Contributions to the literature
-
By including guidelines on any clinical topic, this review of 118 studies published between 2014 and 2021 provides a comprehensive picture of implementation planning practices.
-
Compared to an earlier version, this updated review found that guidelines are implemented with a broader range of interventions types and that more interventions are selected and tailored based on frameworks, pre-identifying barriers, and stakeholder engagement.
-
However, even studies that did not employ these approaches achieved impact, raising important questions about their value that can only be answered through a future systematic review based on this data.
Background
-
What approaches were used for implementation planning (i.e., pre-identified barriers, use of frameworks, or stakeholder engagement)?
-
What interventions have been used to implement guidelines in any healthcare context?
-
Do implementation planning approaches (pre-identify barriers, use of frameworks, stakeholder engagement) or multi-faceted interventions appear to lead to positive impact?
Methods
Approach
Eligibility criteria
Search strategy
Study selection
Data extraction and analysis
Results
Search results
Characteristics of included studies
Implementation planning approaches
Implementation planning approach | Details about the planning approach | References | Total studies (n, % of studies using the approach) |
---|---|---|---|
Theories & frameworks used 25/118 (21.2%) | Process models | ||
• Implementation of change model by Grol and Wensing [160] | 5 (20%) | ||
• Knowledge-to-Action Framework [161] | 2 (8%) | ||
Determinant frameworks | |||
• Theoretical Domains Framework [162] | 7 (28%) | ||
• Consolidated Framework for Implementation Research (CFIR) [163] | 2 (8%) | ||
• Promoting Action on Research Implementation (PARiHS) framework [164] | [74] | 1 (4%) | |
Classic theories | |||
• Social cognitive theories | 7 (28%) | ||
• Theory of reasoned action [165] | 5 (20%) | ||
• Theory of diffusion [166] | 3 (12%) | ||
Implementation theories | |||
• Normalization process theory [167] | 2 (8%) | ||
• Capability, opportunity, motivation—behavior (COM-B) model/behavior change wheel [168] | 5 (20%) | ||
Evaluation frameworks | |||
• Reach, Effectives, Adoption, IMplementation (RE-AIM) framework [169] | [94] | 1 (4%) | |
Barriers pre-identified 59/118 (50%) | Through the literature | 33 (55.9%) | |
Surveys/questionnaires | 16 (27.1%) | ||
Group discussions | 11 (18.6%) | ||
Interviews | 10 (16.9%) | ||
Focus groups | 9 (15.3%) | ||
Observations | 5 (8.5%) | ||
Delphi technique | [86] | 1 (1.7%) | |
Method not reported | 7 (11.9%) | ||
Intervention tailored to pre-identified barriers 38/118 (32.2%) | Behaviour change wheel [170] | 5 (13.2%) | |
Method not reported | 33 (86.8%) | ||
Stakeholder engagement 42/118 (35.6%) | Co-design with professionals: | ||
• Group discussions | 23 (54.8%) | ||
• Interviews | [79] | 1 (2.4%) | |
• Focus groups | [99] | 1 (2.4%) | |
• Method not reported | 8 (19%) | ||
Co-design with professionals & patients | |||
• Group discussions | 5 (11.9%) | ||
• Method not reported | 2 (4.8%) | ||
Co-design with patients | |||
• Group discussions | 2 (4.8%) |
Theories and frameworks
Pre-identified barriers and tailoring
Stakeholder engagement
Implementation interventions
Intervention type (modified Mazza framework) | As single intervention (n, %) References | As part of a multi-faceted approach (n, %) References | Total studies (n, %) |
---|---|---|---|
Professional | |||
Educate groups about guideline intent/benefits | 6, 5.1% | 46, 39% | 52, 44.1% |
Provide feedback on compliance | 40, 33.9% | 40, 33.9% | |
Print material (summary, algorithm, referral forms, etc.) | 2, 1.7% | 36, 30.5% | 38, 32.2% |
Present guideline materials at meetings | 4, 3.4% | 33, 28% | 37, 31,4% |
Distribute guideline material | 2, 1.7% | 26, 22% | 28, 23.7% |
Provide feedback from healthcare professionals | 21, 17.8% | 21, 17.8% | |
Educate individuals about guideline intent/benefits | 2, 1.7% | 15, 12.7% | 17, 14.4% |
Provide reminders to individuals/groups about intent/benefits | 2, 1.7% | 15, 12.7% | 17, 14.4% |
Tailor guideline | 1, 0.8% [154] | 12, 10.2% | 13, 11% |
Recruit an opinion leader who recommends implementation | 11, 9.3% | 11, 9.3% | |
Enable self-audit (training, material) | 9, 7.6% | 9, 7.6% | |
Provide alerts when practice deviates | 4, 3.4% | 5, 4.2% | 9, 7.6% |
Provide feedback about patients (outcome data, self-report) | 5, 4.2% | 5, 4.2% | |
Achieve consensus that guideline should be implemented | 4, 3.4% | 4, 3.4% | |
Advertise guideline material | 4, 3.4% | 4, 3.4% | |
Patient/consumer | |||
Education (single or group) | 26, 22% | 26, 22% | |
Print material (summary, etc.) | 23, 19.5% | 23, 19.5% | |
Counselling | 13, 11% | 13, 11% | |
Reminder | 3, 2.5% | 3, 2.5% | |
Financial | |||
Health professional | |||
Grant or allowance to group/institution (not tied to compliance) | 7, 5.9% | 7, 5.9% | |
Grant or allowance to individual (not tied to compliance) | 1, 0.8% [126] | 5, 4.2% | 6, 5% |
Incentive (individual financial reward or benefit for compliance) | 1, 0.8% [122] | 3, 2.5% | 4, 3.4% |
Incentive (group or institutional financial reward or benefit) | 1, 0.8% [79] | 1, 0.8% | |
Patient | |||
Grant or allowance (not tied to compliance) | 1, 0.8% [83] | 1, 0.8% | |
Organizational | |||
Health professional | |||
Create an implementation/multidisciplinary team | 21, 17.8% | 21, 17.8% | |
Reallocated or new role | 10, 8.5% | 10, 8.5% | |
Communication between distant health professionals | 9, 7.6% | 9, 7.6% | |
Additional human resources (number/type) | 2, 1.7% | 5, 4.2% | 7, 5.9% |
Patient | |||
Consumer feedback, suggestions, complaints | 3, 2.5% | 3, 2.5% | |
Structural changes | |||
Information/communication technology | 15, 12.7% | 33, 28% | 48, 40.7% |
Quality improvement, performance measurement system | 10, 8.5% | 15, 12.7% | 25, 21.2% |
Method of service delivery | 2, 1.7% | 19, 16.1% | 21, 17.8% |
Integration of services | 3, 2.5% | 7, 5.9% | 10, 8.5% |
Organizational structure (including reorganization) | 3, 2.5% | 3, 2.5% | |
Physical structure, facilities or equipment | 2, 1.7% | 2, 1.7% | |
Total studies | 30 | 88 | 118 |
Impact on knowledge, behavior, and outcomes
Target group | Outcome measures | Type of impact reported in included studies (n, %) References | Total studies (n, %) | ||
---|---|---|---|---|---|
Positive (all reported outcomes improved) | Mixed (some reported outcomes improved) | No change (no outcomes improved) | |||
Patient/family | Patient outcomes (e.g., reduced cholesterol) | --- | --- | 3, 2.5% | |
Behavior (e.g., medication adherence) | --- | 1, 0.8% [69] | 3, 2.5% | ||
Multiple outcomes | 1, 0.8% [147] | 1, 0.8% [130] | 1, 0.8% [116] | 3, 2.5% | |
Healthcare professional | Knowledge, attitudes, beliefs | 1, 0.8% [145] | 4, 3.4% | ||
Behavior (e.g., medication prescribing) | 60, 50.8% | ||||
Institutional/health system outcomes (e.g., reduced mortality or length of hospital stay) | --- | --- | 1, 0.8% [84] | 1, 0.8% | |
Multiple outcomes | 1, 0.8% [88] | 15, 12.7% | |||
Both patient/family and healthcare professionals | Multiple outcomes | 29, 24.6% | |||
Total | 66, 55.9% | 31, 26.3% | 21, 17.8% | 118, 100% |
Factors influencing impact
Approach | Overall positive impact (n, %) | Mixed or no change (n, %) | Total (n, %) |
---|---|---|---|
Theory or framework used | 10 (8.5%) | 15 (12.7%) | 25 (21.2%) |
Pre-identified barriers | 28 (23.7%) | 31 (26.3%) | 59 (0.5%) |
Intervention tailored to pre-identified barriers | 15 (12.7%) | 23 (19.5%) | 38 (32.2%) |
Stakeholder engagement | 22 (18.6%) | 20 (16.9%) | 42 (35.6%) |
Single intervention | 21 (17.8%) | 9 (7.6%) | 30 (25.4%) |
Multi-faceted intervention | 45 (38.1%) | 43 (36.4%) | 88 (74.6%) |