“More bang for the buck”: exploring optimal approaches for guideline implementation through interviews with international developers

Guidelines are syntheses of best available evidence that, in addition to professional judgment and patient preferences, support decision-making by clinicians, managers and policy makers about the organization, delivery and improvement of health care [1, 2]. However, population-based studies continue to show that guidelines produced worldwide by prominent agencies for chronic and acute conditions are underused [3‐7]. Modeling by the World Health Organization found that for cancer, a third of cases could be prevented, another third cured, and the rest effectively managed if care consistently complied with existing guidelines [8]. The same may be true of many other conditions that feature low compliance with guideline-recommended care, and which impose considerable burden on individuals and health systems.

It is imperative that we improve, or seek new ways of promoting guideline use, but there are many possible ways to do this. To identify the most productive avenue for ongoing investigation it is essential to first analyze related issues, and select an approach that is relevant and actionable. Many factors influence whether and how guidelines are used, including guideline characteristics (quality of format and content), and individual (provider characteristics), institutional (capacity to collect, adapt, share and apply evidence), and health system (policies, resources) attributes [9‐12]. While these factors may challenge use of guidelines, it appears that a number of issues may be influential further upstream of the setting in which guidelines are meant to be applied.

Repeat survey of Canadian guideline developers in 1994, 2002 and 2008, and a survey of organizations in Africa, Asia, Europe, Latin America, the United States, and United Kingdom found that few actively implemented their guidelines [13, 14]. There may be several reasons for this. Evidence on the impact of different guideline implementation strategies is unclear. Educational (materials, meetings), social engagement (opinion leaders, educational outreach), embedding (clinical support systems, reminders), and incentive (audit & feedback, pay-for-performance) approaches had a small to moderate impact either alone or in combination, but not consistently, and many of these studies did not include economic analyses [15‐22]. Most strategies are not routinely applied outside of experimental studies and few program evaluations are published which would provide information about the impact and implications of these strategies in a variety of contexts. By systematic review we found no studies evaluating implementation of breast cancer management guidelines [23], and only two studies evaluating implementation for colorectal cancer management guidelines [24]. Therefore, little data about cost and contextual effectiveness is available to guide decisions about which implementation strategies are most useful in the real world.

Guideline implementation is quite complex, involving multiple stages including creating actionable products, adapting them to local context, assessing barriers, selecting and applying interventions, monitoring use, evaluating outcomes, and sustaining use [25]. Interviews with health professionals in the United Kingdom revealed they had difficulty in acquiring resources to fund implementation, often turning to “soft” money from pharmaceutical companies or charities for more traditional passive (mailing, posting on web site) or educational (meetings) strategies [17]. Thus implementation capacity, which could be defined as the knowledge, resources, infrastructure and practices required to implement guidelines may be lacking, and therefore limits use of, or successful application of existing strategies for promoting guideline uptake.

This research suggests that to improve guideline use, we may need to better implement them, perhaps by enhancing the implementation capacity of guideline developers or their sponsors. In other research guideline developers said they did not actively implement their guidelines, but these interviews did not thoroughly explore why, or their views about approaches and resources that could enhance their implementation capacity [14]. Consultation with guideline developers would explore whether this was at all feasible and, if so, how, thereby more clearly identifying promising avenues for research and practice on implementation capacity, or potentially identifying alternative options. Such information is essential if we are to improve guideline implementation and use. This research was conducted to learn about the implementation capacity and activities of representatives from guideline development agencies, and solicit their recommendations for improving implementation capacity or for alternative approaches by which to promote guideline use. While the views of guideline users are important and could differ from those of guideline developers, interviews with users were beyond the scope of this study, and will be pursued in future research.

The importance of guidelines as decision-making tools that promote evidence-informed practice and serve as “one of the foundations for efforts to improve health care” was recently emphasized in a review of the guideline enterprise [31]. Other research has focused on identifying gaps (over/underuse of guidelines) in care, highlighting the need to better implement guidelines, and identifying factors contributing to those gaps [3‐11]. Considerable research has also found that many guideline implementation strategies can be effective, but their cost and usefulness in different settings remains unclear [15‐23]. Promising research is underway on how to tailor these implementation strategies for various contexts [32]. However, the issue of who bears responsibility for using these strategies to implement guidelines remains, along with the need to better describe and enable the capacity for doing so. Our research fills the unique niche of investigating the feasibility and resource implications of differing implementation approaches according to locus of responsibility and real world circumstances.

We learned that not all guideline development organizations are mandated to implement their guidelines. Those with an implementation mandate featured widely inconsistent funding and staffing models, differing approaches for choosing implementation strategies most often dependent on guideline characteristics, and a range of dissemination and implementation activities including access (web sites, publications), alerts (newsletters, media campaigns), distribution (regular mail, email), education, champions, and organizational partnerships. These findings highlight variable implementation practices and emphasize the lack of insight on how to optimize implementation capacity. While implementation approaches and strategies need not be standardized across organizations, the findings suggest that even if we learn more about how to tailor implementation strategies to enhance their effectiveness, it is not clear who would apply these strategies, and how, given variable mandates, lack of frameworks to guide implementation decision making, and limited resources.

It is well recognized that producing guidelines does not improve the quality of health care, yet the issue of how to achieve implementation of guidelines remains. Participants were asked to comment on the pros and cons associated with three implementation approaches that differed by responsibility, and to recommend an optimal approach. Most participants selected the option of including information within guidelines that would help users to implement them. Given variable mandate and resources for guideline implementation, it was considered the most feasible and cost-effective approach, and therefore most likely to have impact due to potentially broad use. Participants referred to this as “more bang for the buck”. While the other two strategies considered were perceived to have some merit, their feasibility and application were questioned, so it is not surprising that an innovative approach was preferred. Many research studies have found that implementation capacity is a key barrier of guideline implementation [1, 7], and that, quite reasonably, as a result of limited mandate and resources many developers do not implement their guidelines [13, 14, 17]. While intermediaries were commonly viewed as an effective mechanism for promoting use of guidelines, uncertainty about their characteristics and roles as expressed by participants was similar to that described in published research [16, 17, 30].

We are investigating how to tailor guidelines with information that supports user implementation. A review of the medical literature identified features desired by different users, or associated with guideline use [33]. The Guideline Implementability Framework included 22 elements organized within eight domains: adaptability, usability, relevance, validity, applicability, communicability, resource implications, implementation and evaluation. Subsequent analysis of 20 high quality guidelines on various clinical indications found that most did not contain implementability elements, highlighting numerous opportunities to potentially improve guideline development and use by integrating one or more of these elements [33]. We have identified and described tools that could be included in guidelines to help users address Resource Implications (equipment or technology needed; industrial standards; policies governing their use; type and number of health professionals needed to deliver services; education, training or competencies needed by staff to deliver services; anticipated changes in workflow or processes during or after adoption), Implementation (identifying barriers associated with adoption; selecting and tailoring implementation strategies that address barriers) and Evaluation (tools based on performance measures to assess baseline and post intervention compliance with guidelines). These tools will populate an open directory to which others can contribute. This is a core activity of the Guideline Implementability Research and Application Network (GIRAnet), and may lead to a sustainable effort where guideline developers, implementers and researchers contribute to, and draw from this shared resource on an international basis [34].

Interpretation of study results may be confounded by several issues. The limitation most commonly associated with exploratory or qualitative research is transferability or relevance to other settings. We attempted to mitigate this through purposive sampling of 30 guideline development agencies from seven different countries that produced guidelines for a variety of disciplines and clinical indications. While we achieved thematic saturation, meaning that no further unique ideas emerged with successive interviews, and we found no trends by country, type of guideline developer organization, or guideline clinical indication, we sampled only from industrialized, English-speaking countries, which may have introduced selection bias. The notable exception was the World Health Organization which produces guidelines for non-industrialized countries and therefore provided opinions based on relevance of strategies for implementing guidelines in those settings. Another possible limitation is that participants were prompted to discuss only three differing approaches for guideline implementation. While there are many strategies for implementing guidelines, we chose these three high level approaches specifically because they represented a diversity of responsibility for guideline implementation, but each still encompassed a range of possible implementation strategies. Finally, even if capacity were improved to optimize these approaches, a number of contextual barriers challenge guideline use in the settings where health care is delivered. While this is true, the approach of creating implementable guidelines, thought to be most promising by guideline developers and which we are investigating, is meant to help users overcome those contextual barriers. Tailoring of guideline products in this manner may be complementary to tailoring of strategies to implement those guidelines, but further research is needed to develop these approaches, and more rigorously evaluate their individual and combined impact.

To develop and broadly apply the guideline implementability approach, participants highlighted two key implications that must be considered. Guideline developers will need some direction on how to generate guidelines with user tools, templates or instructions for implementation. We found that no guideline development instructional manuals offered advice on how to generate implementable guidelines [35]. Therefore further research is needed to explore the processes and resources used by developers who have produced guidelines containing user implementation tools, templates and instructions, and share this information about processes and resources with other guideline developers via an instructional manual or training opportunities. Two, while enhanced guidelines are meant to provide users with tools, templates and instructions for implementing the recommendations, these enhanced guidelines may become too complex, and may still require promotion to ensure that potential users are aware of them. A meta-review of factors influencing guideline implementation found that complexity of guidelines was the most frequently cited barrier [7]. In particular, the review found that guidelines which are easy to understand, can be easily tried out, and do not require specific resources are more likely to be implemented. Thus while guidelines containing additional tools, templates or instructions to support user implementation may be lengthy, this content is meant to help users more easily accommodate the recommendations by identifying resource implications and implementation strategies. The review also found that effective strategies have multiple components. Thus, supplementing the range of dissemination strategies already used by international guideline developers with guidelines that equip users with tools, templates and instructions to implement them represents an approach that warrants further investigation.

Given variable mandate and resources, international guideline developers thought that including information within guidelines that would help users to implement them was the most feasible approach, and more likely to promote guideline use due to potentially broad application. These findings are not likely to change policy across jurisdictions that govern resourcing of guideline developers to undertake guideline implementation, but may emphasize the need to evaluate current and future strategic and operational plans that involve health care quality improvement according to whether and how guideline implementation is considered. Guideline developers may also use these findings to launch internal planning of guideline development and implementation approaches, staffing and methods, and as the basis for consultation with funders and end users about how to optimize current strategies. Ongoing research is needed to examine implementation capacity by guideline developers in jurisdictions other than those involved in this study, the role of different facilitative intermediaries, and whether and how users can be better enabled to implement guidelines.