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      Only One Third of Tehran's Physicians are Familiar with ‘Evidence-Based Clinical Guidelines’

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          Abstract

          Background:

          Clinical guidelines have increasingly been used as tools for applying new knowledge and research findings. Although, efforts have been made to produce clinical guidelines in Iran, it is not clear whether they have been used by physicians and what factors are associated with them?.

          Methods:

          Four hundred and forty three practicing physicians in Tehran were selected from private clinics through weighted random sampling. The data collection tool was a questionnaire on familiarity and attitude toward clinical guidelines. The descriptive and analytical findings were analyzed with t-tests, Chi 2, logistic and linear multivariate regression by SPSS, version 16.

          Results:

          31.8% of physicians were familiar with clinical guidelines. Based on the logistic regression model physicians’ familiarity with clinical guidelines was positively and significantly associated with ‘working experience in a health service delivery point’ OR = 2.13 (95% CI, 1.17-3.90), ‘familiarity with therapeutic protocols’ OR = 2.09 (95% CI, 1.22-3.57) and ‘holding a specialty degree’ OR = 2.51 (95% CI, 1.24-5.07). The mean overall attitude scores in the ‘usefulness’, ‘reliability’, and ‘problems and barriers’ domains were, respectively, 78.9 (SD = 16.5), 78.9 (SD = 19.7) and 50.4 (SD = 15.9) out of a total of 100 scores in each domain. No significant association was observed between attitude domains and other independent variables using multivariate linear regression.

          Conclusions:

          Little familiarity with clinical guidelines may represent weakness in of production and distribution of domestic evidence. Although, physicians considered guidelines as useful and reliable tools, but problems such as difficult access to guidelines and lack of facilities to apply them were stated as well.

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          Most cited references27

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          Effectiveness and efficiency of guideline dissemination and implementation strategies.

          To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group. Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care. In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources. There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.
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            Falling on stony ground? A qualitative study of implementation of clinical guidelines' prescribing recommendations in primary care.

            We aimed to explore key themes for the implementation of guidelines' prescribing recommendations. We interviewed a purposeful sample of 25 participants in British primary care in late 2000 and early 2001. Thirteen were academics in primary care and 12 were non-academic GPs. We asked about implementation of guidelines for five conditions (asthma, coronary heart disease prevention, depression, epilepsy, menorrhagia) ensuring variation in complexity, role of prescribing in patient management, GP role in prescribing and GP awareness of guidelines. We used the Theory of Planned Behaviour to design the study and the framework method for the analysis. Seven themes explain implementation of prescribing recommendations in primary care: credibility of content, credibility of source, presentation, influential people, organisational factors, disease characteristics, and dissemination strategy. Change in recommendations may hinder implementation. This is important since the development of evidence-based guidelines requires change in recommendations. Practitioners do not have a universal view or a common understanding of valid 'evidence'. Credibility is improved if national bodies develop primary care guidelines with less input from secondary care and industry, and with simple and systematic presentation. Dissemination should target GPs' perceived needs, improve ownership and get things right in the first implementation attempt. Enforcement strategies should not be used routinely. GPs were critical of guidelines' development, relevance and implementation. Guidelines should be clear about changes they propose. Future studies should quantify the relationship between evidence base of recommendations and implementation, and between change in recommendations and implementation. Small but important costs and side effects of implementing guidelines should be measured in evaluative studies.
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              Clinicians' attitudes to clinical practice guidelines: a systematic review.

              To systematically review surveys of clinicians' attitudes to clinical practice guidelines. MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000. We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%. Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%-75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%-83%), good educational tools (71%; 63%-79%) and intended to improve quality (70%; 60%-80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%-36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%-47%), would increase litigation (41%; 32%-49%) and were intended to cut healthcare costs (52.8%; 39%-66%). Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.
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                Author and article information

                Journal
                Int J Prev Med
                Int J Prev Med
                IJPVM
                International Journal of Preventive Medicine
                Medknow Publications & Media Pvt Ltd (India )
                2008-7802
                2008-8213
                March 2013
                : 4
                : 3
                : 349-357
                Affiliations
                [1]Department of Epidemiology, School of Public Health and Knowledge Utilization Research Centre, Tehran University of Medical Sciences, Tehran, Iran
                [1 ]Department of Epidemiology, School of Public Health and Knowledge Utilization Research Centre, Tehran University of Medical Sciences, Tehran, Iran
                Author notes
                Correspondence to: Associate Prof. Saharnaz Nedjat, School of Public Health and Knowledge Utilization Research Centre, Tehran University of Medical Sciences, Tehran, Iran. E-mail: nejatsan@ 123456tums.ac.ir
                Article
                IJPVM-4-349
                3634175
                23626893
                16860dba-3141-458a-876e-688f60180cfa
                Copyright: © International Journal of Preventive Medicine

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 22 April 2012
                : 13 September 2012
                Categories
                Original Article

                Health & Social care
                attitude,clinical guidelines,evidence-based medicine,physician
                Health & Social care
                attitude, clinical guidelines, evidence-based medicine, physician

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