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Background In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. Objectives Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. Methods This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. Results Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). Conclusion The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Because of high rates of trimethoprim-sulfamethoxazole resistance in Escherichia coli, Denver Health switched to levofloxacin as the initial therapy for urinary tract infections (UTIs) in 1999. We evaluated the effects of that switch 6 years later.Levofloxacin prescriptions per 1000 outpatient visits and levofloxacin resistance in outpatient E. coli were evaluated over time. E. coli isolated in 2005 were further characterized by specimen source and antimicrobial susceptibilities. Risk factors for levofloxacin-resistant E. coli UTI among nonpregnant adult outpatients were evaluated in a case-control study.Between 1998 and 2005, levofloxacin use increased from 3.1 to 12.7 prescriptions per 1000 visits (P.01) and resistance in outpatients increased from 1% to 9% (P.01). Although prescriptions for sulfonamide antibiotics decreased by half during the same period, E. coli resistance to trimethoprim-sulfamethoxazole increased from 26.1% to 29.6%. Levofloxacin-resistant E. coli were more likely resistant to other antibiotics than levofloxacin-susceptible isolates (90% vs 43%, P.0001). Risk factors for levofloxacin-resistant E. coli UTI were hospitalization (odds ratio for each week of hospitalization, 2.0; 95% confidence interval, 1.0-3.9) and use of levofloxacin (odds ratio, 5.6; 95% confidence interval, 2.1-27.5) within the previous year.Fluoroquinolone prescriptions increased markedly after an institutional policy change for empiric treatment of UTI, and a rapid increase in fluoroquinolone resistance among outpatient E. coli followed. Risk factors for infection with resistant E. coli were recent hospitalization and levofloxacin use. Risk factors should be considered before initiating empiric treatment with a fluoroquinolone.

Study objective We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections. Methods Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics. Results The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval −3% to 5%) and at intervention sites decreased by 10% (95% confidence interval −18% to −2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction. Conclusion Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.

Background . This study examined the potential for tobacco use and other health risk behavior interventions in the context of an urban sexually transmitted diseases (STD) clinic. Methods . A cross-sectional survey of two populations. Adolescents seen at an STD clinic or at the teen clinic of a community health center completed a self-administered computer survey in 1996. Risk behaviors, attitudes, and readiness to stop smoking were analyzed for 225 patients at the STD clinic and 248 patients at the teen clinic. Results . Compared with adolescents in the teen clinic, adolescents in the STD clinic were more likely to have smoked frequently (OR 1.7, 95% CI 1.1, 3.0), used any illegal drug (OR 2.7, 95% CI 1.3, 5.5), recently binged on alcohol (OR 1.7, 95% CI 1.0, 2.8), and had more than 10 lifetime sexual partners (OR 1.9, 95% CI 1.0, 3.4). Weapon carrying, readiness to stop smoking, and attitudes toward smoking did not differ between sites. Conclusions . Cigarette smoking and other health risk behaviors are more prevalent among adolescents in an STD clinic than among adolescents in a community health center. STD clinics are potential sites for cigarette, alcohol, and drug use interventions among “hard to reach” adolescents.

Burden of suffering It is estimated that approximately 15,000 women will be diagnosed with invasive carcinoma of the cervix and 4,800 women will die from this disease in 1995. (1) Rates for carcinoma in situ peak between the ages of 20 and 30, and the incidence of invasive cervical cancer increases with age. (2) Twenty-five percent of all invasive cervical cancers occur in women over age 65. Any woman who has been sexually active is at risk for cervical cancer. (3) Additional risk factors include early onset of sexual intercourse, (4,5) history of multiple sexual partners, (5) history of sexually transmitted disease (especially HPV (6) and HIV(7)), smoking, (8) and never having been screened. (9)

Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use.Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period.In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group.This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

Article-at-a-Glance Background Lean principles have been used at Denver Health Medical Center since 2005 to streamline nonclinical processes. Despite allocation of significant resources, particularly the expense of low molecular weight heparin (LMWH), to prophylaxis of venous thromboembolism (VTE), the incidence of postoperative VTE was significantly worse than national benchmarks. VTE risk factors were not consistently assessed, and the prescribing of prophylaxis varied widely. Lean was employed to standardize and implement risk assessment and evidence-based VTE prophylaxis for the institution. Methods In a rapid improvement event, a multidisciplinary group formulated an evidence-based risk assessment tool and clinical practice guideline for VTE prophylaxis, with plans for hospitalwide implementation and monitoring. Results The effects were immediate and improved steadily with feedback to clinicians. Within six months, compliance with the standard approached 100%. One year after implementation, the use of LMWH decreased more than 60% below baseline, and the use of sequential compression devices decreased by nearly 30%. With increased use of unfractionated heparin, the cost savings on VTE prophylaxis exceeded $15,000 per month, for a total of $425,000 since implementation. Moreover, the incidence of VTE decreased markedly during the same period. By reducing VTE rates, a total cost savings of $6.2 million was estimated for the past 28 months. Conclusions Applying Lean to the clinical management of VTE prophylaxis improved compliance with standards and saved the hospital a significant amount of money. This was achieved without compromising clinical outcomes. This experience could be replicated at other institutions.

Purpose Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes, yet only a minority of these patients are screened or achieve optimal low-density lipoprotein (LDL) cholesterol levels. Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing. Methods The study cohort comprised 884 diabetic patients at 12 primary care practices. Practice sites were randomized to one of three intervention groups: electronic educational detailing, direct (face-to-face) educational detailing, or control. Direct and electronic detailing were performed over a 12-month period. All sites were notified of our goal to enhance lipid testing among diabetic patients. Chart abstraction was performed 15 months after the start of the intervention. For the entire population (n=884), the proportion of patients with lipid testing was calculated, and changes from pre- to postintervention were compared across groups. We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation. Results Favorable provider actions increased significantly with the intervention (+22% compared with +6% in controls, P =.01). By logistic regression, electronic detailing increased the likelihood of lipid testing (odds ratio 3.0, confidence interval 1.6-5.7), as did direct detailing (odds ratio 1.8, confidence interval 0.9-3.7) in patients with no preintervention LDL test (n=432). Lipid testing tended to increase to a greater extent at intervention sites (+23% for the combination of electronic and direct detailing vs +11% for controls, P =.06). Conclusions Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients.