title: Effectiveness of implementation strategies for clinical guidelines to community pharmacy: a systematic review.
abstract: BACKGROUND
  The clinical role of community pharmacists is expanding, as is the use of clinical guidelines in this setting. However, it is unclear which strategies are successful in implementing clinical guidelines and what outcomes can be achieved. The aim of this systematic review is to synthesise the literature on the implementation of clinical guidelines to community pharmacy. The objectives are to describe the implementation strategies used, describe the resulting outcomes and to assess the effectiveness of the strategies.
  
  
  METHODS
  A systematic search was performed in six electronic databases (Medline, EMBASE, CINAHL, Web of Science, Informit, Cochrane Library) for relevant articles. Studies were included if they reported on clinical guidelines implementation strategies in the community pharmacy setting. Two researchers completed the full-search strategy, data abstraction and quality assessments, independently. A third researcher acted as a moderator. Quality assessments were completed with three validated tools. A narrative synthesis was performed to analyse results.
  
  
  RESULTS
  A total of 1937 articles were retrieved and the titles and abstracts were screened. Full-text screening was completed for 36 articles resulting in 19 articles (reporting on 22 studies) included for review. Implementation strategies were categorised according to a modified version of the EPOC taxonomy. Educational interventions were the most commonly utilised strategy (n = 20), and computerised decision support systems demonstrated the greatest effect (n = 4). Most studies were multifaceted and used more than one implementation strategy (n = 18). Overall outcomes were moderately positive (n = 17) but focused on process (n = 22) rather than patient (n = 3) or economic outcomes (n = 3). Most studies (n = 20) were rated as being of low methodological quality and having low or very low quality of evidence for outcomes.
  
  
  CONCLUSIONS
  Studies in this review did not generally have a well thought-out rationale for the choice of implementation strategy. Most utilised educational strategies, but the greatest effect on outcomes was demonstrated using computerised clinical decision support systems. Poor methodology, in the majority of the research, provided insufficient evidence to be conclusive about the best implementation strategies or the benefit of clinical guidelines in this setting. However, the generally positive outcomes across studies and strategies indicate that implementing clinical guidelines to community pharmacy might be beneficial. Improved methodological rigour in future research is required to strengthen the evidence for this hypothesis.
  
  
  BACKGROUND
  PROSPERO 2012: CRD42012003019 .
authors.affiliation: School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. kim.watkins@uwa.edu.au.
authors.forename: Kim
authors.initials: K
authors.lastname: Watkins
authors.affiliation: School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. 20671245@student.uwa.edu.au.
authors.forename: Helen
authors.initials: H
authors.lastname: Wood
authors.affiliation: Faculty of Pharmacy, The University of Sydney, Sydney, Australia. carl.schneider@sydney.edu.au.
authors.forename: Carl R
authors.initials: CR
authors.lastname: Schneider
authors.affiliation: School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. rhonda.clifford@uwa.edu.au.
authors.forename: Rhonda
authors.initials: R
authors.lastname: Clifford
mesh_terms: D003157:Community Pharmacy Services / Q000458:organization & administration* / Q000592:standards; D020000:Decision Support Systems, Clinical; D006801:Humans; D007318:Inservice Training; D017410:Practice Guidelines as Topic