BACKGROUND: As a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination.
METHODS: This overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA).
RESULTS: This overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways-single intervention, educational meeting-single intervention, organizational culture, and audit and feedback-both strategies implemented in combination with others-were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term.
CONCLUSION: This overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.
People with coronavirus disease (COVID-19) might have several risk factors for delirium, which could in turn notably worsen the prognosis. Although pharmacological approaches for delirium are debated, haloperidol and other first-generation antipsychotics are frequently employed, particularly for hyperactive presentations. However, the use of these conventional treatments could be limited in people with COVID-19, due to the underlying medical condition and the risk of drug–drug interactions with anti-COVID treatments. On these premises, we carried out a rapid review in order to identify possible alternative medications for this particular population. By searching PubMed and the Cochrane Library, we selected the most updated systematic reviews of randomised trials on the pharmacological treatment of delirium in both intensive and non-intensive care settings, and on the treatment of agitation related to acute psychosis or dementia. We identified medications performing significantly better than placebo or haloperidol as the reference treatment in each population considered, and assessed the strength of association according to validated criteria. In addition, we collected data on other relevant clinical elements (i.e. common adverse events, drug-drug interactions with COVID-19 medications, daily doses) and regulatory elements (i.e. therapeutic indications, contra-indications, available formulations). A total of 10 systematic reviews were included. Overall, relatively few medications showed benefits over placebo in the four selected populations. As compared with placebo, significant benefits emerged for quetiapine and dexmedetomidine in intensive care unit (ICU) settings, and for none of the medications in non-ICU settings. Considering also data from indirect populations (agitation related to acute psychosis or dementia), aripiprazole, quetiapine and risperidone showed a potential benefit in two or three different populations. Despite limitations related to the rapid review methodology and the use of data from indirect populations, the evidence retrieved can pragmatically support treatment choices of frontline practitioners involved in the COVID-19 outbreak, and indicate future research directions for the treatment of delirium in particularly vulnerable populations.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
BACKGROUND:: Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse.
AIMS:: We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice.
METHODS:: We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified.
RESULTS:: Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only.
CONCLUSION:: More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
BACKGROUND: A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.
OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.
METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.
MAIN RESULTS: We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories – strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.
AUTHORS' CONCLUSIONS: Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
BACKGROUND: One target of the Sustainable Development Goals is to achieve "universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". A fundamental concern of governments in striving for this goal is how to finance such a health system. This concern is very relevant for low-income countries.
OBJECTIVES: To provide an overview of the evidence from up-to-date systematic reviews about the effects of financial arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on financial arrangements, and informing refinements in the framework for financial arrangements presented in the overview.
METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language, or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of financial arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment, or financial burden of patients, e.g. out-of-pocket payment, catastrophic disease expenditure) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.
MAIN RESULTS: We identified 7272 reviews and included 15 in this overview, on: collection of funds (2 reviews), insurance schemes (1 review), purchasing of services (1 review), recipient incentives (6 reviews), and provider incentives (5 reviews). The reviews were published between 2008 and 2015; focused on 13 subcategories; and reported results from 276 studies: 115 (42%) randomised trials, 11 (4%) non-randomised trials, 23 (8%) controlled before-after studies, 51 (19%) interrupted time series, 9 (3%) repeated measures, and 67 (24%) other non-randomised studies. Forty-three per cent (119/276) of the studies included in the reviews took place in low- and middle-income countries. Collection of funds: the effects of changes in user fees on utilisation and equity are uncertain (very low-certainty evidence). It is also uncertain whether aid delivered under the Paris Principles (ownership, alignment, harmonisation, managing for results, and mutual accountability) improves health outcomes compared to aid delivered without conforming to those principles (very low-certainty evidence). Insurance schemes: community-based health insurance may increase service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). It is uncertain whether social health insurance improves utilisation of health services or health outcomes (very low-certainty evidence). Purchasing of services: it is uncertain whether increasing salaries of public sector healthcare workers improves the quantity or quality of their work (very low-certainty evidence). Recipient incentives: recipient incentives may improve adherence to long-term treatments (low-certainty evidence), but it is uncertain whether they improve patient outcomes. One-time recipient incentives probably improve patient return for start or continuation of treatment (moderate-certainty evidence) and may improve return for tuberculosis test readings (low-certainty evidence). However, incentives may not improve completion of tuberculosis prophylaxis, and it is uncertain whether they improve completion of treatment for active tuberculosis. Conditional cash transfer programmes probably lead to an increase in service utilisation (moderate-certainty evidence), but their effects on health outcomes are uncertain. Vouchers may improve health service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). Introducing a restrictive cap may decrease use of medicines for symptomatic conditions and overall use of medicines, may decrease insurers' expenditures on medicines (low-certainty evidence), and has uncertain effects on emergency department use, hospitalisations, and use of outpatient care (very low-certainty evidence). Reference pricing, maximum pricing, and index pricing for drugs have mixed effects on drug expenditures by patients and insurers as well as the use of brand and generic drugs. Provider incentives: the effects of provider incentives are uncertain (very low-certainty evidence), including: the effects of provider incentives on the quality of care provided by primary care physicians or outpatient referrals from primary to secondary care, incentives for recruiting and retaining health professionals to serve in remote areas, and the effects of pay-for-performance on provider performance, the utilisation of services, patient outcomes, or resource use in low-income countries.
AUTHORS' CONCLUSIONS: Research based on sound systematic review methods has evaluated numerous financial arrangements relevant to low-income countries, targeting different levels of the health systems and assessing diverse outcomes. However, included reviews rarely reported social outcomes, resource use, equity impacts, or undesirable effects. We also identified gaps in primary research because of uncertainty about applicability of the evidence to low-income countries. Financial arrangements for which the effects are uncertain include external funding (aid), caps and co-payments, pay-for-performance, and provider incentives. Further studies evaluating the effects of these arrangements are needed in low-income countries. Systematic reviews should include all outcomes that are relevant to decision-makers and to people affected by changes in financial arrangements.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
OBJECTIVE: To assess the available scientific evidence regarding the efficacy of interventions aimed to enhance medication adherence in patients with multiple chronic conditions (PMCC).
DESIGN: Overview of systematic reviews.
DATA SOURCES: The following databases were consulted (September 2013): Pubmed, EMBASE, the Cochrane Library, CRD and WoS to identify interventions aimed to enhance medication adherence in PMCC, or otherwise, patients with chronic diseases common in the PMCC, or polypharmacy.
STUDY SELECTION: Systematic reviews of clinical trials focused on PMCC or similar were included. They should compare the efficacy of any intervention aimed to improve compliance to prescribed and self-administered medications with clinical practice or other interventions.
DATA EXTRACTION: Information about the study population, nature of intervention and efficacy in terms of improved adherence was extracted.
RESULTS: 566 articles were retrieved of which 9 systematic reviews were included. None was specifically focused on PMCC but considered patients with chronic diseases common in the PMCC, patients with more than one chronic disease and polypharmacy. The overall effectiveness of interventions was modest without relevant differences between behavioural, educational and combined interventions. Some components of these interventions including patient counselling and regimen simplification appear to be effective tools in improving adherence in this population group.
CONCLUSION: There is a large heterogeneity of interventions aimed to improve adherence with modest efficacy, none in PMCC.
ANTECEDENTES: Muchos países están desarrollando estrategias de prevención del suicidio para las cuales se requiere evidencia actualizada y de alta calidad. MÉTODOS: Se realizaron búsquedas en PubMed y en la Biblioteca Cochrane utilizando múltiples términos relacionados con la prevención del suicidio para los estudios publicados entre el 1 de enero de 2005 y el 31 de diciembre de 2014. Se evaluaron siete intervenciones: La educación pública y médica, las estrategias de los medios de comunicación, el cribado, la restricción del acceso a los medios de suicidio, los tratamientos y el apoyo por internet o por línea telefónica. Se extrajeron datos sobre los resultados primarios de interés, a saber, comportamiento suicida (suicidio, intento o ideación) y resultados intermedios o secundarios (búsqueda de tratamiento, identificación de individuos en riesgo, tasas de prescripción o uso de antidepresivos o referencias). 18 expertos en prevención de suicidios de 13 países europeos revisaron todos los artículos y evaluaron la fuerza de la evidencia utilizando los criterios de Oxford. Debido a que la heterogeneidad de las poblaciones y la metodología no permitieron metanálisis formal, presentamos un análisis narrativo. RESULTADOS: Se identificaron 1797 estudios, incluyendo 23 revisiones sistemáticas, 12 metaanálisis, 40 ensayos controlados aleatorios (ECA), 67 estudios de cohortes y 22 estudios ecológicos o basados en la población. La evidencia de restricción del acceso a medios letales en la prevención del suicidio se ha fortalecido desde 2005, especialmente en lo que se refiere al control de los analgésicos (disminución general del 43% desde 2005) y los puntos calientes de suicidio por salto (reducción del 86% A 91%). Se ha demostrado que los programas de concienciación en la escuela reducen los intentos de suicidio (odds ratio [OR] 0 · 45, IC del 95% 0 · 24-0 85], p = 0, 014) y la ideación suicida (0, 5, -0 · 92; p = 0 · 025). Los efectos anti-suicidas de la clozapina y el litio han sido probados, pero podrían ser menos específicos de lo que se pensaba anteriormente. Los tratamientos farmacológicos y psicológicos eficaces de la depresión son importantes en la prevención. No existen pruebas suficientes para evaluar los posibles beneficios de la prevención del suicidio en la atención primaria, en la educación general del público y en las directrices de los medios de comunicación. Otros enfoques que necesitan más investigación incluyen la formación de guardián, la educación de los médicos, y el apoyo de Internet y ayuda. La escasez de ECA es una limitación importante en la evaluación de las intervenciones preventivas. INTERPRETACIÓN: En la búsqueda de iniciativas eficaces de prevención del suicidio, ninguna estrategia única claramente está por encima de las demás. Las combinaciones de estrategias basadas en la evidencia a nivel individual y el nivel de población deben ser evaluadas con diseños de investigación sólidos. FINANCIACIÓN: Plataforma de Expertos en Salud Mental, Foco en la Depresión, y el Colegio Europeo de Neuropsicofarmacología.
BACKGROUND AND AIM: The Danish Health and Medicines Authority assembled a group of experts to develop a national clinical guideline for patients with schizophrenia and complex mental health needs. Within this context, ten explicit review questions were formulated, covering several identified key issues.
METHODS: Systematic literature searches were performed stepwise for each review question to identify relevant guidelines, systematic reviews/meta-analyses, and randomized controlled trials. The quality of the body of evidence for each review question was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Clinical recommendations were developed on the basis of the evidence, assessment of the risk-benefit ratio, and perceived patient preferences.
RESULTS: Based on the identified evidence, a guideline development group (GDG) recommended that the following interventions should be offered routinely: antipsychotic maintenance therapy, family intervention and assertive community treatment. The following interventions should be considered: long-acting injectable antipsychotics, neurocognitive training, social cognitive training, cognitive behavioural therapy for persistent positive and/or negative symptoms, and the combination of cognitive behavioural therapy and motivational interviewing for cannabis and/or central stimulant abuse. SSRI or SNRI add-on treatment for persistent negative symptoms should be used only cautiously. Where no evidence was available, the GDG agreed on a good practice recommendation.
CONCLUSIONS: The implementation of this guideline in daily clinical practice can facilitate good treatment outcomes within the population of patients with schizophrenia and complex mental health needs. The guideline does not cover all available interventions and should be used in conjunction with other relevant guidelines.
La clozapina constituye el tratamiento de elección en los pacientes con esquizofrenia que no presentan remisión de los síntomas pese al manejo con antipsicóticos por periodos de tiempo y en dosis adecuados. Sin embargo, un porcentaje importante persiste sintomático pese al tratamiento con dosis óptimas de clozapina, por lo que se ha planteado que agregar un segundo antipsicótico podría mejorar la respuesta clínica. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, identificamos 17 revisiones sistemáticas que en conjunto incluyen 62 estudios, entre ellos 26 estudios aleatorizados pertinentes. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que agregar un segundo antipsicótico a la clozapina en pacientes con esquizofrenia resistente probablemente resulta en poca o nula diferencia en la respuesta clínica, y aumenta los efectos adversos.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
ANTECEDENTES: Existen muchas revisiones sistemáticas sobre las intervenciones para mejorar medicamentos seguros y eficaces utilizan por los consumidores, pero la investigación se distribuye a través de enfermedades, poblaciones y entornos. El alcance y enfoque de dichas revisiones también varían ampliamente, creando desafíos para los tomadores de decisiones que tratan de informar las decisiones mediante el uso de las pruebas en las medicinas de los consumidores utilizan.
Esta es una actualización de una visión 2011 de las revisiones sistemáticas, que sintetiza la evidencia, con independencia de la enfermedad, el tipo de la medicina, la población o el ajuste, en la efectividad de las intervenciones para mejorar los medicamentos de los consumidores utilizan.
OBJETIVOS: Evaluar los efectos de las intervenciones que se dirigen a los consumidores de la salud para promover medicamentos seguros y eficaces utilizan, sintetizando evidencia a nivel de revisión.
ESTRATEGIA DE BÚSQUEDA: Se incluyeron revisiones sistemáticas publicadas en la Base de Datos Cochrane de Revisiones Sistemáticas y la Base de Datos de Resúmenes de Revisiones de Efectos. Se identificaron las revisiones pertinentes mediante búsquedas manuales en las bases de datos de sus fechas de inicio a marzo de 2012.
Criterios de selección: Se seleccionaron y calificadas opiniones basadas en la relevancia a los medicamentos de los consumidores usar, utilizando criterios desarrollados para este resumen.
Recopilación y análisis de datos: Se utilizaron formularios estandarizados para extraer los datos y evaluaron la calidad metodológica de opiniones con la función AMSTAR. Utilizamos lenguaje estandarizado para resumir los resultados dentro ya través de exámenes; y dio declaraciones a la línea de fondo acerca de la efectividad de la intervención. Dos revisores analizaron y opiniones seleccionaron y extrajeron y analizaron los datos. Usamos una taxonomía de las intervenciones para categorizar opiniones y síntesis de guía.
Resultados principales: Se incluyeron 75 revisiones sistemáticas de variada calidad metodológica. Comentarios evaluaron intervenciones con diversos fines, incluyendo soporte para el cambio de comportamiento, la minimización de riesgos y la adquisición de competencias. No hay comentarios dirigidos a promover la participación a nivel de los sistemas de los consumidores en las actividades relacionadas con los medicamentos. Medicamentos adherencia fue el resultado más informado, con frecuencia, pero también se informó que otros, como el conocimiento, los resultados clínicos y el servicio de uso. Los eventos adversos fueron menos comúnmente identificados, mientras que las asociadas a los mismos, o los costos de las intervenciones, fueron raramente reportados.
Mirando a través de comentarios, para la mayoría de los resultados, los programas de medicamentos auto-monitoreo y auto-gestión aparecen generalmente eficaz para mejorar uso de los medicamentos, la adhesión, los eventos adversos y los resultados clínicos; y para reducir la mortalidad en la terapia antitrombótica personas autogestionario. Sin embargo, algunos participantes no pudieron completar estas intervenciones, lo que sugiere que puede no ser adecuado para todos.
Otras intervenciones prometedoras para mejorar el cumplimiento y otros resultados clave medicamentos de uso, que requieren una mayor investigación para ser más seguros de sus efectos, se incluyen:
· Regímenes de dosificación simplificado: con efectos positivos sobre la adhesión;
· Intervenciones que incluyen los farmacéuticos en la gestión de medicamentos, como los medicamentos opiniones (con efectos positivos sobre la adherencia y el uso, los problemas de los medicamentos y los resultados clínicos) y los servicios de atención farmacéutica (consulta entre farmacéutico y paciente para resolver los problemas de los medicamentos, desarrollar un plan de atención y proporcionan seguimiento arriba, con efectos positivos sobre la adherencia y el conocimiento).
Varias otras estrategias mostraron algunos efectos positivos, especialmente en relación con la adherencia, y otros resultados, pero sus efectos fueron menos consistentes necesidad general y así un mayor estudio. Estos incluyen:
· Retrasado prescripciones de antibióticos: eficaz para disminuir el uso de antibióticos, pero con efectos mixtos en los resultados clínicos, los efectos adversos y la satisfacción;
· Estrategias prácticas como recordatorios, indicaciones y / u organizadores, envases con recordatorios y los incentivos materiales: con positivo, aunque los efectos poco precisos sobre la adherencia;
· Educación entregado con entrenamiento en habilidades de autocuidado, el asesoramiento, el apoyo, la formación o el incremento de seguimiento; información y asesoramiento entregan juntos; o la educación / información como parte de los paquetes por farmacéuticos entregada de cuidado: con efectos positivos sobre la adherencia, uso de medicamentos, los resultados clínicos y conocimientos, pero con efectos mixtos en algunos estudios;
· Incentivos financieros: con efectos positivos, pero mixta, sobre la adherencia.
Varias estrategias también mostraron promesa en la promoción de adopción de la inmunización, pero requieren más estudios para estar más seguro de sus efectos. Estas intervenciones organizativas incluidas; recordatorios y retiro; incentivos financieros; visitas a domicilio; vacunación gratuita; sentar las intervenciones del personal de salud; y facilitadores que trabajan con los médicos para promover la adopción de la inmunización. Las estrategias de educación y / o de información también mostraron algunos efectos positivos, pero aún menos consistente en la captación de la inmunización, y la necesidad de una nueva evaluación de la eficacia y la investigación de la heterogeneidad.
Hay muchos diferentes vías posibles a través del cual el uso de medicamentos de los consumidores podrían ser objeto de mejorar los resultados y las intervenciones simples pueden ser tan efectivas como las estrategias complejas. Sin embargo, hay una única intervención evaluada fue eficaz para mejorar los resultados de los medicamentos de uso en todas las enfermedades, medicamentos, poblaciones o ajustes.
Aun cuando las intervenciones mostraron promesa, las pruebas reunidas a menudo sólo proporcionó parte de la imagen: por ejemplo, los regímenes de dosificación simplificados parecen eficaces para mejorar la adherencia, pero todavía no hay información suficiente para identificar un régimen óptimo.
En algunos casos las intervenciones parecen ineficaces: por ejemplo, la evidencia sugiere que la terapia directamente observada puede ser generalmente ineficaces para mejorar el cumplimiento del tratamiento, la adhesión o los resultados clínicos.
En otros casos, las intervenciones pueden tener efectos variables a través de los resultados. A modo de ejemplo, las estrategias que proporcionen información o educación como intervenciones individuales parecen ineficaces para mejorar la adherencia medicamentos o los resultados clínicos, pero pueden ser efectivos para mejorar el conocimiento; un resultado importante para la promoción de medicamentos informados opciones de los consumidores.
A pesar de una duplicación en el número de revisiones incluidas en este resumen actualizado, todavía existe incertidumbre acerca de la efectividad de muchas intervenciones, y la evidencia de lo que funciona sigue siendo escasa para varias poblaciones, incluidos los niños y los jóvenes, cuidadores y personas con multimorbilidad.
Conclusiones de los autores: Este resumen se presenta evidencia de 75 comentarios que se han sintetizado las pruebas y otros estudios que evalúan los efectos de las intervenciones para mejorar los consumidores el uso de medicamentos.
Montaje de forma sistemática las pruebas a través de comentarios permite la identificación de intervenciones eficaces o prometedoras para mejorar los medicamentos de los consumidores utilizan, así como aquellos para los que la evidencia indica la ineficacia o la incertidumbre.
Los tomadores de decisiones enfrentan a la implementación de intervenciones para mejorar los medicamentos de los consumidores el uso puede utilizar este resumen para informar las decisiones acerca de qué intervenciones pueden ser más prometedora para mejorar los resultados particulares. La taxonomía de intervención también puede ayudar a las personas a considerar las estrategias disponibles en relación con los propósitos específicos, por ejemplo, la obtención de habilidades o participar en la toma de decisiones. Los investigadores y los financiadores pueden utilizar este resumen para identificar dónde se necesita más investigación y evaluar su prioridad. Las limitaciones de la literatura disponible debido a la falta de evidencia de los resultados importantes y poblaciones importantes, tales como las personas con multimorbilidad, también deben ser considerados en la práctica las decisiones y políticas.
As a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination.
METHODS:
This overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA).
RESULTS:
This overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways-single intervention, educational meeting-single intervention, organizational culture, and audit and feedback-both strategies implemented in combination with others-were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term.
CONCLUSION:
This overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.
Síntesis amplia»Revisión panorámica de revisiones sistemáticas
