Getting clinical guidelines into practice – what works best?

In this blog for health professionals and those designing interventions to implement clinical guidelines Robert Walton, a former general practitioner, highlights a recent Cochrane review offering practical advice. 

Pharmaceutical companies are expert in changing professional behaviour to promote their products using tried and tested strategies honed over many years.  But “Why should the Devil have the best tunes?” as General Booth from the Salvation Army is reputed to have said, justifying setting more uplifting words to secular melodies.  Could similar strategies be used to implement evidence-based practice for the benefit of patients?

Using local opinion leaders to promote evidence-based practice

Opinion leaders have been used very effectively by industry to promote new pharmaceutical products and a newly updated Cochrane review suggests that these same methods could be adapted to increase adherence to evidence-based guidelines.  Local opinion leaders are well respected and trusted sources of information in the professional community.  Interestingly opinion leaders derive their unique influence, not from formal managerial positions but because of their technical competence and social accessibility which earns them the respect of their peers.

The Cochrane review included evidence from 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients. Moderate certainty evidence indicated that compliance with evidence based guidelines increased by 10.8%, interquartile range (IQR): 3.5% to 14.6% .  Whilst this is a modest effect and the authors are careful to point out that the effectiveness varied both within and between studies, changing professional practice is a difficult task so these findings are important.

Other methods of guideline implementation supported by Cochrane evidence

To put the findings into context, another Cochrane review that looked at educational meetings and workshops as a way of improving compliance with clinical guidelines found a similar effect size, again with moderate certainty evidence   Meetings that had higher attendance where mixed didactic and interactive methods were used and the topic was perceived to have a serious outcome were associated with increased compliance with evidence-based practice.

Audit of professional behaviour with feedback of results is also associated with increased compliance and although the pooled effect size in another Cochrane review was somewhat lower than in the two reviews previously mentioned, the range of effect sizes was again large  Whilst some of this variation was explained because of factors such as baseline performance level and source and frequency of feedback, it seems likely that all interventions of this type will vary in their effectiveness according to factors relating to the intervention components and the interactions between them. Other important factors will be specific characteristics of the recipient of the intervention and the context in which the intervention operates.

What guideline implementation strategies may not work so well?

Printed educational materials are commonly used to promote compliance with guidelines although the evidence supporting their use may not be as strong as that for the interventions previously mentioned.  Another Cochrane review included 45 studies and found small beneficial effects supported by low or very low quality evidence   However, passive dissemination of printed materials is likely to be relatively cheap, making this still a potentially attractive option for policy makers.  It is perhaps surprising that few studies included in these Cochrane reviews included economic considerations which would be an important part of any implementation strategy.

One strategy suggested to make interventions more effective is that they should be tailored specifically to the factors explaining current professional practice and should address specific barriers to professional behaviour change.  However another Cochrane review showed that whilst the evidence was of moderate certainty the effect sizes of interventions designed in this way were relatively small.

The way forward?

Realistically, interventions that are implemented in real life will draw on several different strategies and have different components which interact with each other such that, if well designed, the overall effect will be greater than the sum of the parts. A considerable challenge remains in predicting how these interactions will take place and modelling them accurately so that interventions may be adjusted and optimised for the benefit of patients.

Join in the conversation on Twitter with @rtwalton123 @CochraneEPOC @CochraneUK or leave a comment on the blog.

References may be found here.


Robert Walton

About Robert Walton

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Robert Walton is a Cochrane UK Senior Fellow in General Practice. Robert qualified in medicine in London in 1983, having taken an intercalated degree in human pharmacology and immunology. He trained at St Georges Hospital, London and became a member of the Royal College of Physicians in 1986. His work applying computerised decision support to prescribing drugs in the Department of Public Health and Primary care in Oxford led to a doctoral thesis in 1998. Robert was elected a Fellow of the Royal College of General Practitioners in 1999 and the RoyalCollege of Physicians in 2001. He became a Senior Investigator in the National Institute for Health Research (NIHR) in 2016. Robert is Clinical Professor of Primary Medical Care at Queen Mary and joint lead of the NIHR Research Design Service east London team, his research interests are in primary care, genetics, clinical trials and personalised medicine. Robert leads a five-year NIHR funded programme developing a novel training intervention to promote smoking cessation in pharmacies in east London which involves a substantive systematic review and meta analysis on behaviour change interventions in community pharmacies and will lead to a large scale cluster-randomised clinical trial. His research team is also developing a smartphone game to promote smoking cessation and researching a personalised/stratified medicine approach to tobacco dependence using computerised decision support. He sits on the NIHR Programme Grants for Applied Research sub panel A and works as an evaluator for the European Union Horizon 2020 programme (Global Alliance for Chronic Diseases, New Therapies for Rare Diseases). He contributes to UK national guidance, serving on the National Institute for Health and Care Excellence (NICE) Outcome Indicator and Technology Appraisals Committees. He worked as a general practitioner in Oxford from 1988 to 2019.

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