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.
Blog last updated: November 2021* and last checked 19 April 2023
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 effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. 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 (updated September 2021) found a similar effect size, again with moderate-certaintyThe certainty (or quality) of evidence is the extent to which we can be confident that what the research tells us about a particular treatment effect is likely to be accurate. Concerns about factors such as bias can reduce the certainty of the evidence. Evidence may be of high certainty; moderate certainty; low certainty or very-low certainty. Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence. Find out more here: https://training.cochrane.org/grade-approach evidence. The authors concluded that:
“Compared with no interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. , educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’.. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi‐strategy approaches might positively influence the effects of educational meetings.
Additional trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future”.
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 guideline although the evidence supporting their use may not be as strong as that for the interventions previously mentioned. 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 reviewsCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 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.
*Editor’s note: blog last updated in November 2021, to reflect an updated version of Continuing education meetings and workshops: effects on professional practice and healthcare outcomes.
