Elsevier

The Lancet

Volume 362, Issue 9391, 11 October 2003, Pages 1225-1230
The Lancet

Series
From best evidence to best practice: effective implementation of change in patients' care

https://doi.org/10.1016/S0140-6736(03)14546-1Get rights and content

Summary

Major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. Data show that many patients do not receive appropriate care, or receive unnecessary or harmful care. Many approaches claim to offer solutions to this problem; which ones are as yet the most effective and efficient is unclear. We aim to provide an overview of present knowledge about initiatives to changing medical practice. Substantial evidence suggests that to change behaviour is possible, but this change generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and facilitators to change. In general, evidence shows that none of the approaches for transferring evidence to practice is superior to all changes in all situations.

Section snippets

How do characteristics of evidence affect its uptake?

Characteristics of research evidence might affect whether it is used in clinical practice. Some research findings are easily adopted. For example, conservative treatment in children with acute otitis media proved to be as effective as myringotomy. Publication of this finding in a scientific journal was sufficient for almost all doctors to stop doing this procedure within a short time, probably because the study was triggered by practitioners' scepticism of the benefits of the established

Complexity of performance change: the case of hand hygiene

Reduction in hospital-acquired infections is one of the priorities in health care in many countries. These infections are estimated to affect about one in 11 patients, with 13% mortality and a lengthened stay in hospital of a factor of 2·5.22 The extra cost per patient with an infection in the UK is about £3000. Between 15% and 30% of infections are considered preventable—eg, by improved hand hygiene.

We have been aware of the importance of handwashing since the mid 1800s, when Ignaz Philipp

Barriers and facilitators to evidence uptake

Analyses of barriers to changing practice, such as a review of 76 studies in doctors,28 have shown that obstacles to change in practice can arise at different stages in the health-care system, at the level of the patient, the individual professional, the health-care team, the health-care organisation, or the wider environment.29, 30, 31 Most theories on implementation of evidence in health care emphasise the importance of developing a good understanding of such obstacles to develop an effective

Transfer of evidence into practice: interventions

The number of original studies and systematic reviews about the effectiveness of different interventions to change clinical practice is growing, which can help in selection of appropriate strategies.38, 39, 40, 41 Main conclusions from an overview of 54 reviews11, 42, 43 are outlined below.

Change is possible when a well-designed intervention is used; most interventions studied had some effects (average of about 10% for main targets). However, none of the interventions is superior for all

Educational strategies

At least nine systematic reviews have addressed distribution of educational materials to professionals (table 2).55, 58, 60, 61, 70, 77, 78, 85, 96 However, the number of studies with enough power, correct analysis, and substantial effects was small, leading reviewers to conclude that the effects of educational materials is limited.60 A systematic review of guideline implementation strategies noted a median improvement of 8% across four cluster randomised trials.11 In view of the feasibility

Interventions aimed at improving hand hygiene

What interventions might be useful to improve hand hygiene practices? We noted one specific systematic review of 22 studies assessing interventions to improve hand hygiene.101 Of these, 15 took place on intensive care units and only three were randomised controlled trials. The main findings (table 3) are outlined below.

Educational interventions (training sessions, newsletters, classes, and videos) were used in 11 studies and seemed to have only a short-term effect on handwashing practice.

Conclusions and messages

Sometimes, the step from best evidence to best practice is simple; however, most of the time it is not, and we need various strategies targeting obstacles to change at different levels, which could even present conflicting values for individual practitioners.100 Therefore, changes in clinical practice are only partly within doctors' control; the prevailing professional and organisational culture towards quality determines the outcome to a large extent.100 Nevertheless, doctors can learn

References (103)

  • T Bodenheimer

    The American health care system; the movement for improved quality in health care

    N Engl J Med

    (1999)
  • M Schuster et al.

    How good is the quality of health care in the United States?

    Milbank Q

    (1998)
  • R Grol

    Successes and failures in the implementation of evidence-based guidelines for clinical practice

    Med Care

    (2001)
  • T Shaneyfelt

    Building bridges to quality

    JAMA

    (2001)
  • G Gyatt et al.

    Jaschke R, Cook D, Haynes B. Practitioners of evidence-based care

    BMJ

    (2000)
  • Lanier DC, Roland M, Burstin H, Knottnerus JA. Doctor performance and public accountability. Lancet (in...
  • R Grol

    Improving the quality of medical care

    JAMA

    (2001)
  • B Bushman

    Vote counting methods in meta-analysis

  • J Grimshaw et al.

    Changing physician's behaviour: what works and thoughts on getting more things to work

    J Cont Educ Health Prof

    (2002)
  • C Van Weel et al.

    De bijdrage van klinisch wetenschappelijk onderzoek aan een betere patiëntenzorg

    Ned Tijdschr Geneesk

    (2003)
  • S Woolf et al.

    Potential benefits, limitations, and harms of clinical guidelines

    BMJ

    (1999)
  • D Davis et al.

    Translating guidelines into practice: a systematic review of theoretical concepts, practical experience and research evidence in the adoptions in clinical practice

    CMAJ

    (1997)
  • R Grilli et al.

    Evaluating the message: the relationship between compliance rate and the subject of a practice guideline

    Med Care

    (1994)
  • R Grol et al.

    Attributes of clinical guidelines that influence use of guidelines in general practice: observational study

    BMJ

    (1998)
  • J Burgers et al.

    Characterics of effective clinical guidelines for general practice

    Br J Gen Pract

    (2003)
  • T Shaneyfelt et al.

    Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature

    JAMA

    (1999)
  • Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project

    Qual Saf Health Care

    (2003)
  • J Burgers et al.

    Characteristics of high-quality guidelines: evaluations of 86 clinical guidelines developed in ten European countries and Canada

    Int J Techn Ass Health Care

    (2002)
  • S Stone

    Hand hygiene: the case for evidence based education

    J R Soc Med

    (2001)
  • R Pratt et al.

    The EPIC project: developing national evidence-based guidelines for preventing healthcare associated interventions

    J Hosp Infect

    (2001)
  • Handwashing: a modern measure with big effects

    BMJ

    (1999)
  • L Teare et al.

    Hand hygiene

    BMJ

    (2001)
  • M Cabana et al.

    Why don't physicians follow clinical practice guidelines

    JAMA

    (1999)
  • R Grol

    Beliefs and evidence in changing clinical practice

    BMJ

    (1997)
  • A Haines et al.

    Integrating research evidence into practice

  • A Oxman et al.

    An overview of strategies to promote implementation of evidence-based health care

  • S Hugonnet et al.

    Hand hygiene: beliefs or science?

    Clin Microbiol Infect

    (2000)
  • D Pittet

    Improving compliance with hand hygiene in hospitals

    Inf Control Hosp Epidemiol

    (2000)
  • E Ferlie et al.

    Improving the quality of health care in the United Kingdom and the United States: a framework for change

    Milbank Q

    (2001)
  • R Garside

    Organisational context for quality: lessons from the field of organizational development and change management

    Qual Health Care

    (1998)
  • J Grimshaw et al.

    Developing and implementing clinical practice guidelines

    Eff Bull

    (1995)
  • J Lomas et al.

    A taxonomy and critical review of tested strategies of the application of clinical practice recommendations: from “official” to “individual” clinical policy

    Am J Prev Med

    (1988)
  • L Bero et al.

    Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings

    BMJ

    (1998)
  • R Grol et al.

    Implementation, effective change in patient care (in Dutch)

    (2001)
  • J Grimshaw et al.

    Changing provider behavior: an overview of systematic reviews of interventions

    Med Care

    (2001)
  • SM Austin et al.

    Effect of physician reminders on preventive care: meta-analysis of randomized clinical trials

    Appl Med Care

    (1994)
  • GM Anderson et al.

    Strategies for improving prescribing practice

    CMAJ

    (1996)
  • EA Balas et al.

    The clinical value of computerized information services: a review of 98 randomized clinical trials

    Arch Fam Med

    (1996)
  • EA Balas et al.

    Effect of physician profiling on utilization. Meta-analysis of randomized clinical trials

    J Gen Intern Med

    (1996)
  • JS Beaudry

    The effectiveness of continuing medical education: a quantitative synthesis

    J Contin Educ Health Prof

    (1989)
  • Cited by (3425)

    • Removing barriers to plant-based diets: Assisting doctors with vegan patients

      2024, Journal of Behavioral and Experimental Economics
    View all citing articles on Scopus
    View full text