Barriers and strategies in guideline implementation: a scoping review based on theoretical domain framework_Chinese Journal of Evidence-Based Medicine

Authors：

LIAO Jiaojiao ¹ , WANG Zhaoyu ¹ , WANG Hui ¹ ,  TAO Liyuan ^1,3 ,  ZHAN Siyan ^1,2

1. Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing 100191, P. R. China;
2. School of Public Health, Peking University, Beijing 100191, P. R. China;
3. School of Public Health, Harvard University, Massachusetts 02115, USA;

Corresponding author：

TAO Liyuan, Email: tendytly@163.com; ZHAN Siyan, Email: siyan-zhan@bjmu.edu.cn

Keywords：

Scoping review; Clinical practice guideline; Adherence; Obstacle; Implementation strategy

DOI：

10.7507/1672-2531.202311175

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To review main obstacles to health care professionals adherence to clinical practice guidelines (CPGs) by employing the scoping review method and a determinants framework, and to explore the effect of implementation strategies in intervention researches on guideline adherence. Methods The articles published from January 1, 2011 to June 10, 2023 were retrieved in PubMed, CINAHL, MEDLINE, Embase, Scopus, Cochrane Library, SinoMed, CNKI, and WanFang Data databases. The original literature on the CPGs implementation obstacles and strategies were included, and the primary and secondary screening of the literatures were completed by four researchers according to the inclusion and exclusion criteria. The basic characteristics of the literature, the factors affecting the implementation of the CPGs, and the strategies were extracted. The results were analyzed and summarized using qualitative and quantitative methods. Results A total of 61 articles were included in the scoping review. The factors affecting the implementation of CPGs could be divided into five categories: guidelines themselves, external factors, internal factors, individual factors, and implementation process. The most common implementation obstacles were insufficient knowledge or skills of professionals regarding guidelines (n=21, 34.4%), insufficient necessity of using guidelines according to doctors (n=17, 27.9%), and unreasonable hospital factors (n=16, 26.2%). The factors that promoted the implementation of CPGs included guidelines based on high-quality evidence (n=5, 8.2%), good department or hospital culture (n=4, 6.6%), convenient accessibility of guideline knowledge and information (n=4, 6.6%), and doctors’ excellent professional ability (n=4, 6.6%). The overall effectiveness of the guideline implementation strategy was 50%. Clinical decision support system (CDSS) could improve the adherence of CPGs. Guideline education or training was one of the most commonly used methods, but the effect of improving guideline compliance was unstable. Conclusion The main obstacles to the implementation of guidelines are insufficient ability and need of professionals for guidelines, poor hospital structure, and lack of resources. However, the obstacles are not absolute. It is recommended to use implementation strategies to improve the absorption and implementation of guidelines, among which CDSS is an effective measure to promote guideline adherence.

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2.	Pronovost PJ. Enhancing physicians' use of clinical guidelines. JAMA, 2013, 310(23): 2501-2502.
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6.	Cloutier MM, Salo PM, Akinbami LJ, et al. Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma. J Allergy Clin Immunol Pract, 2018, 6(3): 886-894.
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1. Alonso-Coello P, Irfan A, Solà I, et al. The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies. Qual Saf Health Care, 2010, 19(6): e58.
2. Pronovost PJ. Enhancing physicians' use of clinical guidelines. JAMA, 2013, 310(23): 2501-2502.
3. Eccles MP, Grimshaw JM, Shekelle P, et al. Developing clinical practice guidelines: target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest. Implement Sci, 2012, 7: 60.
4. Baron DM, Metnitz PG, Fellinger T, et al. Evaluation of clinical practice in perioperative patient blood management. Br J Anaesth, 2016, 117(5): 610-616.
5. Rye M, Torres EM, Friborg O, et al. The evidence-based practice attitude scale-36 (EBPAS-36): a brief and pragmatic measure of attitudes to evidence-based practice validated in US and Norwegian samples. Implement Sci, 2017, 12(1): 44.
6. Cloutier MM, Salo PM, Akinbami LJ, et al. Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma. J Allergy Clin Immunol Pract, 2018, 6(3): 886-894.
7. 黄超, 杜亮, 陈耀龙, 等. 中国医务人员对临床实践指南的使用和需求调查. 中国循证医学杂志, 2019, 19(6): 635-638.
8. Young JM, Ward JE. Implementing guidelines for smoking cessation advice in Australian general practice: opinions, current practices, readiness to change and perceived barriers. Fam Pract, 2001, 18(1): 14-20.
9. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines. A framework for improvement. JAMA, 1999, 282(15): 1458-1465.
10. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med, 2018, 169(7): 467-473.
11. Hermens ML, van Splunteren PT, van den Bosch A, et al. Barriers to implementing the clinical guideline on borderline personality disorder in the Netherlands. Psychiatr Serv, 2011, 62(11): 1381-1383.
12. Allen N, Schwartz D, Sood AR, et al. Perceived barriers to guidelines in peritoneal dialysis. Nephrol Dial Transplant, 2011, 26(5): 1683-1689.
13. Plambech MZ, Lurie AI, Ipsen HL. Initial, successful implementation of sepsis guidelines in an emergency department. Dan Med J, 2012, 59(12): A4545.
14. Van't Leven N, Graff MJ, Kaijen M, et al. Barriers to and facilitators for the use of an evidence-based occupational therapy guideline for older people with dementia and their carers. Int J Geriatr Psychiatry, 2012, 27(7): 742-748.
15. van den Berg AD, Palmer NO. An investigation of West Sussex general dental practitioners' awareness, attitudes and adherence to NICE dental recall guidelines. Prim Dent Care, 2012, 19(1): 11-22.
16. Donnellan C, Sweetman S, Shelley E. Implementing clinical guidelines in stroke: a qualitative study of perceived facilitators and barriers. Health Policy, 2013, 111(3): 234-244.
17. McCluskey A, Vratsistas-Curto A, Schurr K. Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study. BMC Health Serv Res, 2013, 13: 323.
18. Rebbeck T, Macedo LG, Maher CG. Compliance with clinical guidelines for whiplash improved with a targeted implementation strategy: a prospective cohort study. BMC Health Serv Res, 2013, 13: 213.
19. Jansson M, Ala-Kokko T, Ylipalosaari P, et al. Critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia--a survey study. Intensive Crit Care Nurs, 2013, 29(4): 216-227.
20. Yang J, Han C, Yoon HK, et al. Experiences and barriers to implementation of clinical practice guideline for depression in Korea. BMC Psychiatry, 2013, 13: 150.
21. Barkun AN, Bhat M, Armstrong D, et al. Effectiveness of disseminating consensus management recommendations for ulcer bleeding: a cluster randomized trial. CMAJ, 2013, 185(3): E156-E166.
22. Ahmad N, Hassan Y, Tangiisuran B, et al. Guidelines adherence and hypertension control at a tertiary hospital in Malaysia. J Eval Clin Pract, 2013, 19(5): 798-804.
23. Mala G, Moser A, Dinant GJ, et al. Why tuberculosis service providers do not follow treatment guideline in Ethiopia: a qualitative study. J Eval Clin Pract, 2014, 20(1): 88-93.
24. Hadely KA, Power E, O'Halloran R. Speech pathologists' experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study. BMC Health Serv Res, 2014, 14: 110.
25. Cahill NE, Murch L, Cook D, et al. Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically ill patients: results of a multicenter feasibility study. Crit Care, 2014, 18(3): R96.
26. Giuliani S, McArthur A, Greenwood J. Preoperative fasting among burns patients in an acute care setting: a best practice implementation project. JBI Database System Rev Implement Rep, 2015, 13(11): 235-253.
27. Miao M, Power E, O'Halloran R. Factors affecting speech pathologists' implementation of stroke management guidelines: a thematic analysis. Disabil Rehabil, 2015, 37(8): 674-685.
28. de Beurs DP, de Groot MH, de Keijser J, et al. The effect of an e-learning supported Train-the-Trainer programme on implementation of suicide guidelines in mental health care. J Affect Disord, 2015, 175: 446-453.
29. Balbale SN, Hill JN, Guihan M, et al. Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study. Implement Sci, 2015, 10: 130.
30. Maggioni AP, Van Gool K, Biondi N, et al. Appropriateness of prescriptions of recommended treatments in organisation for economic co-operation and development health systems: findings based on the long-term registry of the European Society of Cardiology on Heart Failure. Value Health, 2015, 18(8): 1098-1104.
31. Ince P, Tai S, Haddock G. Using plain English and behaviourally specific language to increase the implementation of clinical guidelines for psychological treatments in schizophrenia. J Ment Health, 2015, 24(3): 129-133.
32. Nasser SM, Cooke G, Kranzer K, et al. Strength of recommendations in WHO guidelines using GRADE was associated with uptake in national policy. J Clin Epidemiol, 2015, 68(6): 703-707.
33. Kane JC, Adaku A, Nakku J, et al. Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda. Implement Sci, 2016, 11: 36.
34. Mc Goldrick EL, Crawford T, Brown JA, et al. Identifying the barriers and enablers in the implementation of the New Zealand and Australian Antenatal Corticosteroid Clinical Practice Guidelines. BMC Health Serv Res, 2016, 16(1): 617.
35. McKee G, Kerins M, Hamilton G, et al. Barriers to ESC guideline implementation: results of a survey from the European Council on Cardiovascular Nursing and Allied Professions (CCNAP). Eur J Cardiovasc Nurs, 2017, 16(8): 678-686.
36. Toohill J, Sidebotham M, Gamble J, et al. Factors influencing midwives' use of an evidenced based normal birth guideline. Women Birth, 2017, 30(5): 415-423.
37. Melman S, Schreurs RHP, Dirksen CD, et al. Identification of barriers and facilitators for optimal cesarean section care: perspective of professionals. BMC Pregnancy Childbirth, 2017, 17(1): 230.
38. Munce SEP, Graham ID, Salbach NM, et al. Perspectives of health care professionals on the facilitators and barriers to the implementation of a stroke rehabilitation guidelines cluster randomized controlled trial. BMC Health Serv Res, 2017, 17(1): 440.
39. Pearson EJM, Morris ME, McKinstry CE. Cancer related fatigue: implementing guidelines for optimal management. BMC Health Serv Res, 2017, 17(1): 496.
40. Cheng-Lai A, Snead J, Ng C, et al. Comparison of adherence to the 2013 ACC/AHA Cholesterol Guideline in a teaching versus nonteaching outpatient clinic. Ann Pharmacother, 2018, 52(4): 338-344.
41. Damush TM, Miech EJ, Sico JJ, et al. Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration. Neurology, 2017, 89(24): 2422-2430.
42. Mudge S, Hart A, Murugan S, et al. What influences the implementation of the New Zealand stroke guidelines for physiotherapists and occupational therapists. Disabil Rehabil, 2017, 39(5): 511-518.
43. Aloush SM. Does educating nurses with ventilator-associated pneumonia prevention guidelines improve their compliance. Am J Infect Control, 2017, 45(9): 969-973.
44. 李晨露, 程云, 赵丽蓉. 临床护士实践鼻饲护理循证指南的障碍和支持因素. 护理学杂志, 2017, 32(3): 65-68.
45. Radwan M, Akbari Sari A, Rashidian A, et al. Factors hindering the adherence to clinical practice guideline for diabetes mellitus in the Palestinian primary healthcare clinics: a qualitative study. BMJ Open, 2018, 8(9): e021195.
46. Fonteyne V, Rammant E, Ost P, et al. Evaluating the current place of radiotherapy as treatment option for patients with muscle invasive bladder cancer in Belgium. Clin Genitourin Cancer, 2018, 16(6): e1159-e1169.
47. Luitjes SHE, Hermens RPMG, de Wit L, et al. An innovative implementation strategy to improve the use of Dutch guidelines on hypertensive disorders in pregnancy: a randomized controlled trial. Pregnancy Hypertens, 2018, 14: 131-138.
48. Ramerman L, Hoekstra PJ, de Kuijper G. Exploring barriers and facilitators in the implementation and use of guideline recommendations on antipsychotic drug prescriptions for people with intellectual disability. J Appl Res Intellect Disabil, 2018, 31(6): 1062-1070.
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