Systematic review of implementation strategies
Michelle Irving and co-authors undertook a systematic review on the implementation of evidence-based medicine in chronic kidney disease (CKD). A comprehensive search of MEDLINE and EMBASE from January 1966 to June 2007 was undertaken. Twenty two studies, including 7 randomized controlled trials and 15 before-after studies were included. Four main interventions were evaluated in over 700 dialysis centres/hospitals or general practices:
- audit and feedback;
- computerized decision support system (CDSS);
- opinion leader/multidisciplinary team;
- passive dissemination of guidelines;
Due to heterogeneity, a formal meta-analysis was not possible.
Audit and feedback significantly increased 14 of the 25 study outcomes with a median improvement of 2.5% (range: -4.5-48.4%). CDSS significantly increased 3 of the 4 study outcomes with a median improvement of 12.8% (range: 1.1-42.1%). Opinion leader/multidisciplinary team significantly increased 24 of the 30 study outcomes with a median improvement of 8.2 %( range: -4.0-79.8%). Dissemination of guidelines resulted in a median improvement in study outcomes of 2.7% (range 0.5-25.8).
We found that well planned and executed interventions were able to improve CKD management to varying degrees. More active and multifaceted interventions were more effective than passive dissemination and single strategy methods. Interventions need to address all barriers to implementation and provide adequate workforce assistance. Specific quality indicator targets were associated with greater improvements in care.