Related ArticlesToward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998.

J Gen Intern Med. 2006 Feb;21 Suppl 2:S14-20

Authors: Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, Vale L

OBJECTIVES: To determine effectiveness and costs of different guideline dissemination and implementation strategies. DATA SOURCES: MEDLINE (1966 to 1998), HEALTHSTAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group. REVIEW METHODS: INCLUSION CRITERIA: Randomized-controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors, and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria. RESULTS: We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multifaceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1% in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. CONCLUSIONS: Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for quality improvement activities.

PMID: 16637955 [PubMed - in process]

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Related ArticlesUsing the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units.

J Gen Intern Med. 2006 Feb;21 Suppl 2:S35-42

Authors: Eldridge NE, Woods SS, Bonello RS, Clutter K, Ellingson L, Harris MA, Livingston BK, Bagian JP, Danko LH, Dunn EJ, Parlier RL, Pederson C, Reichling KJ, Roselle GA, Wright SM

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC’s emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement. OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO. DESIGN: Six Sigma Project with pre-post design. PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals. MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire. RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products. CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC’s evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

PMID: 16637959 [PubMed - in process]

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Factors predicting the guideline compliant supply (or non-supply) of non-prescription medicines in the community pharmacy setting.

Qual Saf Health Care. 2006 Feb;15(1):53-7

Authors: Watson MC, Bond CM, Grimshaw J, Johnston M

BACKGROUND: The reclassification of prescription only medicines to pharmacy and general sales list medicines (also known as non-prescription medicines) provides the public with greater access to medicines that they can purchase for self-care. There is evidence that non-prescription medicines may be associated with inappropriate supply. This study investigated factors predicting evidence-based (guideline compliant) supply or non-supply of non-prescription medicines. METHOD: Secondary analysis of results from a randomised controlled trial of educational interventions to promote the evidence based supply of non-prescription medicines. Ten actors made simulated patient (customer) visits to 60 community pharmacies using seven scenarios reflecting different types of presentations. The dependent variable was appropriate (guideline compliant) supply of antifungal medication for treatment of vaginal candidiasis. RESULTS: No significant association was shown between guideline compliant behaviour and pharmacy type or location, or with the actor making the visit. The likelihood of guideline compliant outcome was significantly greater with symptom presentations than with condition or product presentations (p or = 3, respectively. CONCLUSIONS: The nature and extent of information exchange between pharmacy staff and customers has a strong influence on the guideline compliant supply of non-prescription medicines. Future interventions to promote the safe and effective use of non-prescription medicines should address the apparent deficit in communication between pharmacy staff in general, and medicine counter assistants in particular, which may reflect both pharmacy staff skills and customer expectations.

PMID: 16456211 [PubMed - indexed for MEDLINE]

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Paper tigers–do clinical guidelines improve health care quality in patients with testicular germ cell tumors in Germany?

Health Policy. 2006 Feb;75(3):338-46

Authors: Schrader M, Weissbach L, Weikert S, Schostak M, Miller K

In Germany, germ cell tumors are characterized by a marked excess mortality, i.e. a discrepancy between the actual mortality and the mortality expected with adequate implementation of the standard therapy. Moreover, Germany not only has a significantly increased mortality in an international comparison but also shows marked regional differences in the quality of medical care. This is partly due to difficulties in implementing the standard therapy. An attempt was made to improve the quality of medical care by setting up evidence-based diagnostic and therapeutic guidelines in 1996. Contrary to expectations, however, these guidelines have thus far remained largely ineffective, their implementation being hampered by a solely passive dissemination strategy. Added to this are inadequate medical care structures in which the guidelines cannot be properly implemented because of the organizational, social and professional context. Decisive for a quality improvement in the diagnosis, therapy and care of germ cell tumor patients is active dissemination of the guidelines supplemented by a change in the care structure. It is also important to establish indicators for measuring the success of guideline implementation and to perform continuous progress monitoring in order to specifically overcome evident barriers. Future research is required to create a better theoretical basis and to develop further strategies for guideline dissemination and implementation.

PMID: 15899536 [PubMed - indexed for MEDLINE]

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Related ArticlesAssessment of the appropriateness of requested radiological examinations for outpatients and the potential financial consequences of guideline application.

JBR-BTR. 2006 Jan-Feb;89(1):8-11

Authors: Van Breuseghem I, Geusens E

The purpose of this study was to evaluate whether requested radiological examinations for referred outpatients are in concordance with the guidelines as proposed by the consilium radiologicum. A second purpose was to evaluate the financial effect of strict guideline application. The radiological requests for 1000 referrals were evaluated by 2 radiologists. A consensus score of 74.4% guideline conformity was reached. A mean save of 9.5 Euro per patient was calculated after strict guideline application. It is concluded that guidelines are a valuable tool for patient management in referring for radiological examinations and have a substantial effect on the available budget. Further improvements and fine-tuning of the guidelines are mandatory to increase their validity.

PMID: 16607870 [PubMed - in process]

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