Attributes of clinical guidelines and association with uptake: a systematic review

Problem

Rigorously developed clinical guidelines can play a pivotal role in promoting evidence-based practice and improving the quality and outcomes of healthcare. Yet the incorporation of guideline recommendations into routine clinical care is often inconsistent. Uptake of clinical guidelines may be related to their structure, implementation strategies and characteristics of targeted professionals or patients. However, assessment of the quality and structure of guidelines does not necessarily correlate with successful implementation. Attempts to improve uptake of clinical guidelines, through delivery with an implementation strategy, have produced inconsistent results. Successful implementation of clinical guidelines may also be related to the characteristics, or attributes, of the specific recommendations that make up the guideline.

Approach

This systematic review aims to identify studies that assess the impact of the specific attributes or characteristics of individual clinical recommendations on uptake of that recommendation. We aimed to include any comparative studies evaluating the characteristics, qualities, attributes or features of a clinical recommendation that assesses association with uptake. We also assessed studies which discussed attributes of recommendations, or barriers and enablers to uptake, but did not test this. We excluded studies assessing or comparing characteristics of individuals or organisations that use clinical recommendationsA database search of MEDLINE, EMBASE, CINAHL, EBM Reviews and HMIC Databases, was conducted. Screening of the titles and abstracts (n= 2330) was undertaken by authors independently to ensure that the articles satisfied the inclusion criteria. For included articles full text versions were obtained for further assessment.

Findings

There were nine studies which tested if the perceived attributes of the guideline influenced guideline uptake and 119 studies which discussed attributes of guidelines or barriers and enablers to uptake but did not test this. Many papers reported that clinicians perceive that concise, specific recommendations, supported by strong evidence, and guidelines which are testable will more likely be used and this is also demonstrated in the papers which tested guideline uptake. Clinicians also felt that guidance should be accessible, concern routine care and be from a trustworthy source, although this was shown in fewer papers and not shown to be important in the research testing guideline uptake. Overwhelmingly, clinicians think guidelines should suit patients and be flexible to their needs and preferences. However, this has no impact on guideline use and the most important factors are if the recommendation is compatible with current practice and does not require new skills and routine change.

Consequences

Prospective assessment of the attributes of recommendations that are positively or negatively associated with successful uptake could identify those guidelines that will need greater resources in an implementation strategy and lend further insights into processes of change. Greater understanding of these attributes could guide local and national policy on guideline production, dissemination and use.