Author Year

Targeted behaviour

Guideline

developers

Literature review

Critical appraisal

Consensus processes

Key stakeholder involvement

Barriers/facilitator assessment

Bekkering 2005

Targeted behaviour:

management of non‐specific low back pain

Number of recommendations: 4 main recommendations

The Royal Dutch Physiotherapy Association.

CPGs² were constructed on the basis of the phases of the physiotherapy process, using the Dutch method of developing physiotherapy guidelines, and evidence from systematic reviews were identified through searching electronic databases

Not mentioned but probably included in the Dutch method of developing CPGs

Based on scientific evidence.

If no evidence was available, consensus between experts was obtained

The CPGs were pilot‐tested among 100 physiotherapists and reviewed by an external multidisciplinary panel

Barriers to change were assessed through a survey as part of the CPG development process

Daucourt 2003

Targeted behaviour: appropriate thyroid function testing

Number of recommendations: not reported

The Committee for Co‐ordinating Clinical Evaluation and Quality in
Aquitaine (CCECQA) developed guidelines in collaboration with a regional working group and a national review group

The CPG developers

conducted

a comprehensive

review of the literature

‐

CPG³ development involved an expert consensus process.

‐

‐

Fine 2003

Targeted behaviour: appropriate duration of intravenous antibiotic therapy for treatment of pneumonia

Number of recommendations: a 2‐step recommendation

Researchers who were part of the Pneumonia Patient Outcomes Research Team (PORT)

The CPG was based on a review of the medical literature, and empiric evidence on time to reach clinical stability

‐

The CPG development process involved the consensus of an 8‐member national guideline panel

The guideline was reviewed by clinical opinion leaders at each study site, and was approved for local use by the relevant utilisation management department.

‐

Shah 2014

Targeted behaviour: management of cardiovascular risk
factors and outcomes of cardiovascular disease in people with
diabetes

Number of recommendations:

no information

Canadian Diabetes Association (and Expert Committee members)

Expert Committee members evaluated the relevant literature, and guidelines were developed and initially reviewed
by the Expert Committee

After formulating new recommendations or modifying existing
ones based on new evidence, each recommendation was
assigned a grade from A through D

Based on scientific evidence/review of the literature

A draft document was circulated nationally and
internationally for review by numerous stakeholders and
experts in relevant fields.
Subsequently, a panel of 6 methodologists,
who were not directly involved with the initial review and
assessment of the evidence, independently reviewed each
recommendation, its assigned grade and supportive citations

‐

Author Year

Delivery of the intervention

Theoretical models/ frameworks used

Evidence base

Targeted to barriers

Key stakeholder involvement

Bekkering 2005

Type of intervention:

simple, but multicomponent; active only

Intervention target: the healthcare professional

Targeted behaviour:

management of nonspecific low back pain

Mode: face‐to‐face

Provider: The primary investigator and 1 of 2 additional trainers with adequate clinical experience in the management of low back pain supervised the training sessions

‐

"The sessions were based on interventions that have all been shown to be effective, such as interactive education and discussion, feedback, and reminders".^1,2,3,4,5

The content of the strategy was determined on the basis of information about the expected barriers for implementation gathered during the development of the CPGs

2 experts gave advice on the content of the strategy

Daucourt 2003

Type of intervention:

multicomponent; passive only

Intervention target: the healthcare professional

Targeted behaviour: appropriate thyroid function testing

Mode: Paper‐based materials

Provider: none

‐

"Among the clinical guideline diffusion strategies, the most effective are feedback, reminders, academic detailing and financial incentives^1,2,4,5 Administrative procedures such as the implementation of test request forms have also proved effective."

‐

‐

Fine 2003

Type of intervention:

single; active + passive

Intervention target: the healthcare professional

Targeted behaviour: appropriate duration of intravenous antibiotic therapy for treatment of pneumonia

Mode: Paper‐based material (detail sheets/treatment recommendations in patient records) and telephone reminder

Provider: nurse delivered telephone reminder

‐

"The multifaceted guideline dissemination strategy consisted of interventions of proven benefit, including real‐time physician reminders" ^1,6,7,8

‐

‐

Shah 2014

Type of intervention:

passive

Intervention target:

family physicians (and diabetes patients at high risk of cardiovascular disease)

Targeted behaviour: management of cardiovascular risk factors and outcomes of cardiovascular disease in people with diabetes

Mode: printed educational materials

Targeting the family physician:

The cardiovascular disease toolkit was a collection of printed educational materials, packaged in a brightly‐coloured box with CDA branding, sent to Canadian family physicians. The contents included an introductory letter from the Chair of the practice
guidelines’ Dissemination and Implementation Committee; an
8‐page summary of selected sections of the practice guidelines
targeted towards family physicians; a 4‐page synopsis of the key guideline elements pertaining to cardiovascular disease risk; a small double‐sided laminated card with a simplified algorithm for cardiovascular risk assessment, vascular protection strategies, and
screening for cardiovascular disease, and a pad of tear‐off sheets for patients with a cardiovascular risk self‐assessment tool and a list
of recommended risk reduction strategies

Provider: NA¹³

The implicit theory behind its
development was that the guidelines were too long and complex to be easily incorporated into clinical practice, so the toolkit aimed to simplify the information, tailor it towards clinical practice, and
provide explicit actionable recommendations

"The literature has demonstrated that the benefits of printed educational interventions are, at best, modest. A systematic review of methods to improve practice guideline adherence demonstrated an absolute improvement of 8% for educational materials. A more recent Cochrane review found that printed educational materials led to a median absolute improvement in performance of only 2% (25). Studies of printed materials specifically tied to clinical practice guidelines also showed modest benefits. A small English study randomised 42 family physicians to receive an algorithm for monitoring and treatment of hypertension of diabetic patients based on practice guidelines, but found no difference in blood pressure control between the intervention and control groups. However, some processes of care were slightly improved: patients in the intervention group were prescribed higher doses of antihypertensive medications, and had more physician visits to monitor blood pressure. In a larger Canadian study, family physicians were randomised to receive a 1‐page summary of a 3‐year‐old practice guideline on anti‐anginal therapy from the local medical governing body. No differences were noted in prescription of β‐blockers, antiplatelet agents, or lipid‐lowering drugs between groups in the 7000 patients reviewed" ^9,10,11,12

‐

The toolkit was
created for the CDA by clinical experts including family
physicians, endocrinologists, and other healthcare professionals,
with guidance from clinicians with expertise in knowledge
translation and implementation

Author Year

Tailoring

Feedback

Educational outreach/ Academic detailing/ Small group discussions

Reminders (paper, electronic, telephone)

Decision support tools

Other

(test order forms, supportive materials etc.)

Bekkering 2005

The content of the strategy was determined on the basis of information about the expected barriers for implementation gathered during the development of the clinical guidelines.

‐

2 interactive training sessions, each lasting 2½ hours, for groups of 8 – 12 physiotherapists (including feedback on current management and reminders). For each session a preparation time of 2 hours was recommended.

‐

‐

‐

Daucourt 2003

‐

‐

‐

Pocket memorandum card.

‐

Test request form.

Fine 2003

‐

‐

‐

Paper‐based detail sheet/ treatment recommendations put into the patient's record + real‐time nurse telephone reminder

‐

‐

Shah 2014

‐

‐

‐

‐

‐

Printed educational materials

Author Year

Clinical outcomes;

Medical complications

Quality of life

Satisfaction with care

Mortality

Healthcare resource use (including medications prescribed)

Costs

Bekkering 2005

‐

Quality of Life

(assessed with the EQ‐5D¹), mean (SD):

BL:

Intervention: 0.6730 (0.2042); Control: 0.6134 (0.2661),

P = 0.006.

At 6 weeks:

Intervention: 0.7778 (0.1978); Control: 0.7497 (0.2316)

At 12 weeks:

Intervention: 0.8141 (0.1988); Control: 0.7873 (0.2210)

Note: results for 26 and 52 weeks reported graphically

‐

‐

Mean annual cost (Euros) per patient (SD):

Direct cost²:

Intervention: 374 (437).

Control: 449 (572).

The costs (Euro) of releasing a new guideline for low back pain to 18,000

physiotherapists:

Intervention (active strategy): 87,416

Control (passive strategy): 63,101

Daucourt 2003

‐

‐

‐

‐

Cost paper awaits translation

Fine 2003

In‐hospital medical complications, number (%):

Intervention:157 (55); Control: 206 (63), P = 0.04

Functional status³

SF‐12 physical health composite score: Intervention:45 ± 7, n = 181;
Control: 45 ± 7, n = 223; P = 0.71

SF‐12 mental health composite score: Intervention: 45 ± 6; Control: 45 ± 7, P = 0.71

Patient satisfaction with care⁴ , number (%):

Not satisfied with overall care: Intervention: 12 (5.3), n = 228; Control: 11 (4.0), n = 273, P = 0.67

Believed length of stay was too short: Intervention: 59 (26.1); Control: 54 (20.2), P = 0.16

Return to usual activities⁵,Hazard ratio (95% CI):

Nonworkers: 1.09 (0.83 to 1.43), P = 0.55

Workers: 0.85 (0.54 to 1.35); P = 0.49

Return to work (workers) 0.99 (0.63 to 1.58),

P = 0.98

Mortality⁶

all‐cause, number (%): Intervention: 22 (8), n = 283; Control: 29 (9), n = 325, P = 0.70

Pneumonia‐related mortality, number (%): Intervention: 15 (5); Control: 23 (7), P = 0.44

Length of index hospital (days) stay, median (IQR): Intervention: 5.0 (3.0 to 7.0); Control: 5.0 (3.0 to 8.0); Hazard ratio (95% CI): 1.16 (0.97 to 1.38), P = 0.11

Rehospitalisation⁷ number (%): Intervention:37 (14); Control:33 (11), P = 0.42

Duration (days) of intravenous antibiotic therapy, median (IQR): Intervention: 3.0 (2.0 to 5.0),n = 283; Control: 4.0 (2.6 to 6.0), n = 325; Hazard ratio (95% CI): 1.23 (1.00 to 1.52), P = 0.06

‐

Shah 2014

Clinical data study:

Intervention: n = 40 practices/795 patients; Control: n = 40 practices/797 patients

Cardiovascular risk reduction (secondary outcomes):

Proportion of participants reaching glycaemic control targets (HbA1c < 7.0%): Intervention: 58.5%; Control: 58.8%; OR 0.93 (0.71 to 1.21), P = 0.58

Proportion of participants reaching blood pressure control targets (< 130/80): Intervention: 52.8%; Control: 63.5%, OR 0.72 (0.53 to 0.98), P = 0.04

Proportion of participants reaching LDL‐cholesterol control targets (< 2.0 mmol/L): Intervention: 59.2%; Control: 61.7% , OR 0.90 (0.68 to 1.18), P = 0.43

Proportion of participants reaching Total to HDL‐cholesterol ratio (< 4.0): Intervention: 74.2%; Control: 76.8%, OR 0.85 (0.63 to1.14), P = 0.27

Clinical (secondary outcomes):

When HbA1c > 8.0%: Intervention: 11.8%; Control: 13.0%, OR 0.98 (0.48 to 1.98), P = 0.95

When blood pressure > 140/90: Intervention: 5.6%; Control: 7.2%, OR 0.67 (0.25 to 1.82), P = 0.43

When LDL cholesterol > 3.0 mmol/L: Intervention: 43.5%; Control: 45.2%, OR 0.94 (0.53 to 1.67), P = 0.83

Administrative data study : Intervention: 2008 practices (467,713 participants); Control: 1999 practices (466, 076 participants)

Secondary outcomes:
Clinical events (all‐cause death, MI, MI or unstable angina, stroke, stroke or TIA, and combined outcomes): OR: from 0.98 to 1.04, P values from 0.21 to 0.96

‐

Administrative data study : Intervention: 2008 practices (467,713 participants); Control: 1999 practices (466,076 participants)

Primary outcome: Death or non‐fatal myocardial infarction: Intervention: 2.5%; Control: 2.5%; OR 1.00 (0.96 to 1.03), P = 0.77

Secondary outcomes: Medication initiation (ACEI/ARB > 1 antihypertensive class, or > 2, or > 3, statin, glucose‐lowering drugs, insulin, nitrate): OR, range: from 0.96 to 1.02, P values from 0.03 to 0.94

Clinical data study:

Primary outcome: Proportion of participants prescribed statins (new or renewed prescription): Intervention: 700 (88.1%); Control: 725 (90.1%); OR 0.73, 95% CI 0.42 to 1.26, P = 0.26

Proportion of participants prescribed an ACEI/ARB: Intervention: Control: Secondary outcome.

Administrative data study :

Secondary outcomes: CAD assessment (electrocardiogram, cardiac stress test, nuclear imaging, coronary angiography, coronary revascularisation, cardiology or internal medicine visit): OR, range: from 0.96 to 1.00, P values from 0.02 to 0.83

‐

Author Year

Adherence Outcomes

Participants (Settings)

Control Adherence

Intervention Adherence

Median ARD

Bekkering 2005

(Hoijenboos 2005)

Targeted behaviour: management of non specific low back pain

GL tool used: interactive training workshop X2

Adherence to 4 guideline recommendations:

i) Limit number of sessions in normal course back pain

ii) Set functional treatment goals

iii) Use mainly active interventions

iv) Give adequate information

Note: an increase was desirable for all outcomes

113 physiotherapists

(68 private physiotherapy practices)

i) Post:

14 (13), n = 253

ii) Post:

180 (71)

iii) Post:

154 (60)

iv) Post:

221 (87)

i) Post:

32 (27), n = 247

ii) Post: 188 (79)

iii) Post: 183 (77)

iv) Post: 229 (96)

+0.115

11.5% higher adherence in the intervention group

i) 0.14%

ii) 0.08%

iii) 0.17%

iv) 0.09%

Daucourt 2003

Targeted behaviour: appropriate thyroid function testing

Guideline tool used:
1) Dual intervention (2 + 3);
2) Order request form;
3) Pocket memorandum card

Global Guideline Conformity Rate

1412 physicians

(6 general hospitals)

Pre: 62.0%

(95% CI 47.7 to 76.4)

Dual intervention group: Post: 77.9% (95% CI 68.9 to 87.0)

Note: only results for the dual intervention presented here

+0.159%

Fine 2003

Targeted behaviour: appropriate duration of intravenous antibiotic therapy for treatment of pneumonia

GL tool used: detail sheet/ treatment recommendations+ telephone reminder

No adherence outcomes reported, only proxies

545 physicians

(7 not‐for‐profit hospitals)

‐

‐

‐

Shah 2014

Targeted behaviour: improved cardiovascular risk factor management in people with diabetes

Guideline tool used: printed educational material

No adherence outcomes reported, only proxies

2 separate studies:

Administrative data study: n = 4007 practices: Intervention: 2008; Control: 1999

Clinical data study. n = 80 practices (1592 patients); Intervention: 40 practices (8795 patients); Control: 40 practices (8797 patients)

‐

‐

‐