How to Implement Clinical Practice Guidelines in Iran

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Abstract

Background:

Evidence-based medicine would come to the result by evidence-based implementation. Clinical Practice Guidelines (CPG) as one of the evidence-based knowledge products requires appropriate interventions after being produced to be applied.

Objectives:

The aim of this qualitative study was to identify the strategies for application of CPGs produced in Iran.

Materials and Methods:

The purposive snowball sampling was performed and it continued until reaching the theoretical saturation. In-depth semistructured individual interviews and Focus Group Discussion (FGD) were performed aiming at triangulation. The thematic framework approach was used for the analysis.

Results:

Twelve interviews were conducted with three health system policy makers and decision makers, four experienced in the production or adaptation of clinical practices, and five experts in evidence-based medicine development and education. In addition, 11 policy makers, managers, and decision makers of the health system took part in FGD. The proposed interventions were classified in the following themes: Health professionals-oriented, Financial, Organizational, Regulatory, and Multifaceted interventions.

Conclusions:

Along with adaptation and development process of CPGs, their utilization should also be planned; otherwise spent time and money would be in vain. Certainly, imposing above-mentioned interventions with the ultimate goal of sustainable behavior change in health system service providers is beyond the capacity of specific groups or few academic centers. It requires the participation of all practitioners under the monitoring and support of the Ministry of Health and Medical Education. Deployment of the family physician plan and referral system is an opportunity which must be considered a trophy.

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Most cited references 24

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Changing provider behavior: an overview of systematic reviews of interventions.

J. M. Grimshaw, L Shirran, R. Thomas … (2001)

Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals. To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care. An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998. Forty-one reviews were identified covering a wide range of interventions and behaviors. In general, passive approaches are generally ineffective and unlikely to result in behavior change. Most other interventions are effective under some circumstances; none are effective under all circumstances. Promising approaches include educational outreach (for prescribing) and reminders. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions. Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.

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Effectiveness and efficiency of guideline dissemination and implementation strategies.

Geraint E R Thomas, Gavin C. Donaldson, G MacLennan … (2004)

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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Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs.

Richard Grol, Niek Klazinga, Marjukka Makela … (2003)

To describe systematically the structures and working methods of guideline programs. Descriptive survey using a questionnaire with 32 items based on a framework derived from the literature. Answers were tabulated and checked by participants. Key informants of 18 prominent guideline organizations in the United States, Canada, Australia, New Zealand, and nine European countries. History, aims, methodology, products and deliveries, implementation, evaluation, procedure for updating guidelines, and future plans. Most guideline programs were established to improve the quality and effectiveness of health care. Most use electronic databases to collect evidence and systematic reviews to analyze the evidence. Consensus procedures are used when evidence is lacking. All guidelines are reviewed before publication. Authorization is commonly used to endorse guidelines. All guidelines are furnished with tools for application and the Internet is widely used for dissemination. Implementation strategies vary among different organizations, with larger organizations leaving this to local organizations. Almost all have a quality assurance system for their programs. Half of the programs do not have formal update procedures. Principles of evidence-based medicine dominate current guideline programs. Recent programs are benefiting from the methodology created by long-standing programs. Differences are found in the emphasis on dissemination and implementation, probably due to differences in health care systems and political and cultural factors. International collaboration should be encouraged to improve guideline methodology and to globalize the collection and analysis of evidence needed for guideline development.

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Author and article information

Journal

Journal ID (nlm-ta): Iran Red Crescent Med J

Journal ID (iso-abbrev): Iran Red Crescent Med J

Journal ID (doi): 10.5812/ircmj

Journal ID (publisher-id): Kowsar

Title: Iranian Red Crescent Medical Journal

Publisher: Kowsar

ISSN (Print): 2074-1804

ISSN (Electronic): 2074-1812

Publication date (Electronic): 05 November 2013

Publication date (Print): November 2013

Volume: 15

Issue: 11

Electronic Location Identifier: e9702

Affiliations

[1 ]School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran

Author notes

[* ]Corresponding Author: Zahra Baradaran Seyed, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-9124240074, E-mail: baradaran@ 123456ut.ac.ir .

Article

DOI: 10.5812/ircmj.9702

PMC ID: 3971789

PubMed ID: 24719697

SO-VID: 982a50ed-7ce5-489b-a259-c2a5828495a5

License:

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

History

Date received : 17 December 2012

Date revision received : 31 March 2013

Date accepted : 09 May 2013

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How to Implement Clinical Practice Guidelines in Iran

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Abstract

Background:

Objectives:

Materials and Methods:

Results:

Conclusions:

Related collections

Chinese Journal of General Practice

Most cited references 24

Changing provider behavior: an overview of systematic reviews of interventions.

Effectiveness and efficiency of guideline dissemination and implementation strategies.

Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs.

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Cited by 5

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