Effectiveness of implementation strategies for clinical guidelines to community pharmacy: a systematic review

After consulting with a librarian from the Medical and Dental Library at the University of Western Australia, a comprehensive search strategy was devised. Search terms and medical subject headings (MeSH headings) chosen were those relevant to “community pharmacy” AND “clinical guidelines” AND “implementation” (Additional file 1—Search terms). The search was conducted in six electronic databases (Medline, EMBASE, CINAHL, Web of Science, Informit and Cochrane Library) up to and including the 9 November 2014. No restrictions were placed on the search.

The search results from each of the databases were collated. Articles retrieved that were not printed in English were removed along with duplicate results. The decision to remove articles not written in English was based on resource limitations. There is evidence to suggest this was unlikely to introduce systematic bias into this review[32]. Articles were then screened for eligibility based on the previously devised PICO (participants, interventions, comparators, outcomes) framework [33]. Initially titles and abstracts were screened. Full-text screening was undertaken in articles meeting the inclusion criteria or where the abstract provided insufficient information. A final list of articles was identified for inclusion in the review. Two authors (KW and HW) independently conducted the full-search strategy and eligibility assessment. Discrepancies in study selection were resolved through discussion, and where consensus could not be achieved, by mediation with a third author (CS).

Studies were not excluded based on research design. Experimental, quasi-experimental, intervention and observational studies were all eligible for inclusion. Studies were selected based on the PICO (participants, interventions, comparators, outcomes) framework [33] outlined below.

Studies were included if the intervention was in the community pharmacy setting. This included interventions directed to professional staff (pharmacists, interns (unregistered pharmacists) and pharmacy students) and pharmacy support staff (pharmacy assistants, pharmacy technicians). The definition of a community pharmacy used was “a retail business registered for the provision of pharmaceutical services and from which goods and services relating to the provision of pharmaceutical services may be available to the public” [34]. Not included in the review were studies set in hospital pharmacies, multidisciplinary medical clinics run by health funds or other private organisations, outpatient clinics, consultant pharmacist services and Accredited Drug Dispensing Outlets (ADDOs).

Of interest were interventions involving the implementation of clinical guidelines. Studies were included if they reported dissemination and implementation strategies directed to community pharmacy which aimed to influence behaviour of pharmacists, and/or other staff, towards uptake and adherence of guideline-based practice. Studies were excluded if they were “patient programmes” and not aimed at influencing practice behaviours in the community pharmacy setting. This included interventions where pharmacists were instructed to provide services for the course of the project, but the aim was not to make this “usual practice” for the pharmacist. For example, the paper by Armour and colleagues in 2007, that described a guideline-based asthma management programme [35].

The description of the intervention strategies was a modified version of the Cochrane Effective Practice and Organisation Care Review Group (EPOC) taxonomy’s section on implementation strategies [36]. This included educational materials, educational meetings, educational outreach visits, mass media campaign, audit and feedback, reminders, practice support and fee for service [36]. Also investigated was the basis for the interventions. Interventions were considered “tailored” if barriers to implementation were initially identified and then addressed in the development of the implementation strategy [36, 37]. “Based on theory” was the term for interventions that used a documented theory, model or framework for the design of the intervention [20]. Interventions addressing “organisational culture” represent those interventions that focus on changing some aspect of the community pharmacy as an organisation [36, 38]. These include many constructs such as leadership effectiveness, workflows within the organisation, staffing and time management issues.

The operational definition of clinical guidelines was “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” [5, 36]. This definition was chosen on the basis that it has been included in the updated EPOC taxonomy [36] and also been used in two similar reviews with a similar scope, but in different practice settings [1, 16]. In the application of this definition, it was acknowledged that some studies would be excluded, for example, studies that looked at the implementation of practice standards that did not include guidance on clinical activities [39, 40] and articles that looked at policy documents and frameworks [41, 42]. One of the key determinations from the definition was that the guidelines needed to relate to “specific clinical circumstances.” The use of two reviewers and a moderator provided methodological rigour in application of the definition.

For most of the studies in this review, the primary comparator was “usual practice”. Usual practice is indicated by no implementation strategy being directed to the community pharmacy to change current practice.

Outcomes were based on the EPOC classification scheme and included patient outcomes, practitioner outcomes and economic outcomes [43]. Patient health outcome measures of interest included, physical health and treatment outcomes (e.g. mortality, morbidity and surrogate physiological health measures) and psychosocial outcomes (e.g. quality of life) [43]. Practitioner/process outcome measures related to quality of care provided by community pharmacy. This included adherence to recommended practice or guidelines (e.g. extent to which health care providers gave appropriate advice, delivered clinical interventions and followed referral guidelines) [43]. Economic outcomes calculated resource use and measured costs and cost savings associated with guideline implementation (e.g. human resources, consumables and equipment) [43]. Secondary (surrogate) outcomes are those that may indirectly reflect important outcomes, including measures such as knowledge, attitudes and satisfaction of both patients and practitioners [43]. Also of interest was how outcomes were determined. Objective measures involve an impartial measurement and are usually considered more reliable than self-reported measures, which are subjective [44]. Examples of objective data include information from medical or health records, while subjective data may be obtained from a self-report questionnaire.

A comprehensive data abstraction table was developed based on two standard checklists: The Cochrane data collection form (for intervention reviews of randomised controlled trials and non-randomised controlled trials) and the transparent reporting of evaluations with non-randomised designs (TREND) statement checklist (for non-randomised evaluations of behavioural and public health interventions) [45, 46]. The data abstraction table was piloted initially using two articles and revised by consensus (KW and HW). Using the revised table, data abstraction was completed independently by two authors (KW and HW). Discrepancies in data abstraction were resolved through discussion, and where consensus could not be achieved, by mediation with a third author (CS).

A narrative synthesis was undertaken because the methodological and clinical heterogeneity of the studies in this review determined that meta-analysis was not appropriate. A narrative synthesis satisfied the aim by considering different implementation strategies and determining their effectiveness in achieving outcomes reflecting the benefit of clinical guidelines in the community pharmacy setting.

Risk of bias was assessed for all studies included in the review. Studies that were either randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs) or controlled before and after studies (CBAs) were evaluated for bias using the EPOC risk of bias tool [47]. Other studies in this review were cohort or quasi-experimental studies and were evaluated for quality using the Newcastle-Ottawa quality assessment scale for cohort studies [48]. These tools were chosen based on the Cochrane recommendation to use a domain-based evaluation for risk of bias assessments, rather than a tool with a summary score [49]. The Newcastle-Ottawa tool was one of only two tools recommended by Deeks in a review of 182 instruments for measuring risk of bias in cohort studies [50].

The Grading of Recommendations Assessment, Development and Evaluation working group (GRADE) approach [51] was used, in conjunction with the risk of bias tools, to evaluate quality of evidence for outcomes. This is because risk of bias can vary across outcomes, a consideration which is often ignored in systematic reviews [52]. To complete the GRADE assessment, worksheets were used to prepare a summary of findings table [53].This involved a three-step process of assessing the relative importance of all study outcomes, assessing the certainty of evidence across studies for an outcome and summarising the findings [53].

All quality evaluations including risk of bias and quality of evidence for outcomes were completed independently and then by consensus of two authors, KW and HW, with mediation by CS when required.

A critical appraisal of economic outcomes and economic modelling was not undertaken as it was beyond the scope of this review.

Searching the databases resulted in a total of 1937 articles. After adjusting for duplicates and non-English language articles, 1446 remained. Title and abstract screening excluded all but 36 articles. Examining the full-text records and reference lists of the remaining 36 articles resulted in 19 articles reporting on 22 studies, meeting the inclusion criteria. Five articles were discussed with the moderator to achieve consensus (Kappa score 0.86) Fig. 1.

The 22 studies comprised 10 RCTs [54‐63], 3 NRCTs [64‐66], 1 CBA trial [67] and 8 quasi-experimental or observational studies [68‐75] (Tables 1 and 2). The studies were conducted in Australia (n = 8) [54‐56, 60, 64, 65, 68, 69], the USA (n = 4) [57‐59, 73], the UK (n = 3) [62, 63, 75], the Netherlands (n = 2) [61, 72], Belgium (n = 1) [67], Canada, (n = 1) [71], Finland (n = 1) [74], Germany (n = 1) [70] and Switzerland (n = 1) [66]. The time frame for intervention-duration ranged from 1 day to 2 years. The included studies had sample sizes ranging from a group of 8 pharmacists to an intervention group of 1222 community pharmacies. Power calculations to determine an appropriate sample size were performed in three studies [62, 66, 70].

The 22 studies included in the review were assessed for risk of bias using separate tools depending on the study design. Consensus was achieved through discussion. Moderation was required for one domain (“comparability domain” in the Newcastle-Ottawa tool), which was the main area of disagreement (Tables 3 and 4).

Fourteen studies were assessed using the EPOC risk of bias tool for RCTs, NRCTs and CBA studies. Of these, 11 studies were evaluated as having a high risk of bias [55‐59, 61, 63‐67] and three studies assessed as having an unclear risk of bias [54, 60, 62]. Several domains contributed to risk of bias in multiple studies. These included, inadequately addressing incomplete data, lack of similarity in baseline measurements and protection from contamination in the study. It was not clear if these inadequacies were due to lack of reporting or flaws in research design. Two of the studies evaluated as having an overall unclear risk of bias used implementation strategies involving a computer prompt [54, 60].

The Newcastle-Ottawa tool for cohort studies was used to evaluate eight studies [68‐75]. The study by Egen showed the least risk of bias with the domains around selection of study groups and outcomes deemed low risk [70]. However, like all of the cohort studies, in this review, the study design or analysis meant the comparability of cohorts could be a source of bias. There was little to suggest that studies had used measures to correct for confounding variables in any of the eight studies evaluated.

Use of the two risk of bias tools lead to the observation that many of the studies in this review were subject to selection bias and performance bias. Selection bias was inherent in the self-selection of study participants. Self-selection of participants occurred in 18 of the 22 studies, even if randomisation methods were subsequently used [54‐58, 60‐64, 66‐69, 71‐74]. Performance bias relates to the propensity for the studies to be threatened by the Hawthorne effect, which is the tendency to modify behaviour when being observed [76, 77]. Simulated patient methodology is one method that has been used in pharmacy-practice research to avoid the Hawthorne effect [78]. In this review, simulated patient methodology was used in ten studies [55, 56, 62‐64, 66, 68‐70, 75]. However, in most instances, the studies used the simulated patients overtly rather than covertly, which while ethically sound, does not eliminate the risk of bias.

The areas of clinical practice that guideline implementation were designed to impact were varied. They involved chronic disease states [57, 60, 65, 71, 75], guidelines for the supply of particular classes of medications [55, 56, 59, 61, 64, 66, 68‐70, 72], community pharmacy’s role in preventative health [58, 67, 73] and guidelines for appropriate pharmacy practice [63, 74]. The variation did not allow for any conclusions to be made about the effectiveness of implementation based on guideline characteristics.

Implementation activities were targeted to community pharmacy, and in particular to pharmacists in 20 studies [54‐62, 65‐75] and pharmacy support staff in 11 studies [56, 58, 61‐64, 66, 68, 69, 72, 75]. In two studies, implementation activities were directed exclusively to pharmacy support staff, while three studies involved implementation activities to other health professionals and/or patients as well as community pharmacy staff [58, 65, 70]. Both the studies in this review involving comparisons between professional and support staff demonstrated that better outcomes were achieved when the patient encountered a pharmacist [62, 75].

Eighteen studies involved multifaceted interventions [54‐58, 60, 62‐70, 73‐75], and single intervention strategies were used in four studies [59, 63, 71, 72]. The multifaceted nature of the majority of implementation strategies did not allow for a clear understanding of the effectiveness of individual strategies. Overall, eight different implementation strategies were reported in studies in the review including, use of educational materials, educational meetings, educational outreach visits, mass media campaigns, audit and feedback, reminders (including CDSS), practice support and fee for service.

The most commonly used implementation strategies were educational interventions. All but two of the studies in the review had an educational component in their intervention including provision of educational materials, educational meetings or educational outreach visits [54‐59, 61‐70, 72‐75]. Seven studies used educational strategies exclusively [59, 63, 65, 72‐75]. Of these, two studies used behaviour change theory to inform the intervention [63, 73] resulting in variable outcomes. The remaining five studies achieved modest positive outcomes. Educational outreach visits (sometimes called academic detailing) were undertaken in three studies [62, 65, 70]. One of the studies by Watson compared educational outreach and education meetings, individually and in combination, against a control [62]. This study did not demonstrate effectiveness for either strategy.

In six studies, educational interventions were combined with audit and feedback [55, 56, 64, 66, 68, 69]. Benrimoj and colleagues authored all of these studies. Five of the studies (from two papers) were in collaboration with De Almeida Neto [55, 56, 64, 68, 69] as the primary author, and one study was in collaboration with Sigrist [66] as the primary author. The studies using audit and feedback were generally effective. All reported positive outcomes except one, which had variable outcomes [66].

Practice support, in the form of follow-up visits, phone calls or via provision of practice tools (e.g. checklists, patient handouts, documentation forms), was used in seven studies [55, 56, 58, 60‐62]. Only one study used practice support as a single intervention [71]. The study was a pilot study that provided pharmacists with practice tools for diabetes management. The proposed method was to implement the tools in conjunction with an education programme; however, the education programme was not available for the pilot study. The use of the practice support tools alone resulted in a modest positive outcome.

Computer prompts, as reminders to support practice change, were the used in four studies [54, 57, 60, 67, 71]. The studies using this implementation strategy in the community pharmacy setting produced variable outcomes. The sub-studies by Curtain and Reeve [54, 60], which were both part of the larger Pharmacy Recording of Medication and Services (PROMISe) project [79], demonstrated very strong evidence of effect, whereas the study by Kradjan [57] demonstrated no effect. The strongly positive outcomes and comparatively robust methodology, seen in the Curtain [54] and Reeve [60] studies, indicate the best evidence for effectiveness of an implementation strategy in the community pharmacy setting.

The study by Egen used an intensive mass media campaign along with specific educational interventions directed to pharmacists and gynaecologists [70]. This multifaceted approach did not demonstrate evidence of effect in pharmacist- or patient-outcome measures.

A monetary incentive (fee for service) was only used in one study as an implementation strategy [57]. However, it was part of a multifaceted implementation, which also involved educational interventions and reminders. There was no evidence of effectiveness demonstrated.

Most implementation strategies were educational and designed to improve knowledge and/or communication skills. However, this choice of implementation strategy was, in almost all instances, not based on an identified deficit in these areas. Tailored implementation strategies, based on addressing identified barriers to successful guideline implementation, were only evident in two studies [61, 63]. The barriers identified included, organisational barriers, knowledge deficits, social factors such as patient indifference and suboptimal communication by non-professional pharmacy staff. Both the studies, which used tailored strategies, were ineffective in producing positive primary outcomes. Two other studies also addressed organisational factors (including workflow and time constraints), but without mentioning that the choice of strategy was tailored [58, 71]. Both proved to be moderately effective. Studies were based on specific behavioural theorems or frameworks in six instances [55, 56, 58, 63, 66, 73]. The behavioural theories, frameworks and strategies used included “Motivational Interviewing” techniques [55]; “Stages of Change Model” [55, 56, 66]; “Trans‐theoretical Model for Change” [73]; “Social Cognitive Theory” [58]; “Health Beliefs Model” [66]; “Theory of Planned Behaviour” [63]; “Calgary-Cambridge Model of Communication Skills” [63] and “Cognitive Behavioural Therapy” [63] techniques. Despite most of the studies in this review reporting positive outcomes, two out of the six studies based on behaviour change models did not [63, 66].

Fifteen studies [54‐56, 58‐60, 64, 65, 67‐69, 71‐73, 75] reported positive outcomes as a result of clinical guidelines implementation. Five studies indicated no significant improvement in primary outcomes measures as a result of the implementation strategy [57, 61‐63, 70] and two studies reported minimal or variable results [66, 74]. Almost all studies reported multiple outcomes making assessment of primary outcomes difficult. Objective measures were used to report outcomes in 18 studies [54‐56, 59‐69, 71, 73‐75]. Self-reported outcomes, both patient and practitioner outcomes, were included in 15 studies [54, 55, 57, 58, 60‐63, 65, 67, 70‐74]. In many instances, these outcomes were assessed via novel un-validated tools, modified validated tools or the reporting was inadequate to ascertain validity and reliability of the tool. Such measures are of limited benefit in evaluating successful guideline implementation. Surrogate measures were used in nine studies and included assessments of attitudes, self-efficacy, and patient and practitioner satisfaction/acceptability of interventions [55, 57, 60, 61, 65, 67, 71, 73, 74]. Four studies did not use any objective measures and relied upon self-reported (subjective) measures [57, 67, 71, 74].

All studies in the review measured process outcomes related to changes in the practice of community pharmacy staff. Patient outcomes were only measured in three studies and all relied upon self-reported outcomes using patient surveys [54, 57, 70]. Only one of the patient outcomes measured was based on a health outcome, but it was a surrogate measure for perceived asthma control [57]. The lack of measurement of robust (objective) patient outcomes determines that few conclusions can be made about the evidence of effectiveness for implementation of guidelines to community pharmacy.

Most studies did not comment on sustainability of outcomes or mentioned it as a limitation of the research. Sustainable practice change was noted in two studies, but the sample sizes were small [71, 73]. Four studies indicated a decline in outcomes over the course of data collection [54, 60, 61, 71]. One study indicated that ongoing communication was required for sustainability [75]. Thus there is little evidence that the positive outcomes generated by implementation of clinical guidelines in most of the studies, are sustainable effects.

Economic outcomes were determined in three studies [54, 59, 62]. All the economic evaluations looked at different measurements. These included the cost of implementing guidelines [62], cost savings to the health system due to improved guideline adherence [54] and an attempt at a more thorough cost-benefit analysis [59]. No analysis was undertaken to assess the quality of the economic modelling undertaken.

Six primary outcome measures were agreed upon and assessed using the GRADE approach [51]. Five outcomes were assessed as having very low quality of evidence. One outcome was assessed as having low quality of evidence. The main reasons for this were the heterogeneity of the studies, variability of outcomes and the potential for bias in studies. None of the outcomes were considered to have moderate or high quality of evidence. Thus, even though the studies demonstrated positive outcomes from clinical guideline implementation, these outcomes are generally not a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high (Table 5).