The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this ...problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs.
To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective.
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites.
We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area.
Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines.
We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service.
Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.
A low ankle brachial index (ABI) indicates atherosclerosis and an increased risk of cardiovascular and cerebrovascular events. Screening for a low ABI can identify an asymptomatic higher risk group ...potentially amenable to preventive treatments.
To determine the effectiveness of aspirin in preventing events in people with a low ABI identified on screening the general population.
The Aspirin for Asymptomatic Atherosclerosis trial was an intention-to-treat double-blind randomized controlled trial conducted from April 1998 to October 2008, involving 28,980 men and women aged 50 to 75 years living in central Scotland, free of clinical cardiovascular disease, recruited from a community health registry, and had an ABI screening test. Of those, 3350 with a low ABI (< or = 0.95) were entered into the trial, which was powered to detect a 25% proportional risk reduction in events.
Once daily 100 mg aspirin (enteric coated) or placebo.
The primary end point was a composite of initial fatal or nonfatal coronary event or stroke or revascularization. Two secondary end points were (1) all initial vascular events defined as a composite of a primary end point event or angina, intermittent claudication, or transient ischemic attack; and (2) all-cause mortality.
After a mean (SD) follow-up of 8.2 (1.6) years, 357 participants had a primary end point event (13.5 per 1000 person-years, 95% confidence interval CI, 12.2-15.0). No statistically significant difference was found between groups (13.7 events per 1000 person-years in the aspirin group vs 13.3 in the placebo group; hazard ratio HR, 1.03; 95% CI, 0.84-1.27). A vascular event comprising the secondary end point occurred in 578 participants (22.8 per 1000 person-years; 95% CI, 21.0-24.8) and no statistically significant difference between groups (22.8 events per 1000 person-years in the aspirin group vs 22.9 in the placebo group; HR, 1.00; 95% CI, 0.85-1.17). There was no significant difference in all-cause mortality between groups (176 vs 186 deaths, respectively; HR, 0.95; 95% CI, 0.77-1.16). An initial event of major hemorrhage requiring admission to hospital occurred in 34 participants (2.5 per 1000 person-years) in the aspirin group and 20 (1.5 per 1000 person-years) in the placebo group (HR, 1.71; 95% CI, 0.99-2.97).
Among participants without clinical cardiovascular disease, identified with a low ABI based on screening a general population, the administration of aspirin compared with placebo did not result in a significant reduction in vascular events.
isrctn.org Identifier: ISRCTN66587262.
Lipid-lowering therapy is recommended for secondary prevention in people with coronary artery disease. It may also reduce cardiovascular events and/or local disease progression in people with lower ...limb peripheral arterial disease (PAD).
To assess the effects of lipid-lowering therapy on all-cause mortality, cardiovascular events and local disease progression in patients with PAD of the lower limb.
The authors searched The Cochrane Peripheral Vascular Diseases Group's Specialised Register (last searched February 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 2, 2007) for publications describing randomised controlled trials of lipid-lowering therapy in peripheral arterial disease of the lower limb.
Randomised controlled trials of lipid-lowering therapy in patients with PAD of the lower limb.
Three authors independently assessed trial quality and extracted data.
Eighteen trials were included, involving a total of 10,049 participants. Trials differed considerably in their inclusion criteria, outcomes measured, and type of lipid-lowering therapy used. Only one trial (PQRST) reported a detrimental effect of active treatment on blood lipid/lipoprotein levels. The pooled results from all eligible trials indicated that lipid-lowering therapy had no statistically significant effect on overall mortality (Odds Ratio (OR) 0.86; 95% Confidence Interval (CI) 0.49 to 1.50) or on total cardiovascular events (OR 0.8; 95% CI 0.59 to 1.09). However, subgroup analysis which excluded PQRST showed that lipid-lowering therapy significantly reduced the risk of total cardiovascular events (OR 0.74; CI 0.55 to 0.98). This was primarily due to a positive effect on total coronary events (OR 0.76; 95% CI 0.67 to 0.87). Greatest evidence of effectiveness came from the use of simvastatin in people with a blood cholesterol >/= 3.5 mmol/litre (HPS). Pooling of the results from several small trials on a range of different lipid-lowering agents indicated an improvement in total walking distance (Weighted Mean Difference (WMD) 152 m; 95% CI 32.11 to 271.88) and pain-free walking distance (WMD 89.76 m; 95% CI 30.05 to 149.47) but no significant impact on ankle brachial index (WMD 0.04; 95% CI -0.01 to 0.09).
Lipid-lowering therapy is effective in reducing cardiovascular mortality and morbidity in people with PAD. It may also improve local symptoms. Until further evidence on the relative effectiveness of different lipid-lowering agents is available, use of a statin in people with PAD and a blood cholesterol level >/=3.5 mmol/litre is most indicated.
Commercially available preparations of garlic have been reported to have beneficial effects on some of the risk factors associated with atherosclerosis.
To assess the effects of garlic (both dried ...and non-powdered preparations) for the treatment of peripheral arterial occlusive disease.
For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12).
Randomised trials of garlic therapy in patients with lower limb atherosclerosis were included. The main outcomes were objective measures of progression of underlying atherosclerosis (e.g. ankle pressure measurements, treadmill testing) and subjective measures (e.g. symptom progression).
Two review authors (RJ and JK) independently extracted data and assessed trial quality. One author (RJ) contacted investigators to obtain information needed for the review that could not be found in published reports.
One eligible trial with 78 participants was found. Both men and women (aged 40 to 75) were included. The follow-up period was short, 12 weeks only.After twelve weeks of treatment, pain-free walking distance increased from 161 to 207 metres in the group receiving garlic and from 172 to 203 metres in the placebo group. This was not a statistically significant difference. There was no difference in change of systolic or diastolic blood pressure, heart rate, ankle and brachial pressures. No severe side effects were observed and nine patients taking garlic (28%) and four patients taking placebo (12%) complained of a noticeable garlic smell.Three trials were excluded from the review because they did not include any clinical measurements.
One small trial of short duration found no statistically significant effect of garlic on walking distance.
There is accumulating evidence that steroid sex hormones have a beneficial effect on a number of risk factors for peripheral arterial disease.
The objective of this review was to determine whether ...exogenous steroid sex hormones are an effective treatment for patients with lower limb atherosclerosis.
For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched August 2012) and CENTRAL 2012, Issue 7. There were no language restrictions.
We selected randomised or quasi-randomised controlled trials of steroid sex hormones in patients with lower limb atherosclerosis.
Both authors extracted data and assessed trial quality independently. Whenever possible investigators were contacted to obtain information needed for the review that could not be found in published reports.
Four trials appeared to meet the inclusion criteria, but one was excluded because of poor methodology. The three remaining trials compared testosterone treatment with placebo in a total of 109 subjects with intermittent claudication or critical leg ischaemia. The most recent trial to meet the inclusion criteria dated from 1971. No trials were available which investigated the potentially beneficial effects of oestrogenic hormones in women with lower limb atherosclerosis.Testosterone therapy produced no significant improvement in tests of walking distance or in a variety of other objective tests for peripheral arterial disease, including venous filling time, muscle blood flow and plethysmography. The relative risk for subjective improvement in symptoms using the combined trial results was also non-significant (relative risk (RR) 1.10, 95% confidence interval (CI) 0.81 to 1.48).
There is no evidence to date that short-term testosterone treatment is beneficial in subjects with lower limb atherosclerosis. However, this might reflect limited data rather than the lack of a real effect.
... a formal system for accrediting producers of guidance that will enable the best and most trusted sources to be easily recognisable through an accreditation mark.
Leng G C (Wolfson Unit for Prevention of Peripheral Vascular Diseases, Department of Public Health Sciences, The Medical School, Teviot Place, University of Edinburgh, EH8 9AG, UK), Lee A J, Fowkes F ...G R, Whiteman M, Dunbar J, Housley E and Ruckley C V. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. International Journal of Epidemiology 1996; 25: 1172–1181. Background Intermittent claudication is associated with a poor prognosis, but less is known of the risks associated with asymptomatic peripheral arterial disease. The aims of this study were to determine the incidence and natural history of claudication, and the incidence of cardiovascular events in symptomatic and asymptomatic peripheral arterial disease. Methods In 1988, 1592 subjects aged 55–74 years were selected randomly from the age-sex registers of 10 general practices in Edinburgh, Scotland. The presence of peripheral arterial disease was determined by the World Health Organization questionnaire on Intermittent claudication, the ankle brachial pressure Index and a reactive hyperaemia test. This cohort was followed prospectively over 5 years for subsequent cardiovascular events and death. Results One hundred and sixteen new cases of claudication were identified (incidence density 15.5 per 1000 person-years). Of those with claudication at baseline, 28.8% still had pain after 5 years, 8.2% underwent vascular surgery or amputation, and 1.4% developed leg ulceration. Claudicants had a significantly increased risk of developing angina compared with normals (RR: 2.31, 95% Cl: 1.04–5.10), and asymptomatic subjects had a slightly Increased risk of myo-cardial infarction and stroke. Deaths from cardiovascular disease were more likely in both claudicants (RR: 2.67, 95% Cl: 1.34–5.29) and subjects with major (RR: 2.08, 95% CI: 1.13–3.83) or minor asymptomatic disease (RR: 1.74, 95% Cl: 1.09–2.76). Subjects with major asymptomatic disease also had an increased risk of non-cardiovascular death (RR: 2.19, 95% Cl: 1.33–3.59), and therefore had the highest overall risk of death (RR: 2.44, 95% Cl: 1.59–3.74). Conclusions Subjects with asymptomatic peripheral arterial disease appear to have the same increased risk of cardiovascular events and death found In claudicants.
Abdominal aortic aneurysm (AAA) is found in 5% to 10% of men aged 65 to 79 years. The major complication is rupture which presents as a surgical emergency. The mortality after rupture is high, 80% ...for patients reaching hospital and 50% for those undergoing surgery for emergency repair. Currently elective surgical repair is recommended for aneurysms discovered to be larger than 5.5 cm to prevent rupture. There is interest in population screening to detect, monitor and repair abdominal aortic aneurysms before rupture.
To determine the effects of screening asymptomatic individuals for AAA on mortality, subsequent treatment, quality of life and cost effectiveness of screening.
The Cochrane Peripheral Vascular Diseases Group searched their Trials Register (last searched 26 January 2007) and CENTRAL (last searched Issue 1, 2007).
Randomised controlled trials of population screening for AAA.
Two authors independently assessed trials and extracted data.
Four studies involving 127,891 men and 9,342 women were included in this review. Only one study included women. Results for men and women were analysed separately. Three to five years after screening there was no significant difference in all-cause mortality between screened and unscreened groups for men or women (men, odds ratio (OR) 0.95; 95% Confidence interval (CI) 0.85 to 1.07; for women OR 1.06; 95% CI 0.93 to 1.21). There was a significant decrease in mortality from AAA in men (OR 0.60; 95% CI 0.47 to 0.78), but not for women (OR 1.99; 95% CI 0.36 to 10.88). In this analysis mortality includes death from rupture and from emergency or elective surgery for aneurysm repair. There was also a decreased incidence of ruptured aneurysm in men (OR 0.45; 95% CI 0.21 to 0.99) but not in women (OR 1.49; 95% CI 0.25 to 8.94). There was a significant increase in surgery for AAA in men (OR 2.03; 95% CI 1.59 to 2.59). This was not reported in women. There were no data on life expectancy, complications of surgery or subjective quality of life.
There is evidence of a significant reduction in mortality from AAA in men aged 65 to 79 years who undergo ultrasound screening. There is insufficient evidence to demonstrate benefit in women. The cost effectiveness may be acceptable, but needs further expert analysis. These findings need careful consideration in judging whether a co-ordinated population-based screening programme should be introduced.
The report recommended that: ‘NICE will manage the synthesis and spread of knowledge through NHS Evidence - a new single portal through which anyone will be able to access clinical and non-clinical ...evidence and best practice, both what high quality care looks like and how to deliver it’. Table 1 Clinically relevant information sources Clinical* Guidelines * Systematic reviews * Other synthesised content (summaries and overviews) * Primary research and on-going trialsCommissioning and improvement* Service guidance * Tools and models * Care pathways * Indicators and metrics * Improvement informationDrugs and technologies* Prescribing and safety information * Technology appraisals * New drug information * Devices, diagnostics and interventional procedure guidance To achieve the ambition of managing the synthesis and spread of knowledge to this range of audiences, there are three main challenges that NHS Evidence needs to be able to address: (i) identifying the most relevant, high-quality information; (ii) making it readily accessible; and (iii) supporting the use of evidence in practice. Producers are formally invited to provide the NHS Evidence Advisory Committee with a submission against internationally agreed criteria for guideline development.3 The accreditation scheme may in future be extended to other types of information, such as systematic reviews. 2.
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