Elsevier

Health Policy

Volume 107, Issues 2–3, October 2012, Pages 168-183
Health Policy

Review
Assessing the effectiveness of strategies to implement clinical guidelines for the management of chronic diseases at primary care level in EU Member States: A systematic review

https://doi.org/10.1016/j.healthpol.2012.08.005Get rights and content

Abstract

Purpose and setting

This review aimed to evaluate the effectiveness of strategies to implement clinical guidelines for chronic disease management in primary care in EU Member States.

Methods

We conducted a systematic review of interventional studies assessing the implementation of clinical guidelines. We searched five databases (EMBASE, MEDLINE, CENTRAL, Eppi-Centre and Clinicaltrials.gov) following a strict Cochrane methodology. We included studies focusing on the management of chronic diseases in adults in primary care.

Results

A total of 21 studies were found. The implementation strategy was fully effective in only four (19%), partially effective in eight (38%), and not effective in nine (43%). The probability that an intervention would be effective was only slightly higher with multifaceted strategies, compared to single interventions. However, effect size varied across studies; therefore it was not possible to determine the most successful strategy. Only eight studies evaluated the impact on patients’ health and only two of those showed significant improvement, while in five there was an improvement in the process of care which did not translate into an improvement in health outcomes. Only four studies reported any data on the cost of the implementation but none undertook a cost-effectiveness analysis. Only one study presented data on the barriers to the implementation of guidelines, noting a lack of awareness and agreement about clinical guidelines.

Conclusion

Our results reveal that there are only a few rigorous studies which assess the effectiveness of a strategy to implement clinical guidelines in Europe. Moreover, the results are not consistent in showing which strategy is the most appropriate to facilitate their implementation. Therefore, further research is needed to develop more rigorous studies to evaluate health outcomes associated with the implementation of clinical guidelines; to assess the cost-effectiveness of implementing clinical guidelines; and to investigate the perspective of service users and health service staff.

Section snippets

Background

The development of clinical guidelines has increased markedly over the past two decades. Clinical guidelines seek to improve the quality of care provided by reducing harmful management and improving the cost-effectiveness of care [1]. A mapping exercise [2] identified how all EU Member States are showing interest in developing and implementing clinical guidelines. Most have an established clinical guideline programme, and a substantial proportion of them develop clinical guidelines on

Types of studies

To be considered for inclusion the study had to assess the effectiveness of a strategy to implement clinical guidelines for the management of illustrative common chronic diseases in primary care in EU Member States. These were Coronary Heart Diseases, Chronic Cardiovascular Diseases, Cerebrovascular Diseases (stroke), Hypertension, Diabetes Mellitus Type 2, Chronic Obstructive Pulmonary Disease, Asthma, Arthritis (Osteoarthritis, Rheumatoid Arthritis, Sacroiliitis, Spondylarthritis,

Search results

The search strategy yielded 2562 citations (eTable 1–eTable 5). After removing duplicates and screening, 27 records that corresponded to 21 studies were included [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37]. There were six studies with two publications each [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]. The selection process is presented in Fig. 1. The

Discussion

We found only 21 studies assessing the implementation of guidelines for the management of chronic conditions in primary care in EU Member States.

Only four studies reported interventions that were fully effective (19%), in eight they were partially effective (38%), while nine found no evidence of effectiveness (43%). However the results varied across included studies. Multifaceted interventions were only slightly more effective compared to those implementing a single intervention. Due to the

Conflicts of interest

We are not aware of any relationships or support which might be perceived as conflict of interest.

Funding

This paper is the result of research that was requested by the European Commission's Directorate–General for Health & Consumer and co-funded through the EU's FP7 Cooperation Work Programme: Health (contract number 242058; contract acronym EUCBCC). The European Observatory on Health Systems and Policies is responsible for conducting this work. The European Commission is not responsible for the content of the paper. Responsibility for the facts described in the report and the views expressed

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