This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.

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Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations

Background Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective. Objectives To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies. Selection criteria Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. Main results We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice. Reviewer's conclusions Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Audit and feedback: effects on professional practice and healthcare outcomes

There is confusion and misunderstanding about the concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. We review the terms and definitions used to describe the concept of moving knowledge into action. We also offer a conceptual framework for thinking about the process and integrate the roles of knowledge creation and knowledge application. The implications of knowledge translation for continuing education in the health professions include the need to base continuing education on the best available knowledge, the use of educational and other transfer strategies that are known to be effective, and the value of learning about plannedaction theories to be better able to understand and influence change in practice settings.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/chp.47

Lost in knowledge translation: time for a map?

ContextDevelopers of health care software have attributed improvements in patient
care to these applications. As with any health care intervention, such claims
require confirmation in clinical trials.ObjectivesTo review controlled trials assessing the effects of computerized clinical
decision support systems (CDSSs) and to identify study characteristics predicting
benefit.Data SourcesWe updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane
Library, Inspec, and ISI databases and consulting reference lists through
September 2004. Authors of 64 primary studies confirmed data or provided additional
information.Study SelectionWe included randomized and nonrandomized controlled trials that evaluated
the effect of a CDSS compared with care provided without a CDSS on practitioner
performance or patient outcomes.Data ExtractionTeams of 2 reviewers independently abstracted data on methods, setting,
CDSS and patient characteristics, and outcomes.Data SynthesisOne hundred studies met our inclusion criteria. The number and methodologic
quality of studies improved over time. The CDSS improved practitioner performance
in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of
10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease
management systems, and 19 (66%) of 29 drug-dosing or prescribing systems.
Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%)
reported improvements. Improved practitioner performance was associated with
CDSSs that automatically prompted users compared with requiring users to activate
the system (success in 73% of trials vs 47%; P = .02)
and studies in which the authors also developed the CDSS software compared
with studies in which the authors were not the developers (74% success vs
28%; respectively, P = .001).ConclusionsMany CDSSs improve practitioner performance. To date, the effects on
patient outcomes remain understudied and, when studied, inconsistent.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

OBJECTIVES: To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. DATA SOURCES: MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group. REVIEW METHODS: Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care. RESULTS: In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources. CONCLUSIONS: There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

https://repository.ubn.ru.nl/bitstream/handle/2066/58616/58616.pdf

Effectiveness and efficiency of guideline dissemination and implementation strategies

Objectives: A systematic review of the
 effectiveness and costs of different guideline development,
 dissemination, and implementation strategies wasundertaken. The resource
 implications of these strategies was estimated, and a framework for
 deciding when it is efficient to develop and introduce clinical
 guidelines was developed.

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AcademicUnitofPsychiatryandBehavioural Sciences, University of Leeds, Leeds, En-gland(DrGilbody);DepartmentofEpidemiologyandPublic Health, University of Newcastle upon Tyne,Newcastle upon Tyne, England (Dr Whitty); ClinicalEpidemiologyProgram,InstituteofPopulationHealth,and Cochrane Effective Professional and Organisa-tional Change Group, Ottawa Health ResearchInstitute and Center for Best Practices, University ofOttawa,Ottawa,Ontario(DrGrimshaw);andHealthServices Research Unit, University of Aberdeen, Ab-erdeen, Scotland (Dr Thomas).

Educational and Organizational Interventions to Improve the Management of Depression in Primary Care

ContextDepression is commonly encountered in primary care settings yet is often
missed or suboptimally managed. A number of organizational and educational
strategies to improve management of depression have been proposed. The clinical
effectiveness and cost-effectiveness of these strategies have not yet been
subjected to systematic review.ObjectiveTo systematically evaluate the effectiveness of organizational and educational
interventions to improve the management of depression in primary care settings.Data SourcesWe searched electronic medical and psychological databases from inception
to March 2003 (MEDLINE, PsycLIT, EMBASE, CINAHL, Cochrane Controlled Trials
Register, United Kingdom National Health Service Economic Evaluations Database,
Cochrane Depression Anxiety and Neurosis Group register, and Cochrane Effective
Professional and Organisational Change Group specialist register); conducted
correspondence with authors; and used reference lists. Search terms were related
to depression, primary care,
and all guidelines and organizational and educational interventions.Study SelectionWe selected 36 studies, including 29 randomized controlled trials and
nonrandomized controlled clinical trials, 5 controlled before-and-after studies,
and 2 interrupted time-series studies. Outcomes relating to management and
outcome of depression were sought.Data ExtractionMethodological details and outcomes were extracted and checked by 2
reviewers. Summary relative risks were, where possible, calculated from original
data and attempts were made to correct for unit of analysis error.Data SynthesisA narrative synthesis was conducted. Twenty-one studies with positive
results were found. Strategies effective in improving patient outcome generally
were those with complex interventions that incorporated clinician education,
an enhanced role of the nurse (nurse case management), and a greater degree
of integration between primary and secondary care (consultation-liaison).
Telephone medication counseling delivered by practice nurses or trained counselors
was also effective. Simple guideline implementation and educational strategies
were generally ineffective.ConclusionsThere is substantial potential to improve the management of depression
in primary care. Commonly used guidelines and educational strategies are likely
to be ineffective. The implementation of the findings from this research will
require substantial investment in primary care services and a major shift
in the organization and provision of care.

https://jamanetwork.com/journals/jama/articlepdf/196771/JRV30013.pdf

Educational and organizational interventions to improve the management of depression in primary care: a systematic review

Background A number of enhancement strategies have been proposed to improve the quality and outcome of care for depression in primary care settings. Decision-makers are likely to need to know whether these interventions are cost-effective in routine primary care settings.

Method We conducted a systematic review of all full economic evaluations (cost-effectiveness and cost–utility analyses) accompanying randomised controlled trials of enhanced primary care for depression. Costs were standardised to UKpounds/US dollars and incremental cost-effectiveness ratios (ICERs) were visually summarised using a permutation matrix.

Results We identified 11 full economic evaluations (4757 patients). A near-uniform finding was that the interventions based upon collaborative care/case management resulted in improved outcomes but were also associated with greater costs. When considering primary care depression treatment costs alone, ICER estimates ranged from £7 ($13, no confidence interval given) to £13 ($24,95% CI –105 to 148) per additional depression-free day. Educational interventions alone were associated with increased cost and no clinical benefit.

Conclusions Improved outcomes through depression management programmes using a collaborative care/case management approach can be expected, but are associated with increased cost and will require investment.

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Paula Whitty

Papers

Effectiveness and efficiency of guideline dissemination and implementation strategies

Effectiveness and efficiency of guideline dissemination and implementation strategies

Educational and Organizational Interventions to Improve the Management of Depression in Primary Care

Educational and organizational interventions to improve the management of depression in primary care: a systematic review

Costs and consequences of enhanced primary care for depression: systematic review of randomised economic evaluations.