title: Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review.
abstract: BACKGROUND
  Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect the implementation of guidelines, and secondly, to provide insight into the "state-of-the-art" regarding research within this field.
  
  
  METHODS
  A search of five literature databases and one website was performed to find relevant existing systematic reviews or meta-reviews. Subsequently, a two-step inclusion process was conducted: (1) screening on the basis of references and abstracts and (2) screening based on full-text papers. After that, relevant data from the included reviews were extracted and the methodological quality of the reviews was assessed by using the Quality Assessment Checklist for Reviews.
  
  
  RESULTS
  Twelve systematic reviews met our inclusion criteria. No previous systematic meta-reviews meeting all our inclusion criteria were found. Two of the twelve reviews scored high on the checklist used, indicating only "minimal" or "minor flaws". The other ten reviews scored in the lowest of middle ranges, indicating "extensive" or "major" flaws. A substantial proportion (although not all) of the reviews indicates that effective strategies often have multiple components and that the use of one single strategy, such as reminders only or an educational intervention, is less effective. Besides, characteristics of the guidelines themselves affect actual use. For instance, guidelines that are easy to understand, can easily be tried out, and do not require specific resources, have a greater chance of implementation. In addition, characteristics of professionals - e.g., awareness of the existence of the guideline and familiarity with its content - likewise affect implementation. Furthermore, patient characteristics appear to exert influence: for instance, co-morbidity reduces the chance that guidelines are followed. Finally, environmental characteristics may influence guideline implementation. For example, a lack of support from peers or superiors, as well as insufficient staff and time, appear to be the main impediments.
  
  
  CONCLUSIONS
  Existing reviews describe various factors that influence whether guidelines are actually used. However, the evidence base is still thin, and future sound research - for instance comparing combinations of implementation strategies versus single strategies - is needed.
authors.affiliation: NIVEL - Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands. a.francke@nivel.nl
authors.forename: Anneke L
authors.initials: AL
authors.lastname: Francke
authors.forename: Marieke C
authors.initials: MC
authors.lastname: Smit
authors.forename: Anke J E
authors.initials: AJ
authors.lastname: de Veer
authors.forename: Patriek
authors.initials: P
authors.lastname: Mistiaen
mesh_terms: D003695:Delivery of Health Care / Q000592:standards*; D004059:Diffusion of Innovation; D019983:Guideline Adherence; D006801:Humans; D009426:Netherlands; D017410:Practice Guidelines as Topic
references.citation: Health Technol Assess. 1998;2(3):i-iv, 1-88
references.pmid: 9561895
references.citation: BMJ. 1996 Jan 13;312(7023):71-2
references.pmid: 8555924
references.citation: Health Res Policy Syst. 2006 Dec 01;4:17
references.pmid: 17140442
references.citation: J Health Serv Res Policy. 1999 Oct;4(4):236-48
references.pmid: 10623041
references.citation: Health Res Policy Syst. 2006 Nov 29;4:14
references.pmid: 17134481
references.citation: CMAJ. 1997 Aug 15;157(4):408-16
references.pmid: 9275952
references.citation: Jt Comm J Qual Improv. 2000 Sep;26(9):525-37
references.pmid: 10983293
references.citation: Health Res Policy Syst. 2006 Dec 01;4:16
references.pmid: 17140441
references.citation: BMJ. 1999 Feb 20;318(7182):527-30
references.pmid: 10024268
references.citation: Health Res Policy Syst. 2006 Dec 08;4:28
references.pmid: 17156460
references.citation: BMC Health Serv Res. 2003 Mar 24;3(1):8
references.pmid: 12659640
references.citation: N Engl J Med. 2004 Dec 30;351(27):2870-4
references.pmid: 15625341
references.citation: Health Res Policy Syst. 2006 Dec 08;4:25
references.pmid: 17156457
references.citation: Health Res Policy Syst. 2006 Nov 21;4:13
references.pmid: 17118181
references.citation: Nurs Stand. 2004 Aug 25-31;18(50):33-40
references.pmid: 15384305
references.citation: J Gen Intern Med. 2006 Feb;21 Suppl 2:S14-20
references.pmid: 16637955
references.citation: BMC Med Res Methodol. 2004 Sep 16;4:22
references.pmid: 15369598
references.citation: Pflege. 2006 Feb;19(1):33-44
references.pmid: 16523848
references.citation: Health Res Policy Syst. 2006 Dec 01;4:19
references.pmid: 17140445
references.citation: Health Res Policy Syst. 2006 Dec 05;4:22
references.pmid: 17147811
references.citation: Health Res Policy Syst. 2006 Nov 29;4:15
references.pmid: 17134482
references.citation: Health Res Policy Syst. 2006 Dec 05;4:23
references.pmid: 17147813
references.citation: BMC Health Serv Res. 2007 Apr 04;7:47
references.pmid: 17408472
references.citation: JAMA. 2006 Apr 26;295(16):1935-40
references.pmid: 16639053
references.citation: Health Res Policy Syst. 2006 Dec 01;4:18
references.pmid: 17140444
references.citation: CMAJ. 1995 Nov 15;153(10):1423-31
references.pmid: 7585368
references.citation: J Clin Epidemiol. 1991;44(11):1271-8
references.pmid: 1834807
references.citation: Med Care. 1994 Mar;32(3):202-13
references.pmid: 8145598
references.citation: JAMA. 1999 Oct 20;282(15):1458-65
references.pmid: 10535437
references.citation: Health Res Policy Syst. 2006 Nov 20;4:12
references.pmid: 17116254
references.citation: J Clin Epidemiol. 1991;44(1):91-8
references.pmid: 1824710
references.citation: Br J Gen Pract. 2003 Jan;53(486):15-9
references.pmid: 12569898
references.citation: Med Care. 2001 Aug;39(8 Suppl 2):II2-45
references.pmid: 11583120
references.citation: Health Res Policy Syst. 2006 Dec 05;4:20
references.pmid: 17147809
references.citation: Health Res Policy Syst. 2006 Dec 08;4:26
references.pmid: 17156458
references.citation: Br J Gen Pract. 1998 Feb;48(427):991-7
references.pmid: 9624774
references.citation: Respir Care Clin N Am. 2005 Mar;11(1):1-13
references.pmid: 15763217
references.citation: Health Res Policy Syst. 2006 Dec 05;4:24
references.pmid: 17147814
references.citation: BMJ. 1998 Sep 26;317(7162):858-61
references.pmid: 9748183
references.citation: Acta Psychiatr Scand. 2007 Jun;115(6):420-33
references.pmid: 17498153
references.citation: Annu Rev Public Health. 1991;12:41-65
references.pmid: 2049143
references.citation: Health Res Policy Syst. 2006 Dec 05;4:21
references.pmid: 17147810
references.citation: Health Res Policy Syst. 2006 Dec 08;4:27
references.pmid: 17156459
references.citation: BMJ. 1999 Mar 13;318(7185):728-30
references.pmid: 10074024
references.citation: Lancet. 2003 Oct 11;362(9391):1225-30
references.pmid: 14568747
references.citation: Rev Epidemiol Sante Publique. 2003 Feb;51(1 Pt 1):65-80
references.pmid: 12684582
references.citation: Health Technol Assess. 2004 Feb;8(6):iii-iv, 1-72
references.pmid: 14960256
references.citation: Harv Rev Psychiatry. 2002 May-Jun;10(3):138-53
references.pmid: 12023929
references.citation: Cochrane Database Syst Rev. 2000;(2):CD000349
references.pmid: 10796531
references.citation: J Wound Care. 2003 Nov;12(10):373-8, 380-2
references.pmid: 14648963
references.citation: Asian Am Pac Isl J Health. 1999 Winter;7(1):47-56
references.pmid: 11567481
references.citation: Med Care. 2001 Aug;39(8 Suppl 2):II55-69
references.pmid: 11583122
references.citation: Obstet Gynecol. 2006 Nov;108(5):1234-45
references.pmid: 17077251
references.citation: World Hosp Health Serv. 2007;43(2):14-20
references.pmid: 17894189