临床实践指南应用障碍与实施策略:一项基于理论框架的范围综述  

Barriers and strategies in guideline implementation:a scoping review based on theoretical framework

作　　者：廖姣姣 王照宇 王卉[1] 陶立元[1,3] 詹思延 LIAO Jiaojiao;WANG Zhaoyu;WANG Hui;TAO Liyuan;ZHAN Siyan(Clinical Epidemiology Research Center,Peking University Third Hospital,Beijing 100191,P.R.China;School of Public Health,Peking University,Beijing 100191,P.R.China;School of Public Health,Harvard University,Massachusetts 02115,USA)

机构地区：[1]北京大学第三医院临床流行病学研究中心,北京100191 [2]北京大学公共卫生学院,北京100191 [3]哈佛大学公共卫生学院,美国马萨诸塞州02115

出　　处：《中国循证医学杂志》2024年第8期934-942,共9页Chinese Journal of Evidence-based Medicine

基　　金：国家自然科学基金项目(编号:82004210、72122001);首都卫生发展科研专项(编号:2020-4-40915);北京市自然科学基金项目(编号:L222027)。

摘　　要：目的利用文献范围综述的方法,使用决定因素框架对指南实施过程中的重要障碍因素进行分类汇总,并探索既往干预研究的实施策略对指南依从性的影响。方法计算机检索PubMed、CINAHL、MEDLINE、Embase、Scopus、Cochrane Library、SinoMed、CNKI、WanFang Data和VIP数据库,搜集与临床实践指南的实施障碍及策略相关研究,检索时限均为2011年1月1日至2023年6月10日。由4人根据纳入和排除标准完成文献初筛和二次筛选,提取文献的基本特征、指南实施的影响因素、指南实施的策略,采用定性和定量的方法分析结果。结果本范围综述共纳入61篇文献。指南实施的影响因素可以分为指南自身、外部因素、内部因素、个人因素和实施过程5个类别,其中最常见的实施障碍为卫生专业人员的指南知识或技能不足(n=21,34.4%),医护认为使用指南的必要性不足(n=17,27.9%),医院自身因素不合理(n=16,26.2%)。而指南实施的促进因素有指南基于高质量研究证据(n=5,8.2%),良好的科室或医院文化(n=4,6.6%),指南知识和信息的可及性较高(n=4,6.6%),以及医生过硬的专业能力(n=4,6.6%)。指南实施策略的整体有效率为50%。临床决策支持系统可以提高指南的依从性,指南的教育和培训是最常用的方法之一,但对于提高指南依从性的效果不稳定。结论指南实施的主要障碍是医生实施指南的能力和需要不足、医院的结构欠佳和资源匮乏。但障碍因素并不绝对,建议使用实施策略来改善指南的吸收和实施,其中临床决策支持系统是促进指南依从性的有效措施。Objective To review main obstacles to health care professionals'adherence to clinical practice guidelines(CPGs)by employing the scoping review method and a determinants framework,and to explore the effect of implementation strategies in intervention researches on guideline adherence.Methods The articles published from January 1,2011 to June 10,2023 were retrieved from the PubMed,CINAHL,MEDLINE,Embase,Scopus,Cochrane Library,SinoMed,CNKI,WanFang Data and VIP databases.The original literature on the CPGs implementation obstacles and strategies was included,and the primary and secondary screening of the literature were completed by four researchers according to the inclusion and exclusion criteria.The basic characteristics of the literature,the factors affecting the implementation of the CPGs,and the strategies used were extracted.The results were analyzed and summarized using qualitative and quantitative methods.Results A total of 61 articles were included in the scoping review.The factors affecting the implementation of CPGs could be divided into five categories:guidelines themselves,external factors,internal factors,individual factors,and implementation process.The most common implementation obstacles were insufficient knowledge or skills of professionals regarding guidelines(n=21,34.4%),insufficient necessity of using guidelines according to doctors(n=17,27.9%),and unreasonable factors within hospital(n=16,26.2%).The factors that promoted the implementation of CPGs included guidelines based on high-quality evidence(n=5,8.2%),good department or hospital culture(n=4,6.6%),convenient accessibility of guideline knowledge and information(n=4,6.6%),and doctors’excellent professional ability(n=4,6.6%).The overall effectiveness of the guideline implementation strategy was 50%.Clinical decision support system(CDSS)could improve the adherence of CPGs.Guideline education or training was one of the most commonly used methods,but the effect of improving guideline compliance was unstable.Conclusion The primary challenges in

关 键 词：范围综述 临床实践指南 依从性 障碍 实施策略 

分 类 号：R-03[医药卫生]