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      Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews

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          Abstract

          Background

          This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.

          Design

          This study is a systematic review of reviews.

          Methods

          MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis.

          Results

          Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation.

          Conclusions

          This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.

          Systematic review registration

          PROSPERO CRD42014009410

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13012-016-0396-4) contains supplementary material, which is available to authorized users.

          Related collections

          Most cited references117

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          Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

          Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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            Developing and evaluating complex interventions: the new Medical Research Council guidance

            Evaluating complex interventions is complicated. The Medical Research Council's evaluation framework (2000) brought welcome clarity to the task. Now the council has updated its guidance
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              Process evaluation of complex interventions: Medical Research Council guidance

              Process evaluation is an essential part of designing and testing complex interventions. New MRC guidance provides a framework for conducting and reporting process evaluation studies
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                Author and article information

                Contributors
                r.lau@ucl.ac.uk
                f.stevenson@ucl.ac.uk
                b.n.ong@keele.ac.uk
                k.s.dziedzic@keele.ac.uk
                streweek@mac.com
                s.eldridge@qmul.ac.uk
                H.A.Everitt@soton.ac.uk
                A.Kennedy@soton.ac.uk
                nadeem.qureshi@nottingham.ac.uk
                A.E.Rogers@soton.ac.uk
                richardpeacock@nhs.net
                elizabeth.murray@ucl.ac.uk
                Journal
                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                1748-5908
                22 March 2016
                22 March 2016
                2015
                : 11
                : 40
                Affiliations
                [ ]eHealth Unit, Research Department of Primary Care and Population Health, University College London, Upper 3rd floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
                [ ]Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, Staffordshire UK
                [ ]Health Services Research Unit, University of Aberdeen, Aberdeen, UK
                [ ]Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
                [ ]Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
                [ ]Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
                [ ]Division of Primary Care, University of Nottingham, Nottingham, UK
                [ ]Archway Healthcare Library, London, UK
                Author information
                http://orcid.org/0000-0003-0625-2228
                Article
                396
                10.1186/s13012-016-0396-4
                4802575
                27001107
                bc977cf4-1098-4710-a62e-d520e1c04c64
                © Lau et al. 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 20 October 2015
                : 28 February 2016
                Funding
                Funded by: NIHR SPCR
                Award ID: Project number 122
                Award Recipient :
                Categories
                Systematic Review
                Custom metadata
                © The Author(s) 2016

                Medicine
                barriers,complex interventions,evidence-based practice,facilitators,health services research,implementation research,primary care,systematic review

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