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Open Access Study protocol

Understanding the relationship between the perceived characteristics of clinical practice guidelines and their uptake: protocol for a realist review

Monika Kastner1*, Elizabeth Estey1, Laure Perrier12, Ian D Graham3, Jeremy Grimshaw3, Sharon E Straus14, Merrick Zwarenstein5 and Onil Bhattacharyya16

Author Affiliations

1 Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada

2 Continuing Education and Professional Development, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

3 Department of Epidemiology and Community Medicine, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada

4 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

5 Sunnybrook Research Institute, Toronto, Ontario, Canada

6 Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada

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Implementation Science 2011, 6:69  doi:10.1186/1748-5908-6-69

Published: 6 July 2011

Abstract

Background

Clinical practice guidelines have the potential to facilitate the implementation of evidence into practice, support clinical decision making, specify beneficial therapeutic approaches, and influence public policy. However, these potential benefits have not been consistently achieved. The limited impact of guidelines can be attributed to organisational constraints, the complexity of the guidelines, and the lack of usability testing or end-user involvement in their development. Implementability has been referred to as the perceived characteristics of guidelines that predict the relative ease of their implementation at the clinical level, but this concept is as yet poorly defined. The objective of our study is to identify guideline attributes that affect uptake in practice by considering evidence from four disciplines (medicine, psychology, management, human factors engineering) to determine the relationship between the perceived characteristics of recommendations and their uptake and to develop a framework of implementability.

Methods

A realist-review approach to knowledge synthesis will be used to understand attributes of guidelines (e.g., its text and content) and how changing these elements might impact clinical practice and clinical decision making. It also allows for the exploration of 'what works for whom, in what circumstances, and in what respects'. The realist review will be structured according to Pawson's five practical steps in realist reviews: (1) clarifying the scope of the review, (2) determining the search strategy, (3) ensuring proper article selection and study quality assessment, (4) extracting and organising data, and (5) synthesising the evidence and drawing conclusions. Data will be synthesised according to a two-stage analysis: (1) we will extract and define all relevant guideline attributes from the different disciplines, then create a shortlist of unique attributes and investigate their relationships with uptake, and (2) we will compare and contrast the attributes and guideline uptake within each and between the four disciplines to create a robust framework of implementability.

Discussion

Creating guidelines that are designed to maximise uptake may be a potentially effective and inexpensive way of increasing their impact. However, this is best achieved by a comprehensive framework to inform the design of guidelines drawing on a range of disciplines that study behaviour change. This study will use a customised realist-review approach to synthesising the literature to better understand and operationalise a complex and under-theorised concept.