Successes and failures in the implementation of evidence-based guidelines for clinical practice

BACKGROUND. The development and implementation of (evidence-based) clinical practice guidelines is one of the promising and effective tools for improv ing the quality of care. However, many guidelines are not used after dissem ination. Implementation activities frequently produce only moderate improve ment. It is important to study specific guideline programs in detail to lea rn from their successes and failures. OBJECTIVES. Experiences with more than 10 years of development and dissemin ation of clinical guidelines for family medicine in the Netherlands are pre sented in this paper. RESULTS. More than 70 evidence-based guidelines have been set in a rigorous procedure and have been spread via a variety of strategies. Knowledge and acceptance of the guidelines in the target group is high. In particular, a multifaceted approach with written (scientific journal, support materials) and personal approaches (local consensus discussions, contact with colleagu es, outreach visits by peers) seems to be effective in the dissemination. T he guideline recommendations are followed in on average 67% of the decision s, but there is a large variation between different physicians and between different guidelines. Specific strategies designed to handle possible obsta cles to implementation are needed to improve adherence. Specific implementa tion projects showed the importance of a "diagnostic analysis" of the targe t group and target setting before the start of the implementation. CONCLUSIONS. A program to implement a guideline should be well designed, we ll prepared, and preferably pilot tested before use. Such a program should be built into the normal channels and structures for improving care. More r esearch into the details of implementation is needed to better understand t he critical determinants of change in practice.