Facilitating Uptake of Guidelines in Physical Therapy: What Can You Do?

The Functions and Aims of Clinical Practice Guidelines

Evidence-based practice (EBP) has become an integral part of health professionals' lexicon, and providing credible evidence to support health decisions is currently viewed as best practice in health care. Clinical practice guidelines (CPGs) are tools that support EBP by distilling research evidence into recommendations that help professionals and patients to make health care decisions in relation to specific clinical circumstances.¹ The primary aim of CPGs is to improve health care outcomes,² and there is emerging evidence that the use of guidelines in physical therapy can improve functional and economic outcomes. For example, the implementation of whiplash guidelines has reduced the cost of care;³ the implementation of post-acute stroke guidelines has produced improved physical and functional patient outcomes;⁴ and care provided in accordance with guidelines for acute low back pain has resulted in decreased pain and disability as well as a decrease in the number of physical therapy visits.⁵

Over the last two decades, efforts have targeted the production of EBP guidelines, and many national organizations (e.g., National Institute of Clinical Effectiveness, Scottish Intercollegiate Guidelines Network, New Zealand Guideline Group) have facilitated the development and dissemination of CPGs. As a result, there has been a proliferation in the number of guidelines available. For example, Timmermans noted that by 2005, there were approximately 4,000 guidelines in existence and about 1,000 being created each year.⁶ Within physical therapy, Maher and colleagues indicated that as of September 2007 there were 478 evidence-based CPG references in PEDro, a database of abstracts and bibliographic information on randomized controlled trials, systematic reviews, and CPGs relevant to physical therapists.⁷

However, despite the success of guideline production, the actual process of ensuring guideline uptake has proved challenging. The research evidence indicates that characteristics of the guideline itself, the practitioner/professional, and the practice context can all affect whether or not a guideline is used in practice.^8–10 What can physical therapists learn from this body of evidence, and what can they do to mitigate the barriers to guideline uptake and use?

Guideline Adoption and Implementation: Factors Influencing Uptake

In a systematic review of the research evidence related to adoption of CPGs, Davis and Taylor-Vaisey⁸ highlighted the importance of understanding factors related to the following:

• the quality of the guideline itself (e.g., complexity; compatibility with existing values, beliefs, and practices)

• characteristics of the health professional (e.g., beliefs, attitudes)

• characteristics of the practice environment (e.g., social norms)

• legislative and regulatory requirements for guideline use (e.g., accreditation and licensing bodies)

• patients themselves (e.g., patient demands for a certain practice)

Similarly, in a meta-review of guideline implementation by health care professionals, Francke et al. demonstrated how characteristics of the guideline itself (e.g., understandability, trialability, resource requirements for implementation), the professional (e.g., awareness of the guideline, familiarity with its content), the patient (e.g., co-morbidities), and the work environment (e.g., support from peers and superiors) can influence implementation.⁹

The process of adoption and implementation also requires the professional to move through various stages. First, he or she must be aware that a guideline exists and become familiar with its content and specific recommendations. Second, the professional must assess the quality of the guideline and reflect on his or her abilities to implement the guideline. Third, the professional needs to determine the resources and supports available in the work environment that can facilitate implementation.

Strategies for Improving Guideline Uptake in Your Day-to-day Practice

By understanding the factors influencing guideline adoption and the challenges that may arise during implementation, physiotherapists can improve their ability to implement relevant guidelines into their day-to-day practice. Several strategies can also be employed to improve guideline uptake.

First, it is necessary to become aware of the potential resources for searching and locating relevant guidelines. As mentioned previously, the PEDro database includes many CPGs relevant to physical therapists. An additional public resource for evidence-based CPGs is the National Guideline Clearinghouse.¹¹

Second, it is beneficial to become a wise consumer and to learn how to evaluate the quality of a guideline and its recommendations. Instruments such as the Appraisal of Guidelines for Research and Evaluation (AGREE)¹² can assist by providing specific questions to guide the appraisal process. It may also be helpful to reflect on how your own beliefs and attitudes influence your appraisal process and your eventual decision(s) as to whether or not to implement the guideline or its recommendations.

Third, once a guideline is found to be of adequate quality, consider scanning your own practice environment to determine the persons and resources that may be beneficial to implementation efforts. This may involve identifying team members who can provide ongoing support and meeting with co-workers, supervisors, and office staff to discuss how the implementation process will unfold.

Fourth, consider the changes needed in your own practice processes to allow the space and time for guideline implementation. For example, consider how changes in your practice may be perceived by your patients and how your documentation process may need to change to reflect the additional guideline recommendations.

Lastly, it may be beneficial to establish methods of monitoring the practice changes and the impact of these changes on specific patient outcomes.

Conclusions

Clinical practice guidelines have become recognized tools in evidence-based health care practice, and their use has been endorsed by various professional groups in physical therapy, occupational therapy, and medicine, to name a few. Despite this support, however, challenges remain with respect to their implementation and rates of uptake. By becoming aware of the factors that can influence guideline uptake and anticipating potential implementation challenges, health care professionals may be able to mitigate some of these challenges and improve the rates of successful uptake.