Implementation of the Dutch Low Back Pain Guideline for General Practitioners: A Cluster Randomized Controlled Trial Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol Implementation of a Guideline for Low Back Pain Management in Primary Care: A Cost-Effectiveness Analysis Effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain: a cluster randomised controlled trial Study protocol of an economic evaluation of an extended implementation strategy for the treatment of low back pain in general practice: a cluster randomised controlled trial Implementation of the Swedish Guideline for Prevention of Mental ill-health at the Workplace: study protocol of a cluster randomized controlled trial, using multifaceted implementation strategies in schools Implementation of a clinical dementia guideline Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain Implementation of multidimensional knowledge translation strategies to improve procedural pain in hospitalized children Effects of Two Guideline Implementation Strategies on Patient Outcomes in Primary Care: A Cluster Randomized Controlled Trial Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. Nutritional support in acute stroke: the impact of evidence-based guidelines. Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol Implementation strategies for a Scottish national epilepsy guideline in primary care: results of the Tayside Implementation of Guidelines in Epilepsy Randomized (TIGER) trial. Protocol for economic evaluation alongside the IMPLEMENT cluster randomised controlled trial Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial. Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers’ perspectives and experiences Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings Reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study. Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review
Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations Background Low back pain ( LBP ) is one of the most prevalent and expensive health care problems in industrialised countries . LBP leads to high health care utility and productivity losses ; leaving the individual , the employer , and society with substantial costs . To improve the care for LBP patients and reduce the high societal and financial burden of LBP , in 2010 the ‘ Multidisciplinary care guideline for nonspecific low back pain ’ was developed in the Netherl and s. The current paper describes the design of a study aim ing to evaluate the ( cost- ) effectiveness of a multifaceted strategy to implement this guideline . Methods In a cluster-r and omised controlled trial , the ( cost- ) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination . Using a stepped-wedge approach , participating general practitioners , physiotherapists , and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session . The timing these clusters receive the training is the unit of r and omisation . LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aim ed at improving beliefs , cognitions , and self-management . The primary outcome measure of this study is patient back beliefs . Secondary outcome measures on patient level include pain , functional status , quality of life , health care utility , and productivity losses . Outcome measures on professional level include knowledge and attitude towards the guideline , and guideline adherence . A process evaluation for the implementation strategy will be performed among the health care providers and the patients . Furthermore , a qualitative subgroup analysis among patients with various ethnic background s will be performed . Discussion This study will give insight into the ( cost- ) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level . The valuable information gained with this study may prove useful for policy-makers , health care providers , and research ers who are in the process of reducing the burden of back pain on individuals and society . Trial Registration Netherl and s Trial Register ( NTR ) : NTR4329 . Registered December 20th , 2013 Background Evidence -based clinical practice guidelines may improve treatment quality , but the uptake of guideline recommendations is often incomplete and slow . Recently new low back pain guidelines are being launched in Denmark . The guidelines are considered to reduce personal and public costs . The aim of this study is to evaluate whether a complex , multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy . Methods / design In a two-armed cluster r and omised trial , 100 general practice s ( clusters ) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included . Practice s are r and omly allocated 1:1 to a simple or a complex implementation strategy . Intervention practice s will receive a complex implementation strategy , including guideline facilitator visits , stratification tools , and quality reports on low back pain treatment . Primary outcome is referral to secondary care . Secondary outcomes are pain , physical function , health-related quality of life , patient satisfaction with care and treatment outcome , employment status , and sick leave . Primary and secondary outcomes pertain to the patient level . Assessment s of outcomes are blinded and follow the intention-to-treat principle . Additionally , a process assessment will evaluate the degree to which the intervention elements will be delivered as planned , as well as measure changes in beliefs and behaviours among general practitioners and patients . Discussion This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice , and will provide insight on essential elements to include in future implementation strategies in general practice .Trial registration Registered as NCT01699256 on Clinical Trials.gov Background Evidence generated from reliable research is not frequently implemented into clinical practice . Evidence -based clinical practice guidelines are a potential vehicle to achieve this . A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines . Recommendations from this review , and other studies , have suggested the use of interventions that are theoretically based because these may be more effective than those that are not . An evidence -based clinical practice guideline for the management of acute low back pain was recently developed in Australia . This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common , has a high burden , and for which there is an evidence - practice gap in the primary care setting . Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria , Australia . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray  , and improving mean level of disability for patients three months post-consultation . Methods / Design This study protocol describes the details of a cluster r and omised controlled trial . Ninety-two general practice s ( clusters ) , which include at least one consenting general practitioner , will be r and omised to an intervention or control arm using restricted r and omisation . Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion . An average of twenty-five patients per general practice will be recruited , providing a total of 2,300 patient participants . General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy . Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory . Investigators ( not involved in the delivery of the intervention ) , patients , outcome assessors and the study statistician will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN012606000098538 ( date registered 14/03/2006 ) Study Design . Cost-effectiveness analysis alongside a cluster r and omized controlled trial . Objective . To study the cost-effectiveness of 2 low back pain guideline implementation ( GI ) strategies . Summary of Background Data . Several evidence -based guidelines on management of low back pain have been published . However , there is still no consensus on the effective implementation strategy . Especially studies on the economic impact of different implementation strategies are lacking . Methods . This analysis was performed alongside a cluster r and omized controlled trial on the effectiveness of 2 GI strategies ( physician education alone [ GI ] or physician education in combination with motivational counseling [ MC ] by practice nurses)-–both compared with the postal dissemination of the guideline ( control group , C ) . Sociodemographic data , pain characteristics , and cost data were collected by interview at baseline and after 6 and 12 months . low back pain – related health care costs were valued for 2004 from the societal perspective . Results . For the cost analysis , 1322 patients from 126 general practice s were included . Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls . In addition , both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data . Conclusion . Trends in cost-effectiveness are visible but need to be confirmed in future studies . Research ers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the r and omization success by review ing non-cost parameters like clinical data alone Objectives : To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain . Design : A cluster r and omised controlled trial comparing an active strategy with st and ard dissemination . Setting : Primary care physiotherapy practice s. Participants : 113 physiotherapists were r and omly allocated to receive the guidelines by mail ( control group ) or to receive an additional active strategy ( intervention group ) which consisted of a multifaceted programme including education , discussion , role playing , feedback , and reminders . Main outcome measures : Adherence to the guidelines was measured by means of individual patients ’ forms recording the treatment completed by the physiotherapist . The forms were assessed using an algorithm based on the number of treatment sessions , treatment goals , interventions , and patient education . Results : Physiotherapists in the intervention group more often correctly limited the number of treatment sessions for patients with a normal course of back pain ( OR 2.39 ; 95 % CI 1.12 to 5.12 ) , more often set functional treatment goals ( OR 1.99 ; 95 % CI 1.06 to 3.72 ) , more often used mainly active interventions ( OR 2.79 ; 95 % CI 1.19 to 6.55 ) , and more often gave adequate patient education ( OR 3.59 ; 95 % CI 1.35 to 9.55 ) . They also adhered more to all four criteria ( OR 2.05 ; 95 % CI 1.15 to 3.65 ) . Conclusions : The active strategy moderately improved adherence to the guidelines . Active strategies are recommended to implement the clinical guidelines on physiotherapy for low back pain Background In Denmark , guidelines on low back pain management are currently being implemented ; in association with this , a clinical trial is conducted . A health economic evaluation is carried out alongside the clinical trial to assess the cost-effectiveness of an extended implementation strategy to increase the general practitioners ' adherence to the guidelines . In addition to usual dissemination , the extended implementation strategy is composed of visits from a guideline facilitator , stratification tools , and feedback on guideline adherence . The aim of this paper is to provide the considerations on the design of the health economic evaluation . Methods / design The economic evaluation is carried out alongside a cluster r and omised controlled trial consisting of 60 general practice s in the North Denmark Region . An expected 1,200 patients between the age of 18 and 65 years with a low back pain diagnosis will be enrolled . The economic evaluation comprises both a cost-effectiveness analyses and a cost-utility analysis . Effectiveness measures include referral to secondary care , health-related quality of life measured by EQ-5D-5L , and disability measured by the Rol and Morris disability question naire . Cost measures include all relevant additional costs of the extended implementation strategy compared to usual implementation . The economic evaluation will be performed from both a societal perspective and a health sector perspective with a 12-month time horizon . Discussion It is expected that the extended implementation strategy will reduce the number of patients referred to secondary care . It is hypothesised that the additional upfront cost of extended implementation will be counterbalanced by improvements in clinical practice and patient-related outcomes , thereby rendering the extended implementation strategy cost-effective . Trial registration Clinical Trials.gov : Given today ’s high prevalence of common mental disorders and related sick leave among teachers , an urgent need exists for a more systematic approach to the management of social and organizational risk factors within schools . In 2015 , we launched the first Swedish occupational health guideline to support a structured prevention of these risks at the workplace . The existence of guidelines does however not guarantee their usage , as studies show that guidelines are often underused . Knowledge is therefore needed on effective implementation strategies that can facilitate the translation of guidelines into practice . The primary aim of the r and omized waiting list-controlled trial described in this study protocol is to compare the effectiveness of a multifaceted implementation strategy versus a single implementation strategy for implementing the Guideline for the prevention of mental ill-health at the workplace within schools . The effectiveness will be compared regarding the extent to which the recommendations are implemented ( implementation effectiveness ) and with regard to social and organisational risk factors for mental ill-health , absenteeism and presenteeism ( intervention effectiveness ) . The trial is conducted among primary schools of two municipalities in Sweden . The single implementation strategy is an educational strategy ( an educational meeting ) . The multifaceted strategy consists of the educational meeting , an implementation team and a series of workshops . The outcome measure of implementation effectiveness is  guideline adherence . The primary outcome of intervention effectiveness is exhaustion . Secondary outcomes include dem and s at work , work organization and job contents , interpersonal relations and leadership , presenteeism , work performance , recovery , work-life balance , work-engagement , self-reported stress , self-perceived health , sickness absence and psychosocial safety climate . Process outcomes as well as barriers and facilitators influencing the implementation process are assessed . Data will be collected at baseline , 6 , 12 , 18 and 24 months by mixed methods ( i.e. survey , focus-group interviews , observation ) . The study described in this protocol will provide valuable knowledge on the effectiveness of implementation strategies for implementing a guideline for the prevention of common mental disorders within schools . We hypothesize that successful implementation will result in reductions in school personnel ’s  perceived social and organizational risk factors , mental ill-health and sick-leave . Clinical Trials.gov ID : NCT03322839 ( trial registration : 09/19/2017 ) Implementation of clinical practice guidelines has been proposed to improve quality in health care . Multifaceted implementation did not increase guideline acceptance . GPs ' self-reports may overestimate performance . Objective - To assess the impact of a multifaceted implementation strategy aim ing to improve GP adherence to a clinical guideline on dementia . Design - Controlled before and after study using data records from regional laboratories . The guideline was mailed to all GPs . The multifaceted implementation strategy was planned with local GPs , and consisted of seminars , outreach visits , reminders and continuing medical education ( CME ) small group training . Setting - Primary health care . Subjects - 535 GP practice s with 727 physicians in Denmark . Main outcome measures - The diffusion and use of the guideline was measured by a mailed survey . Adherence to guideline recommendations was monitored by data on laboratory tests from general practice in patient 's S 65 years : thyroid stimulating hormone requested with vitamin B 12 or methylmalonate . The use of these tests as part of a diagnostic evaluation of dementia was subsequently verified by a question naire to the practice s. Results - Of the GPs who read the guideline , 88 % found it applicable in primary care . No increase in the adherence to guideline recommendations was observed regarding the use of laboratory tests or cognitive tests in the diagnostic evaluation of dementia in general practice . Conclusion - Although GPs regarded the guideline applicable in primary care , no change in practice adherence to guideline recommendations was detected after a multifaceted implementation OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting Background Despite extensive research , institutional policies , and practice guidelines , procedural pain remains undertreated in hospitalized children .  Knowledge translation ( KT ) strategies have been employed to bridge the research to practice gap with varying success . The most effective single or combination of KT strategies has not been found . A multifaceted KT intervention , Evidence -based Practice for Improving Quality ( EPIQ ) , that included tailored KT strategies was effective in improving pain practice s and clinical outcomes at the unit level in a prospect i ve comparative cohort study in 32 hospital units ( 16 EPIQ intervention and 16 St and ard Care ) , in eight pediatric hospitals in Canada . In a study of the 16 EPIQ units ( two at each hospital ) only , the objectives were to : determine the effectiveness of evidence -based KT strategies implemented to achieve unit aims ; describe the KT strategies implemented and their influence on pain assessment and management across unit types ; and identify facilitators and barriers to their implementation . Methods Data were collected from each  EPIQ intervention unit on targeted pain practice s and KT strategies implemented , through chart review and a process evaluation checklist , following four intervention cycles over a 15-month period . Results Following the completion of the four cycle intervention , 78 % of 23 targeted pain practice aims across units were achieved within 80 % of the stated aims . A statistically significant improvement was found in the proportion of children receiving pain assessment and management , regardless of pre-determined aims ( p < 0.001 ) . The median number of KT strategies  implemented was 35 and included reminders , educational outreach and material s , and audit and feedback . Units successful in achieving their aims implemented more KT strategies than units that did not . No specific type of single or combination of KT strategies was more effective in improving pain assessment and management outcomes . Tailoring KT strategies to unit context , support from unit leadership , staff engagement , and dedicated time and re sources were identified as facilitating effective implementation of the strategies . Conclusions Further research is required to better underst and implementation outcomes , such as feasibility and fidelity , how context influences the effectiveness of multifaceted KT strategies , and the sustainability of improved pain practice s and outcomes over time Study Design . Cluster r and omized controlled trial . Objective . To improve quality of care for patients with low back pain ( LBP ) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses  has been implemented in German general practice s. We studied effects on functional capacity ( main outcome ) , days in pain , physical activity , quality of life , or days of sick leave ( secondary outcomes ) compared with no intervention . Summary of Background Data . International research has lead to the development of the German LBP guideline for general practitioners . However , there is still doubt about the most effective implementation strategy . Although effects on process of care have been observed frequently , changes in patient outcomes are rarely seen . Methods . We recruited 1378 patients with LBP in 118 general practice s , which were r and omized to 1 of 3 study arms : a multifaceted guideline implementation ( GI ) , GI plus training of practice nurses in motivational counseling ( MC ) , and the postal dissemination of the guideline ( controls , C ) . Data were collected ( question naires and patient interviews ) at baseline and after 6 and 12 months . Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders . Results . After 6 months , functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls ( 95 % CI = 0.320–6.979 , P = 0.032 ) and 2.652 between the GI group and controls ( 95 % CI = −0.704 to 6.007 , P = 0.120 ) . Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 ( GI ) to 17 days ( MC ) after 6 months ( 12 and 9 days after 12 months ) compared with controls . Conclusion . Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination . Results are more distinct when practice nurses are trained in motivational counseling BACKGROUND AND PURPOSE An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain . The effect of this strategy on patients ' physical functioning , coping strategy , and beliefs regarding their low back pain was studied . SUBJECTS One hundred thirteen primary care physical therapists treated a total of 500 patients . METHODS The physical therapists were r and omly assigned to 1 of 2 groups . The control group received the guidelines by mail ( st and ard passive method of dissemination ) . The intervention group , in contrast , received an additional active training strategy consisting of 2 sessions with education , group discussion , role playing , feedback , and reminders .  Patients with low back pain , treated by the participating therapists , completed question naires on physical functioning , pain , sick leave , coping , and beliefs . RESULTS Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks . Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up . DISCUSSION AND CONCLUSION The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain . Active implementation strategies are not recommended if patient outcomes are to be improved BACKGROUND AND AIMS Stroke patients experience multiple impairments which impair ability to eat and render them vulnerable to the deleterious sequelae of malnutrition . This study aim ed to develop , implement and evaluate evidence -based guidelines for nutrition support following acute stroke using a multifaceted change management strategy . METHODS Prospect i ve quasi-experimental design . Documentation of two groups of 200 acute stroke patients admitted to medical and care of the elderly wards of an acute NHS Trust in South London was surveyed using a checklist before and after implementation of 24 guidelines for nutritional screening , assessment and support . Guidelines were based on systematic literature review and developed by consensus in a nurse-led multiprofessional group ; implemented via a context -specific , multifaceted strategy including opinion leaders and educational programmes linked to audit and feedback . STAFF OUTCOMES : Compliance with guidelines by doctors , nurses , therapists . PATIENT OUTCOMES Changes in Barthel Index scores and Body Mass Index in hospital , infective complications , length of stay , discharge destination . RESULTS Statistically significant improvements in compliance with 15 guidelines occurred in the post-test group . Infective episodes showed a significant reduction in the post-test group but other patient outcomes were unaffected . CONCLUSIONS Implementation of evidence -based guidelines for nutritional support following acute stroke using a multifaceted strategy was associated with improvements in documented practice and selected patient outcomes Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 PURPOSE To determine the effectiveness of two dissemination and implementation strategies to implement a national guideline for epilepsy management in primary care setting s. METHODS Three-arm cluster-r and omized controlled trial . The participants were general practitioners from 68 practice s in Tayside , Scotl and , and 1,133 of their patients with self-reported epilepsy treated with antiepileptic medications ( AEDs ) . Practice s were r and omized blind to a control , intermediate , or intensive intervention . CONTROL Postal dissemination of a nationally developed clinical guideline . Intermediate intervention : Postal dissemination of the guideline supported by interactive , accredited workshops , and dedicated , structured protocol documents . Intensive intervention : Intermediate intervention plus a nurse specialist who supported and educated practice s in the establishment of epilepsy review clinics . The primary outcome was the SF-36 health-related quality -of-life instrument . Secondary measures were a battery of prevali date d epilepsy-specific quality -of-life instruments . These were administered at baseline and after the intervention phase . Process of care was assessed by case-note review on number of review meetings and counseling sessions for epilepsy before and after the interventions . RESULTS None of the intervention groups showed any change in the primary or secondary outcome measures or process-of-care measures . CONCLUSIONS None of the intervention strategies led to improvements in patient quality of life or quality of epilepsy care . Further research is needed to discover why the interventions failed , to identify barriers to adoption of guidelines , and to develop strategies that might improve implementation and uptake in the future Background The recent development and publication of evidence -based clinical practice guidelines ( CPGs ) for acute low back pain ( LBP ) has result ed in evidence -based recommendations that , if implemented , have the potential to improve the quality and safety of care for acute LBP . While a strategy has been specified for dissemination of the CPG for acute LBP in Australia , there is no accompanying plan for active implementation . Evidence regarding the cost-effectiveness of active implementation of CPGs for acute LBP is sparse . The IMPLEMENT study will consider the incremental benefits and costs of progressing beyond development and dissemination to implementation . Methods / design Cost-effectiveness and cost-utility analyses alongside the IMPLEMENT cluster r and omised controlled trial ( C RCT ) from a societal perspective to quantify the additional costs ( savings ) and health gains associated with a targeted implementation strategy as compared with access to the CPG via dissemination only . Discussion The protocol provided here registers our intent to conduct an economic evaluation alongside the IMPLEMENT study , facilitates peer- review of proposed methods and provides a transparent statement of planned analyses . Trial registration Australian New Zeal and Clinical Trials Registry QUESTION Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash ? DESIGN Cluster-r and omised trial . PARTICIPANTS Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients ( 4 dropouts ) who presented to them with acute whiplash . INTERVENTION The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them . OUTCOME MEASURES The primary outcome was patient disability , measured using the Functional Rating Index , collected on admission to the trial and at 1.5 , 3 , 6 and 12 months . Physiotherapist knowledge about the guidelines was measured using a custom-made question naire . Physiotherapist practice and cost of care were measured by audit of patient notes . RESULTS There were no significant differences between groups for any of the patient outcomes at any time . The implementation patients had 0.6 points ( 95 % CI -7.8 to 6.6 ) less disability than the dissemination patients at 12 months ; 44 % more physiotherapists in the implementation group reported that they prescribed two out of the five guideline -recommended treatments ; and 32 % more physiotherapists actually prescribed them . The cost of care for patients in the implementation group was $ 255 ( 95 % CI -1505 to 996 ) less than for patients in the dissemination group . CONCLUSION Although the active implementation program increased guideline -consistent practice , patient outcomes and cost of care were not affected Background Depression is a common mental health disorder for which clinical practice guidelines have been developed . Prior systematic review s have identified complex organizational interventions , such as collaborative care , as effective for guideline implementation ; yet , many healthcare delivery organizations are interested in less re source -intensive methods to increase provider adherence to guidelines and guideline -concordant practice s. The objective of this systematic review was to assess the effectiveness of  healthcare provider  interventions that aim to increase adherence to evidence -based treatment of depression in routine clinical practice . Methods We search ed five data bases through August 2017 using a comprehensive search strategy to identify English- language r and omized controlled trials ( RCTs ) in the quality improvement , implementation science , and behavior change literature that evaluated outpatient provider interventions , in the absence of practice re design efforts , to increase adherence to treatment guidelines or guideline -concordant practice s for depression . We used meta- analysis to summarize odds ratios , st and ardized mean differences , and incidence rate ratios , and assessed quality of evidence ( QoE ) using the GRADE approach . Results Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline -concordant practice s met inclusion criteria . Studies evaluated diverse provider interventions , including distributing guidelines to providers , education/training such as academic detailing , and combinations of education with other components such as targeting implementation barriers . Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies . There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes . We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies . Effects on patients ’ health in these RCTs were inconsistent across studies and outcomes . Conclusions Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines . Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research . Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence -based treatment for depression . Trial registration PROSPERO record CRD42017060460 on Background Hypertension and diabetes , key risk factors for cardiovascular disease , are significant health problems globally . As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000 , clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011 . This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting . Methods A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level , as well as to gain insight into how practitioners view the usability and practicality of the guidelines . Ten family health centres were r and omly chosen from a list of all the family health centres ( n = 136 ) located in Ulaanbaatar City . In each centre , a focus group discussion with nurses ( n = 20 ) and individual interviews with practice doctors ( n = 10 ) and practice managers ( n = 10 ) were conducted . Data was analysed using a thematic approach utilising the Theoretical Domains Framework . Results The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice . They also reported having attended guideline training sessions which were focused on practice skill development . The majority of participants expressed satisfaction with the wide range of re sources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines . The re sources , supplied from 2011 onwards , included screening devices , equipment for blood tests , medications and educational material s. Other enablers were the participants ’ commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines . Primary care providers reported a number of challenges in implementing the guidelines , including frustration caused by increased workload and long waiting times , time constraints , difficulties with conflicting tasks and low patient health literacy . Conclusions This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low re source primary care setting s. It also offers some key lessons that might be carefully considered when other evidence -based clinical guidelines are to be put into effect in low re source setting s and elsewhere Background Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community setting s. Methods A naturalistic study with a prospect i ve , before and after design documented the implementation of six newly developed nursing best practice guidelines ( asthma , breastfeeding , delirium-dementia-depression ( DDD ) , foot complications in diabetes , smoking cessation and venous leg ulcers ) . Eleven health care organisations were selected for a one-year project . At each site , clinical re source nurses ( CRNs ) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities ( i.e. education sessions , policy review ) . Process and patient outcomes were assessed by chart audit ( n = 681 pre-implementation , 592 post-implementation ) . Outcomes were also assessed for four of six topics by in-hospital/home interviews ( n = 261 pre-implementation , 232 post-implementation ) and follow-up telephone interviews ( n = 152 pre , 121 post ) . Interviews were conducted with 83/95 ( 87 % ) CRN 's , nurses and administrators to describe recommendations selected , strategies used and participants ' perceived facilitators and barriers to guideline implementation . Results While statistically significant improvements in 5 % to 83 % of indicators were observed in each organization , more than 80 % of indicators for breastfeeding , DDD and smoking cessation did not change . Statistically significant improvements were found in > 50 % of indicators for asthma ( 52 % ) , diabetes foot care ( 83 % ) and venous leg ulcers ( 60 % ) . Organizations with > 50 % improvements reported two unique implementation strategies which included h and s-on skill practice sessions for nurses and the development of new patient education material s. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time , workload pressure and staff resistance . Conclusion Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse setting s yet many indicators remained unchanged . Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare BACKGROUND Urinary tract infection is the most frequent health care-associated complication . We hypothesized that the implementation of a multifaceted prevention strategy could decrease its incidence after surgery . METHODS In a controlled , prospect i ve , before-after intervention trial with 1328 adult patients scheduled for orthopedic or abdominal surgery , nosocomial infection surveillance was conducted until hospital discharge . A multifaceted intervention including specifically tailored , locally developed guidelines for the prevention of urinary tract infection was implemented for orthopedic surgery patients , and abdominal surgery patients served as control subjects . Infectious and noninfectious complications , adherence to guidelines , and antibiotic use  were monitored before and after the intervention and again 2 years later . RESULTS The incidence of urinary tract infection decreased from 10.4 to 3.9 episodes per 100 patients in the intervention group ( incidence-density ratio , 0.41 ; 95 % CI , 0.20 - 0.79 ; P=.004 ) . Adherence to guidelines was 82.2 % . Both the frequency and the duration of urinary catheterization decreased following the intervention . Recourse to  antibiotic therapy  after surgery dropped in the intervention group from 17.9 to 15.6 defined daily doses per 100 patient-days ( P<.005 ) because of a reduced need for the treatment of urinary tract infection ( P<.001 ) . Follow-up after 2 years revealed a sustained impact of the strategy and a subsequent low use of antibiotics , consistent with stable adherence to guidelines ( 80.8 % ) . CONCLUSIONS A multifaceted prevention strategy can dramatically decrease postoperative urinary tract infection and contribute to the reduction of the overall use of antibiotics after surgery Background Electronic guideline -based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines . A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services . Methods A systematic literature search ( 1990 to December 2008 ) of the English literature indexed in the Medline data base , Embase , the Cochrane Central Register of Controlled Trials , and CRD ( DARE , HTA and NHS EED data bases ) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care setting s. Important inclusion criterions were the multidimensionality of the guideline ( the guideline needed to consist of several aspects or steps ) and real-time interaction with the system during consultation . Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier review s were excluded . Two comparisons were considered : electronic multidimensional guidelines versus usual care ( comparison one ) and electronic multidimensional guidelines versus other guideline implementation methods ( comparison two ) . Results Twenty-seven publications were selected for analysis in this systematic review . Most design s were cluster r and omized controlled trials investigating process outcomes more than patient outcomes . With success defined as at least 50 % of the outcome variables being significant , none of the studies were successful in improving patient outcomes . Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group ( comparison one ) . No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found , neither for the patient outcomes nor for the process outcomes ( comparison two ) . Conclusions There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines . After more than a decade of development of numerous electronic systems , research on the most effective implementation strategy for this kind of guideline -based decision support systems is still lacking . This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care
Meta-analyses did not reveal any differences in effect between multifaceted strategies and controls .
Conclusion This review showed that multifaceted strategies for the implementation of neck and /or back pain guidelines in health care do not significantly improve professional behaviour outcomes .
No effects on patient outcomes or cost of care could be found .
Background For the optimal use of clinical guidelines in daily practice , mere distribution of guidelines and material s is not enough , and active implementation is needed .
This review investigated the effectiveness of multifaceted implementation strategies compared to minimal , single , or no implementation strategy for the implementation of non-specific low back and /or neck pain guidelines in health care .