title: Tools developed and disseminated by guideline producers to promote the uptake of their guidelines.
abstract: BACKGROUND
  The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs.
  
  
  OBJECTIVE
  To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective.
  
  
  METHODS
  We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites.
  
  
  METHODS
  We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area.
  
  
  METHODS
  Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines.
  
  
  RESULTS
  We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service.
  
  
  CONCLUSIONS
  Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.
authors.affiliation: The Norwegian Knowledge Centre for the Health Services, Norwegian Institute of Public Health, Pilestredet Park 7, Oslo, Norway, 0176.
authors.forename: Gerd
authors.initials: G
authors.lastname: Flodgren
authors.forename: Amanda M
authors.initials: AM
authors.lastname: Hall
authors.forename: Lucy
authors.initials: L
authors.lastname: Goulding
authors.forename: Martin P
authors.initials: MP
authors.lastname: Eccles
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Grimshaw
authors.forename: Gillian C
authors.initials: GC
authors.lastname: Leng
authors.forename: Sasha
authors.initials: S
authors.lastname: Shepperd
mesh_terms: D003695:Delivery of Health Care / Q000191:economics / Q000592:standards*; D005194:Family Practice; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006295:Health Resources / Q000706:statistics & numerical data; D008505:Medical Staff, Hospital; D026761:Physical Therapy Specialty / Q000193:education; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D017010:Reminder Systems; D013664:Teaching Materials