oral health assessment and review recommendations and having a practice manager, as well as with the type of treatment offered, with fully private practices more likely, and fully National Health Service practices less likely to comply, when compared with those offering a mixture of treatment. Synthesis of the data identified leadership and context as key drivers of guidance uptake.

CONCLUSIONS

Evidence-based dental recommendations are not routinely translated into practice, with variable leadership and differing practice contexts being central to poor uptake. Guidelines should aim to tailor recommendations and implementation strategies to reflect the complexities and varying contexts that exist in primary care dentistry, thus facilitating the implementation of evidence-based guidance.

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.

Understanding the implementation strategy of a secondary care tobacco addiction treatment pathway (the CURE project) in England: a strategic behavioural analysis

OBJECTIVES

The Conversation, Understand, Replace, Experts and evidence-based treatment (CURE) project implemented an evidence-based intervention that offers a combination of pharmacotherapy and behavioural support to tobacco-dependent inpatients. Understanding key characteristics of CURE's implementation strategy, and identifying areas for improvement, is important to support the roll-out of nationwide tobacco dependence services. This study aimed to (1) specify key characteristics of CURE's exiting implementation strategy and (2) develop theoretical-informed and stakeholder-informed recommendations to optimise wider roll-out.

DESIGN AND METHODS

Data were collected via document review and secondary analysis of interviews with 10 healthcare professionals of a UK hospital. Intervention content was specified through behaviour change techniques (BCTs) and intervention functions within the Behaviour Change Wheel. A logic model was developed to specify CURE's implementation strategy and its mechanisms of impact. We explored the extent to which BCTs and intervention functions addressed the key theoretical domains influencing implementation using prespecified matrices. The development of recommendations was conducted over a two-round Delphi exercise.

RESULTS

We identified six key theoretical domains of influences: 'environmental context and resources', 'goals', 'social professional role and identity', 'social influences', 'reinforcement' and 'skills'. The behavioural analysis identified 26 BCTs, 4 intervention functions and 4 policy categories present within the implementation strategy. The implementation strategy included half the relevant intervention functions and BCTs to target theoretical domains influencing CURE implementation, with many BCTs focusing on shaping knowledge. Recommendations to optimise content were developed following stakeholder engagement.

CONCLUSIONS

CURE offers a strong foundation from which a tobacco dependence treatment model can be developed in England. The exiting strategy could be strengthened via the inclusion of more theoretically congruent BCTs, particularly relating to 'environmental context and resources'. The recommendations provide routes to optimisation that are both theoretically grounded and stakeholder informed. Future research should assess the feasibility/acceptability of these recommendations in the wider secondary-care context.

The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review

INTRODUCTION

Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age.

METHODOLOGY

MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis.

RESULTS

Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age.

CONCLUSIONS

Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.

Iowa Implementation for Sustainability Framework

Background

An application-oriented implementation framework designed for clinicians and based on the Diffusion of Innovations theory included 81 implementation strategies with suggested timing for use within four implementation phases. The purpose of this research was to evaluate and strengthen the framework for clinician use and propose its usefulness in implementation research.

Methods

A multi-step, iterative approach guided framework revisions. Individuals requesting the use of the framework over the previous 7 years were sent an electronic questionnaire. Evaluation captured framework usability, generalizability, accuracy, and implementation phases for each strategy. Next, nurse leaders who use the framework pile sorted strategies for cultural domain analysis. Last, a panel of five EBP/implementation experts used these data and built consensus to strengthen the framework.

Results

Participants (n = 127/1578; 8% response) were predominately nurses (94%), highly educated (94% Master’s or higher), and from across healthcare (52% hospital/system, 31% academia, and 7% community) in the USA (84%). Most (96%) reported at least some experience using the framework and 88% would use the framework again. A 4-point scale (1 = not/disagree to 4 = very/agree) was used. The framework was deemed useful (92%, rating 3–4), easy to use (72%), intuitive (67%), generalizable (100%), flexible and adaptive (100%), with accurate phases (96%), and accurate targets (100%). Participants (n = 51) identified implementation strategy timing within four phases (Cochran’s Q); 54 of 81 strategies (66.7%, p < 0.05) were significantly linked to a specific phase; of these, 30 (55.6%) matched the original framework. Next, nurse leaders (n = 23) completed a pile sorting activity. Anthropac software was used to analyze the data and visualize it as a domain map and hierarchical clusters with 10 domains. Lastly, experts used these data and implementation science to refine and specify each of the 75 strategies, identifying phase, domain, actors, and function. Strategy usability, timing, and groupings were used to refine the framework.

Conclusion

The Iowa Implementation for Sustainability Framework offers a typology to guide implementation for evidence-based healthcare. This study specifies 75 implementation strategies within four phases and 10 domains and begins to validate the framework. Standard use of strategy names is foundational to compare and understand when implementation strategies are effective, in what dose, for which topics, by whom, and in what context.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01157-5.

Use and effects of implementation strategies for practice guidelines in nursing: a systematic review

BACKGROUND

Practice guidelines can reduce variations in nursing practice and improve patient care. However, implementation of guidelines is complex and inconsistent in practice. It is unclear which strategies are effective at implementing guidelines in nursing. This review aimed to describe the use and effects of implementation strategies to facilitate the uptake of guidelines focused on nursing care.

METHODS

We conducted a systematic review of five electronic databases in addition to the Cochrane Effective Practice and Organization of Care (EPOC) Group specialized registry. Studies were included if implementation of a practice guideline in nursing and process or outcome of care provided by nurses were reported. Two reviewers independently screened studies, assessed study quality, extracted data, and coded data using the EPOC taxonomy of implementation strategies. For those strategies not included in the EPOC taxonomy, we inductively categorized these strategies and generated additional categories. We conducted a narrative synthesis to analyze results.

RESULTS

The search identified 46 papers reporting on 41 studies. Thirty-six studies used a combination of educational materials and educational meetings. Review findings show that multicomponent implementation strategies that include educational meetings, in combination with other educational strategies, report positive effects on professional practice outcomes, professional knowledge outcomes, patient health status outcomes, and resource use/expenditures. Twenty-three of the 41 studies employed implementation strategies not listed within the EPOC taxonomy, including adaptation of practice guidelines to local context (n = 9), external facilitation (n = 14), and changes to organizational policy (n = 3). These implementation strategies also corresponded with positive trends in patient, provider, and health system outcomes.

CONCLUSIONS

Nursing guideline implementation may benefit from using the identified implementation strategies described in this review, including participatory approaches such as facilitation, adaptation of guidelines, and organizational policy changes. Further research is needed to understand how different implementation strategy components work in a nursing context and to what effect. As the field is still emerging, future reviews should also explore guideline implementation strategies in nursing in quasi or non-experimental research designs and qualitative research studies.

Introduction to PRISMA 2020 and implications for research synthesis methodologists

Systematic reviews should be reported completely and accurately so that users can interpret and appraise the review findings appropriately. In this commentary, we describe key features of a major update of the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement-PRISMA 2020-and discuss its implications for research synthesis methodologists.

Dissemination interventions to improve healthcare workers' adherence with infection prevention and control guidelines: a systematic review and meta-analysis

Background

The COVID-19 pandemic has challenged health systems worldwide since 2020. At the frontline of the pandemic, healthcare workers are at high risk of exposure. Compliance with infection prevention and control (IPC) should be encouraged at the frontline. This systematic review aimed to assess the effects of dissemination interventions to improve healthcare workers’ adherence with IPC guidelines for respiratory infectious diseases in the workplace.

Methods

We searched CENTRAL, MEDLINE, Embase, and the Cochrane COVID-19 Study Register. We included randomized controlled trials (RCTs) and cluster RCTs that assessed the effect of any dissemination strategy in any healthcare settings. Certainty of evidence was assessed using the GRADE approach. We synthesized data using random-effects model meta-analysis in Stata 14.2.

Results

We identified 14 RCTs conducted from 2004 to 2020 with over 65,370 healthcare workers. Adherence to IPC guidelines was assessed by influenza vaccination uptake, hand hygiene compliance, and knowledge on IPC. The most assessed intervention was educational material in combined strategies (plus educational meetings, local opinion leaders, audit and feedback, reminders, tailored interventions, monitoring the performance of the delivery of health care, educational games, and/or patient-mediated interventions). Combined dissemination strategies compared to usual routine improve vaccination uptake (risk ratio [RR] 1.59, 95% confidence interval [CI] 1.54 to 1.81, moderate-certainty evidence), and may improve hand hygiene compliance (RR 1.70; 95% CI 1.03 to 2.83, moderate-certainty). When compared to single strategies, combined dissemination strategies probably had no effect on vaccination uptake (RR 1.01, 95% CI 0.95 to 1.07, low-certainty), and hand hygiene compliance (RR 1.16, 95% CI 0.99 to 1.36, low-certainty). Knowledge of healthcare workers on IPC improved when combined dissemination strategies were compared with usual activities, and the effect was uncertain in comparison to single strategy (very low-certainty evidence).

Conclusions

Combined dissemination strategies increased workers’ vaccination uptake, hand hygiene compliance, and knowledge on IPC in comparison to usual activities. The effect was negligible when compared to single dissemination strategies. The adoption of dissemination strategies in a planned and targeted way for healthcare workers may increase adherence to IPC guidelines and thus prevent dissemination of infectious disease in the workplace.

Trial registration

Protocol available at http://osf.io/aqxnp.

Trends in Use and Perceptions About Triplet Chemotherapy Plus Bevacizumab for Metastatic Colorectal Cancer

Importance

Triplet chemotherapy with fluorouracil, folinic acid, oxaliplatin, and irinotecan plus bevacizumab (FOLFOXIRI-B) is an effective first-line treatment option for patients with metastatic colorectal cancer (mCRC). However, the degree of implementation of FOLFOXIRI-B in daily practice is unknown.

Objectives

To evaluate the current adoption rate of FOLFOXIRI-B in patients with mCRC and investigate the perspectives of medical oncologists toward this treatment option.

Design, Setting, and Participants

This 1-week, multicenter, cross-sectional study in the Netherlands used a flash mob design, which facilitates ultrafast data generation (flash) through the engagement of numerous researchers (mob). During the study week (March 1-5, 2021), patient data were retrieved from electronic health records of 47 hospitals on patients with mCRC who were referred to a medical oncologist between November 1, 2020, and January 31, 2021. Interviews were simultaneously conducted with 101 medical oncologists from 52 hospitals who regularly treat patients with mCRC.

Exposure

First-line systemic treatment as determined by the treating physician.

Main Outcomes and Measures

The FOLFOXIRI-B prescription rate was the main outcome. Current practice was compared with prescription rates in 2015 to 2018. Eligibility for treatment with FOLFOXIRI-B was estimated. An exploratory outcome was medical oncologists' reported perspectives on FOLFOXIRI-B.

Results

A total of 5948 patients in the Netherlands (median age [interquartile range], 66 [57-73] years; 3503 [59%] male; and 3712 [62%] with left-sided or rectal tumor) were treated with first-line systemic therapy for synchronous mCRC. A total of 282 patients with mCRC underwent systemic therapy during the study period (2021). Of these 282 patients, 199 (71%) were treated with intensive first-line therapy other than FOLFOXIRI-B, of whom 184 (65%) were treated with oxaliplatin doublets with or without bevacizumab; 14 (5%) with irinotecan doublets with or without bevacizumab, panitumumab, or cetuximab; and 1 (0.4%) with irinotecan with bevacizumab. Fifty-four patients (19%) were treated with fluoropyrimidine monotherapy with or without bevacizumab, 1 patient (0.4%) with panitumumab monotherapy, and 3 (1%) with immune checkpoint inhibitors. In total, 25 patients (9%; 95% CI, 6%-12%) were treated with first-line FOLFOXIRI-B compared with 142 (2%; 95% CI, 2%-3%) in 2015 to 2018. During the study period, 21 of 157 eligible patients (13.4%) in the Netherlands were treated with FOLFOXIRI-B. A total of 87 medical oncologists (86%) reported discussing FOLFOXIRI-B as a treatment option with eligible patients. A total of 47 of 85 (55%) generally communicated a preference for a chemotherapy doublet to patients. These oncologists reported a significantly lower awareness of guidelines and trial results. Toxic effects were the most reported reason to prefer an alternative regimen.

Conclusions and Relevance

The findings of this study suggest that FOLFOXIRI-B prescription rates have marginally increased in the last 5 years. Considering that most medical oncologists discuss this treatment option, the prescription rate found in this study was below expectations. Awareness of guidelines and trial data seems to contribute to the discussion of available treatment options by medical oncologists, and the findings of this study suggest a need for repeated and continuing medical education.

Colorectal Cancer screening in ambulatory healthcare service clinics in Abu Dhabi, United Arab Emirates in 2015-2016

Background

Colorectal cancer (CRC) is a major public health issue due to high morbidity and mortality. Different screening programs were implemented to reduce its burden.

Objectives

To estimate the prevalence of CRC screening uptake using fecal immunochemical test (FIT) or guaiac fecal occult blood testing (gFOBT) in Emirati nationals. Other objectives were to measure the incidence of CRC in the screened population, to measure the outcomes of follow-up screening colonoscopy after positive FIT/gFOBT and to identify the causes of not performing follow-up screening colonoscopy after positive FIT/gFOBT.

Methodology

Adult Emirati nationals aged 40–75 years who visited Ambulatory healthcare services clinics, Abu Dhabi in 2015–2016 were included in the study. The electronic medical records of the eligible individuals were reviewed retrospectively. The prevalence of CRC screening was measured among the eligible population using the FIT/gFOBT. The IBM SPSS Statistics program, version 21.0.0, was used for analysis.

Result

45,147 unique individuals were eligible for screening, and only 23.5% were screened using FIT/gFOBT. Of the screened individuals, 13.5% had positive FIT/ gFOBT, and 30.5% of those underwent follow-up screening colonoscopy. CRC was diagnosed in 11 individuals. Colonic polyp were found in 30.5% of individuals who had undergone a follow-up colonoscopy. Collectively 933 individuals did not undergo follow-up screening colonoscopy after having a positive FIT/gFOBT, and about 36.3% had collected the result and referred to a gastroenterologist but did not attend the appointment.

Conclusion

CRC screening uptake using FIT/gFOBT is low among the adult Emirati nationals.

Evaluation of the reporting quality of clinical practice guidelines on lung cancer using the RIGHT checklist

BACKGROUND

In recent years, the number of clinical practice guidelines (CPGs) for lung cancer has increased, but the quality of these guidelines has not been systematically assessed so far. Our aim was to assess the reporting quality of CPGs on lung cancer published since 2018 using the International Reporting Items for Practice Guidelines in Health Care (RIGHT) instrument.

METHODS

We systematically searched the major electronic literature databases, guideline databases and medical society websites from January 2018 to November 2020 to identify all CPGs for small cell and non-small cell lung cancer (NSCLC). The search and extraction were completed using standardized forms. The quality of included guidelines was evaluated using the RIGHT statement. We present the results descriptively, including a stratification by selected determinants.

RESULTS

A total of 49 CPGs were included. The mean proportion across the guidelines of the 22 items of the RIGHT checklist that were appropriately reported was 57.9%. The items most common to be poorly reported were quality assurance (item 17) and description of the role of funders (item 18b), both of which were reported in only one guideline. The proportions of items within each of the seven domains of the RIGHT checklist that were correctly reported were Basic information 75.9%; background 83.2%; evidence 44.5%; recommendations 55.4%; review and quality assurance 12.2%; funding and declaration and management of interests 42.9%; and other information 38.1%. The reporting quality of guidelines did not differ between publication years. CPGs published in journals with impact factor >30 tended to be best reported.

CONCLUSIONS

Our results revealed that reporting in CPGs for lung cancer is suboptimal. Particularly the declaration of funding and quality assurance are poorly reported in recent CPGs on lung cancer.

Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey

CONTEXT

Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States.

OBJECTIVE

This work aimed to understand factors associated with the adoption of AS.

METHODS

We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases).

RESULTS

The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P < .001) less likely than adopters to practice in academic settings, see more than 25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (P = .04), know how to determine whether a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Nonadopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (P = .03) and more likely to be anxious (P = .04), have reservations (P = .03), and have concerns about the psychological burden (P = .009) of AS. Few respondents (3.2%) believed patients were aware of AS.

CONCLUSION

Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.

Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review

Recurrent miscarriage affects 1-2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored 'poor' on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.

Even High-Quality CPGs Seldom Include Implementation Strategies

Background: Implementation is a key step in ensuring that high-quality clinical practice guideline (CPG) recommendations are followed and have a positive impact. This step must be planned during CPG development. This study aims to inform professionals tasked with developing and implementing CPGs regarding implementation strategies and tools reported in high-quality CPGs for chronic non-communicable diseases (NCDs).

Methods: NCD guidelines were selected based on Appraisal of Guideline Research and Evaluation (AGREE) II assessment. CPGs with a score of ≥60% in AGREE II domains 3 (rigor of development), 5 (applicability), and 6 (editorial independence), were considered high quality. The content related to implementation was extracted from CPG full texts and complementary materials. Implementation strategies and tools were assessed and classified using Mazza taxonomy.

Results: Twenty high-quality CPGs were selected, most of which were developed by government institutions (16; 80%) with public funding (16; 80%); almost half (9; 45%) addressed the treatment of cardiovascular diseases. The countries with the most high-quality CPGs were the UK (6; 30%) and Colombia (5; 25%). These countries also had the highest average number of strategies, Colombia with 28 (SD = 1) distributed in all levels, and the UK with 15 (SD = 7), concentrating on professional and organizational levels. Although the content of the Colombian CPGs was similar regardless the disease, the CPGs from the UK were specific and contained data-based feedback reports and information on CPG compliance. Implementation strategies most frequently identified were at the professional level, such as distributing reference material (18; 80%) and educating groups of healthcare professionals (18; 80%). At the organizational level, the most frequent strategies involve changes in structure (15; 75%) and service delivery method (13; 65%).

Conclusion: Countries with established CPG programs, such as the UK and Colombia, where identified as having the highest number of high-quality CPGs, although CPG implementation content had significant differences. Among high-quality CPGs, the most common implementation strategies were at the professional and organizational levels. There is still room for improvement regarding the implementation strategies report, even among high-quality CPGs, especially concerning monitoring of implementation outcomes and selection of strategies based on relevant implementation barriers.

Barriers to and Facilitators of Adherence to Clinical Practice Guidelines in the Middle East and North Africa Region: A Systematic Review

The current review aims to investigate the barriers to and facilitators of the adherence to clinical practice guidelines (CPGs) in the Middle East and North Africa (MENA) region. English language studies published between January 2010 and May 2019 were searched on PubMed, Embase, and EBSCO. The barriers were categorized as clinician-related factors, such as lack of awareness of familiarity with the CPGs, and external factors, such as patients, guidelines, and environmental factors. The search identified 295 titles, out of which 15 were included. Environmental factors, specifically lack of time, resources, incentives, availability, and costs of treatment or diagnostic tests, training, and dissemination plans were the most commonly identified barriers. The familiarity with or awareness of healthcare professionals about the guideline, guideline characteristics, lack of agreement with the guidelines and preference in clinical judgment, physician self-efficacy, and motivation were reported to a lesser extent. Few studies reported on the compliance of facilitators with the guidelines including disseminating and advertising guideline materials, education and training on the guidelines, regulatory and financial incentives, and support from institutions. The review highlights that the studies on barriers to and facilitators of compliance with CPGs in the MENA region are limited in number and quality.

Dissemination and implementation of national physical activity, sedentary behaviour, and/or sleep guidelines among community-dwelling adults aged 18 years and older: a systematic scoping review and suggestions for future reporting and research

Strategies for dissemination (purposive distribution of a guideline to specific audiences) and implementation (actions to support the general public in meeting guideline recommendations/behavioural benchmarks) of national movement guidelines (physical activity (PA), sedentary behaviour, and sleep) have yet to be synthesized. The purpose of this systematic scoping review was to identify strategies for dissemination and implementation of national PA, sedentary behaviour, and/or sleep guidelines among community-dwelling adults (aged >18 years) and/or stakeholders in Canada and analogous countries. Five search approaches (e.g., published literature, grey literature, targeted web-based, custom Google, and content expert consultation) identified records (e.g., empirical studies, organizational reports, website pages, or guideline messages) that discussed and/or evaluated dissemination or implementation strategies for a prespecified list of guidelines. A modified strategy classification system was developed to chart the data. Forty-seven reports met inclusion criteria. Dissemination strategies (n = 42) were more frequently reported than implementation strategies (n = 24). Implementation strategies were more frequently evaluated (n = 13 vs. 7 dissemination strategies) and associated with positive outcomes. The 13 studies that evaluated strategies were at high or serious risk of bias. We identified limited information about the dissemination and implementation of national movement guidelines and identified strategies were rarely evaluated. Greater efforts are required to increase the impact of guidelines among the general public and stakeholders and to build the evidence base in this field. (Open Science Framework registration: https://osf.io/4tyw3.) Novelty An adapted movement guideline dissemination and implementation strategy classification framework is provided. Knowledge translation efforts should be documented and evaluated to advance science and practice in the movement guideline field.

Practical guidelines and apps for improvement of guideline implementation

The European Society for Clinical Nutrition and Metabolism (ESPEN) presents a new series of "practical guidelines" based on previously published scientific guidelines. A first example of such a Practical Guideline has been completed and published recently (ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease), other will follow soon. The practical guidelines are generated by shortening and restructuring of the Scientific guidelines and by presenting the content using flow charts for a fast navigation through the content. The practical guidelines serve as templates for IT-based versions for the smartphone, tablet and PC, for lay versions and for translations into different languages. These efforts are part of a new guideline dissemination and implementation program ESPEN launched in 2018 also with support by the United European Gastroenterology society. First results are presented.