Protocol and registration
The systematic review protocol was registered in PROSPERO with ID number 152512
Identifying the research question
The primary question of this review was to review the effectiveness of implementation strategies for promoting evidence-informed interventions in allied health. A secondary aim was to describe the context in which certain implementation strategies were most effective.’
Eligibility criteria
Studies were selected based on the study design, the participants, implementation strategies and outcomes. Only randomized controlled trials (RCTs) and systematic reviews (SRs) were included. Within the SRs, only the primary RCTs were included that would satisfy the inclusion criteria.
Data was included if the participants were part of an allied health therapy group. The classification of allied health was based on the definition of Turnbull et. al [17] where four allied health groups were defined: a therapy group, a diagnostic and technical group, a scientific group and a complementary services group. In this paper, we will discuss the allied health therapy group only which includes nutritionist and dietitian, occupational therapist, physiotherapist, psychologist, podiatrist, social worker, speech pathologist, exercise physiologist, ambulance paramedic, music therapist, art therapist, exercise physiologist, ambulance officer, intensive care paramedics).
Studies were included if the implementation strategy was applied to the therapists in the allied health care therapy group (no patient only interventions) and if the implementation strategy was used to implement evidence informed healthcare guidelines. Studies were included if the outcomes addressed the impact on patient outcomes or process/profession outcomes. Studies were excluded if they were not original publications or were not published in the English language or were unable to be accessed in full text.
Information sources
Keywords were applied in Cochrane, Medline, Embase and Scopus databases on October 4th 2019.
Search
A systematic search was performed to identify literature regarding the effectiveness of research implementation strategies in allied health contexts. The keywords used were:
(health* or hospital*).
Allied Health Personnel/
("allied health personnel" or "allied health professional*" or "assistant*, healthcare" or "health personnel, allied" or "health professional*, allied" or "healthcare assistant*" or "healthcare support worker*" or "paramedic*" or "paramedical personnel" or "personnel, allied health" or "personnel, paramedical" or "population program specialist*" or "professional*, allied health" or "program specialist*, population" or "specialist*, population program" or "support worker*, healthcare" or "worker*, healthcare support").
"Diffusion of Innovation"/ or Evidence-Based Medicine/ or Evidence-Based Practice/ or Information Dissemination/
("Knowledge translation" or "knowledge transfer" or "knowledge implementation" or "knowledge utili?ation" or "knowledge dissemination" or "knowledge adoption" or "knowledge change*" or "knowledge evaluation" or "knowledge use*" or "knowledge institutionali?ation" or "knowledge communication" or "research translation" or "research transfer" or "research implementation" or "research utili?ation" or "research dissemination" or "research adoption" or "research change*" or "research evaluation" or "research use*" or "research institutionali?ation" or "research communication" or "evidence translation" or "evidence transfer" or "evidence implementation" or "evidence utili?ation" or "evidence dissemination" or "evidence adoption" or "evidence change*" or "evidence evaluation" or "evidence use*" or "evidence institutionali?ation" or "evidence communication" or "Translation of knowledge" or "translation of research" or "translation of evidence" or "transfer of knowledge" or "transfer of research" or "transfer of evidence" or "systematic review evidence" or "implementation strateg*").
A date limited search (from 2000 onwards) was applied as the contextual related factors (i.e. healthcare systems) have evolved over time. In addition, the use of formalised evidence-based clinical decision making became popular from approximately 1996 when Sackett and colleagues defned evidence-based clinical decision making as a combination of not only research evidence, but also clinical expertise, taking into account the patient’s preferences.[18]
Electronic database searches were supplemented by checking the reference list of included articles.
Searches were performed by two authors (KG and JD).
Study selection
From the initial search, duplicates were removed. Titles and abstracts were screened for eligibility based on the criteria above and full texts of potentially included studies were retrieved and further assessed for eligibility. Only level I and II studies (SRs and RCTs) were included as they represent the highest level of evidence. Studies were selected independently by two authors (KG and JD).
Data collation, summary and reporting of findings
A purpose-built Microsoft Excel© sheet was used to extract relevant data from the selected studies including the authors, study design, setting, participants, type of implementation strategy and the associated outcomes. Data was extracted by one author (KG)
Findings were categorised using the taxonomy of professional interventions form[8], and the nine clusters of implementation strategies.[10] The taxonomy of professional interventions include:
- Distribution of educational materials—distribution of published or printed recommendations for clinical care, including clinical practice guidelines, audio-visual materials, and electronic publications
- Educational meetings—health care providers who have participated in conferences, lectures, workshops, or traineeships
- Local consensus processes—inclusion of participating providers in discussion to ensure that they agreed that the chosen clinical problem was important and the approach to managing the problem was appropriate
- Educational outreach visits—use of a trained person who met with providers in their practice settings to give information with the intent of changing the provider's practice
- Local opinion leaders—use of providers nominated by their colleagues as “educationally influential.” The investigators must have explicitly stated that their colleagues identified the opinion leaders
- Patient mediated interventions—new clinical information (not previously available) collected directly from patients and given to the provider, e.g., depression scores from an instrument
- Audit and feedback—any summary of clinical performance of health care over a specified period of time
- Reminders—patient or encounter-specific information, provided verbally, on paper or on a computer screen that is designed or intended to prompt a health professional to recall information
- Marketing—use of personal interviewing, group discussion (“focus groups”), or a survey of targeted providers to identify barriers to change and subsequent design of an intervention that addresses identified barriers
- Mass media—(i) varied use of communication that reached great numbers of people including television, radio, newspapers, posters, leaflets, and booklets, alone or in conjunction with other interventions; and (ii) targeted at the population level
Risk of bias in individual studies
Two reviewers (KG and JD) independently assessed the quality of included publications using a relevant critical appraisal tool from the Scottish Intercollegiate Guidelines Network (SIGN) stable.[19] The relevant SIGN checklist was applied to the study and scored with scores < 3 categorised as low quality (LQ), between 4 and 6 average quality (AQ) and > 7 as high quality (HQ). Any disagreements were resolved by discussion between reviewers, and where agreement could not be reached an independent third reviewer (SM) was consulted. The SIGN checklists were used as they are widely used critical appraisal tools that are available for a range of study designs. [20]
Grading of Recommendations
Studies were assessed for relevancy, reliability, validity, and applicability and the level of Evidence was evaluated using the National Health and Medical Research Council (NHMRC) model for additional levels of evidence and grades for recommendations for developers of guidelines. The NHMRC model is a logical and intuitive way to formulate and grade recommendations that has been widely adopted by Australian guideline developers.[21] The grading process of the NHMRC process is described in Table 1 of the supplementary files.