title: Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline.
abstract: BACKGROUND
  Clinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals - but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes.
  
  
  METHODS
  The TDFI approach was used in a pre-post study in three NHS hospitals with a fourth acting as a control (with usual care and no TDFI). The target behavior identified for change was to increase the use of pH testing as the first line method for checking the position of a nasogastric tube. Repeat audits were undertaken in each hospital following intervention implementation. We used Zou's modified Poisson regression approach with robust standard errors to estimate risk ratios for the use of pH testing. The projected return on investment (ROI) was also calculated.
  
  
  RESULTS
  Following intervention implementation, the use of pH first line increased significantly across intervention hospitals [risk ratio (95% CI) ranged from 3.1 (1.14 to8.43) p < .05, to 8.14 (3.06 to21.67) p < .001] compared to the control hospital, which remained unchanged [risk ratio (CI) = .77 (.47-1.26) p = .296]. The estimated savings and costs in the first year were £2.56 million and £1.41 respectively, giving an ROI of 82%, and this was projected to increase to 270% over five years.
  
  
  CONCLUSIONS
  The TDFI approach improved the uptake of a patient safety guideline across three hospitals. The TDFI approach is clinically and cost effective in comparison to the usual practice.
authors.affiliation: Centre for Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, UK. n.taylor@mq.edu.au.
authors.forename: Natalie
authors.initials: N
authors.lastname: Taylor
authors.affiliation: Institute of Psychological Sciences, University of Leeds, Leeds, LS2 9JT, UK. r.j.lawton@leeds.ac.uk.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Lawton
authors.affiliation: Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK. sally.moore@bthft.nhs.uk.
authors.forename: Sally
authors.initials: S
authors.lastname: Moore
authors.affiliation: York Health Economics Consortium Limited, Level 2, Market Square, University of York, York, YO10 5NH, England. joyce.craig@york.ac.uk.
authors.forename: Joyce
authors.initials: J
authors.lastname: Craig
authors.affiliation: Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK. beverley.slater@bthft.nhs.uk.
authors.forename: Beverley
authors.initials: B
authors.lastname: Slater
authors.affiliation: Leeds Teaching Hospital NHS Trust, Beckett Street, Leeds, LS9 7TF, UK. alison.cracknell@leedsth.nhs.uk.
authors.forename: Alison
authors.initials: A
authors.lastname: Cracknell
authors.affiliation: Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK. john.wright@bthft.nhs.uk.
authors.forename: John
authors.initials: J
authors.lastname: Wright
authors.affiliation: School of Healthcare Studies, University of Bradford, Bradford, West Yorkshire, BD7 1DP, UK. m.a.mohammed5@bradford.ac.uk.
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Mohammed
mesh_terms: D003299:Cooperative Behavior; D003362:Cost-Benefit Analysis; D005260:Female; D017408:Guidelines as Topic; D006282:Health Personnel; D006801:Humans; D008962:Models, Theoretical; D061214:Patient Safety; D006113:United Kingdom