Effective Dissemination and Implementation of Canadian Task Force Guidelines on Preventive Health Care: Literature Review and Model Development

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EXECUTIVE SUMMARY

Background: The Canadian Task Force on Preventive Health Care (CTFPHC) is a publicly funded, independent scientific panel that develops evidence-based clinical practice guidelines (CPGs) on preventive health care. A recent criticism leveled at CPGs in general is that many are not implemented in clinical practice, and thus do not reach their goal of improving quality of health care to patients. The reasons for this apparent failure are many and diverse, and strategies have been developed and tested to address the gap between the production of CPGs and their application in practice. The current report reviews the effectiveness of strategies to facilitate dissemination, uptake and implementation of CPGs, as well as the theoretical approaches that have been applied to the implementation issue. 

Purpose of the Report: The Task Force sees as an important goal the promotion of its guidelines to primary care physicians at the local level to encourage and facilitate uptake and implementation of recommended clinical actions for the ultimate benefit of patients. Briefly: 

• There is a need for a stronger, more focused dissemination initiative to link national guidelines on clinical prevention to family physicians throughout the country. 
• Conceptual models exist which help guide the development of a dissemination plan and a dissemination infrastructure.
• There is evidence to support the more detailed development of a focused and targeted dissemination initiative (e.g., literature on opinion leaders, etc.). 
• The literature also indicates the critical importance of “local buy in” by health care providers (in this case family physicians in particular).
• Unlike the Ontario Cancer Care Initiative (the guidelines implementation cycle developed by Browman et al. 1995 and reviewed in Section 5) or guidelines applied through institutions (e.g., hospitals, nursing homes) there is currently no infrastructure to link a national organization (Canadian Task Force) to the local family physicians who provide care within the provincial systems. 
• The current dissemination strategies using published journals and the CTF WWW site are necessary, but not sufficient components to an effective dissemination and linkage plan. 
• There is the need to identify a feasible linkage and dissemination process that creates a “virtual infrastructure” which links the Canadian Task Force to practising family physicians via an identified group of family physician opinion leaders within each province. 
• These opinion leaders would have an established and defined relationship with the CTF (input as the guidelines develop and promotion of recommendations and guidelines to local family physicians). 

Although focused on prevention, the development of such a model would have benefit to the dissemination of other national guidelines. 

Methods: A comprehensive literature search was conducted, and relevant studies reviewed and synthesized. The focus was on studies of adequate methodological design that evaluated the effectiveness of various approaches to overcoming barriers to the dissemination, uptake and implementation of practice guidelines. In addition, theoretical approaches to the problem were reviewed, as were models that had attempted to examine the issues in related contexts. A potential dissemination-implementation model for the Canadian Task Force was developed. 

Main Findings & Conclusions: Participative, or socially influenced approaches to disseminating new information to physicians have proven to be the most effective, but ultimate behaviour change will depend not only on physicians' personal characteristics and motivations, but also on attributes of the practice context. The primary care setting is somewhat unique, and principles developed within a hospital or other large organizational context may not apply as well as those needed specifically for this type of care setting. The interaction of system-level and personal factors, combined with the unique characteristics of the strategy chosen, make for a very complex decision-making process. When considering the development of a generic model to facilitate implementation of CPGs, ensuring adequate flexibility and adaptiveness within each model phase or component must accommodate this complexity. Any model designed to facilitate diffusion,
dissemination and implementation must address the issues surrounding the four components of a basic diffusion model: sender, message, channel and receiver. The model for a potential CTFPHC dissemination-implementation infrastructure is presented in Section 6, taking into account the results of the review of the evidence, and the role of the four identified components.

Next Steps: These fall into two categories: 1) ongoing research, development and refinement of the model, and 2) dissemination of report results. 

1) Research and Development:

1. Identify linkage mechanisms and partners at every level of the model, including national, provincial and local organizations, and individual opinion leaders. 
2. Further develop the model in conjunction with identified partners, using "lessons learned" from the literature. 
3. Test the model at 
a) an exploratory or pilot level, 
b) refine it, and 
c) test it on a larger scale. 
4. Obtain resources for #2&3, above. 

2) Dissemination Plan:

The current report, and/or background information therein, will be disseminated as follows: 

1. the literature review will be refined and developed into an academic manuscript suitable for publication in a peer-reviewed journal; 
2. the evolved model will be presented at appropriate health care meetings or conferences, including discussion at an upcoming Canadian Task Force meeting, and possibly to other evidence-based medicine groups; 
3. the model could be shared with the United States Preventive Services Task Force to explore their interest in collaboration; 
4. relevant background information will be posted to the Canadian Task Force world wide website.