Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview

Abstract

Introduction: Clinical practice guidelines (CPGs) are designed to improve the quality of care and reduce unjustified individual variation in clinical practice. Knowledge of the barriers and facilitators that influence the implementation of the CPG recommendations is the first step in creating strategies to improve health outcomes. The present systematic meta-review sought to explore the barriers and facilitators for the implementation of CPGs. Methods: A search was conducted in the PubMed, Embase, Cochrane, Health System Evidence and International Guideline Library (G-I-N) databases. Systematic reviews of qualitative, quantitative or mixed-methods studies that identified barriers or facilitators for the implementation of CPGs were included. The selection of the title and abstract, the evaluation of the full text, extraction of the data and the quality assessment were carried out by two independent reviewers. To summarise the evidence, we grouped the barriers and facilitators according to the following contexts: political and social, health organisational system, guidelines, health professionals and patients. Results: Overall, 25 systematic reviews were selected. The relevant barriers in the social-political context were the absence of a leader, difficulties with teamwork and a lack of agreement with colleagues. Relevant barriers in the health system were a lack of time, financial problems and a lack of specialised personnel. Barriers of the CPGs included a lack of clarity and a lack of credibility in the evidence. Regarding the health professional, a lack of knowledge about the CPG and confidence in oneself were relevant. Regarding patients, a negative attitude towards implementation, a lack of knowledge about the CPG and sociocultural beliefs played a role. Some of the most frequent facilitators were consistent leadership, commitment of the members of the team, administrative support of the institution, existence of multidisciplinary teams, application of technology to improve the practice and education regarding the guidelines. Conclusions: The barriers and facilitators described in this review are factors that influence the implementation of evidence in clinical practice. Knowledge of these factors should contribute to the development of a theoretical basis for the creation of CPG implementation strategies to improve professional practice and health outcomes for patients.

Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program

“…Research on CPG implementation barriers is highly documented. A systematic meta-review which included 25 systematic reviews published until 2017 [ 9 ] and three systematic reviews published posteriorly [ 10 , 11 , 12 ] underline as the main barriers the aspects related to: political and social context, such as lack of leadership and lack of coordination by the team; health organizational system context, such lack of staffing, and economic and time resources; clinical practice guideline context, such as recommendations that are not clear, and doubts about the quality of the evidence and rigidity; health professional context, such as lack of knowledge about the CPGs, negative attitude, and clinical inertia of practice and the belief that it is not part of one’s role; and patient context, such as lack of knowledge of the patients about the guidelines, the characteristics of the system and their illness, expectations that are contrary to the doctor’s, and lack of family support. The barriers highlighted in these systematic reviews are generally linked with the implementation of CPGs directed at interventions for the treatment of frequent pathologies and chronic diseases [ 10 , 11 , 12 ].…”

Facilitators and obstacles to implementing the practical approach to the care kit/pack Brazil / Facilitadores e obstáculos para implementar a abordagem prática do kit de cuidados/ pacote Brasil

“…into account the previous experiences in other countries and the prerequisites listed in the scientific literature on the implementation of protocols 15,16,22,23 , such as: adaptation of the material to the epidemiological scenario of the implementation; making the material easy to use; varied forms of access; and support from local and central management. From the interviews, it can be seen that the efforts made during the process of locating the PACK was reflected in the high level of acceptance of the protocol and training by health professionals.…”

“…As for the obstacles to the implementation of the PACK, three situations related to health professionals were cited. Firstly, as shown in the scientific literature 16,26 , the confidence of the interviewed professionals in their own clinical experiences represented an obstacle to the use of the PACK. Secondly, the individual preferences of health professionals regarding other materials and protocols were demonstrated in this study, as well as in similar studies 26,27 .…”

“…In order for protocols to achieve their potential for improving clinical practice and people's health, not only should great care be taken in their development, but there should also be activities to evaluate their implementation 15 . Thus, factors that facilitate the use and obstacles that impact the use of the protocol can be identified 16 . There is a general lack of research that investigates aspects related to protocol implementation in developing countries, and further research is required 16.…”

A Systematic Review on the Effectiveness of Implementation Strategies to Postpone Elective Caesarean Sections to ≥39+(0-6) Week of Gestation.

“…Although, barriers and limitations of the speci c context must be known or evaluated if possible. (48) Most of our included studies identi ed barriers and evaluated the in uence on success. Depending on the structure, hierarchy and status of guideline implementation an interested hospital (or group of hospitals) could follow one of the comprehensively described strategies presented here.…”