title: Provider adherence to implementation of clinical practice guidelines for neurogenic bowel in adults with spinal cord injury.
abstract: OBJECTIVE
  Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the "Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine
  
  
  METHODS
  CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention.
  
  
  RESULTS
  Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1.
  
  
  CONCLUSIONS
  While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.
authors.affiliation: Spinal Cord Injury Service, Veterans Affairs North Texas Health Care System and University of Texas-Southwestern Medical Center, Dallas 75216, USA. lance.goetz@med.va.gov
authors.forename: Lance L
authors.initials: LL
authors.lastname: Goetz
authors.forename: Audrey L
authors.initials: AL
authors.lastname: Nelson
authors.forename: Marylou
authors.initials: M
authors.lastname: Guihan
authors.forename: Helen T
authors.initials: HT
authors.lastname: Bosshart
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Harrow
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Gerhart
authors.forename: Barbara
authors.initials: B
authors.lastname: Krasnicka
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Burns
mesh_terms: D000368:Aged; D003108:Colonic Diseases / Q000209:etiology* / Q000628:therapy*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D005791:Patient Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012189:Retrospective Studies; D012648:Self Care; D013119:Spinal Cord Injuries / Q000150:complications* / Q000503:physiopathology; D014728:Veterans