Key messages
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Tailored implementation strategies (activities designed to tackle specific challenges facing healthcare professionals trying to action a new practice or recommendation) likely lead to slight improvements in how well healthcare professionals follow clinical guidelines.
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Very few studies tested the effectiveness of tailored strategies in low- and middle-income countries.
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Future research should explore how and why tailored strategies work, for whom and in what circumstances. The impact of tailored strategies in low- and middle-income countries should also be studied in more detail.
What are tailored implementation strategies?
Healthcare professionals are encouraged to follow clinical guidelines to give people the best possible care. However, in real life, healthcare professionals often face barriers that make it difficult for them to follow these recommendations. These barriers might be lack of time, limited access to staff or equipment, unclear instructions, or beliefs about clinical guidelines that make change harder. Tailored implementation strategies are bundles of activities chosen to address the specific challenges faced by healthcare professionals in a given setting. The aim is to make it easier for healthcare professionals to follow the guidelines consistently over time. For example, if nurses in a busy clinic find a guideline too long to use during short appointments, a tailored strategy might provide a short visual summary or electronic prompts to remind the nurse about which actions to take. In contrast, a non-tailored strategy might be simply to distribute the full guideline without any consideration of the challenges faced by the nurses.
What did we want to find out?
We wanted to know if tailored strategies work better than non-tailored strategies or no strategy in helping healthcare professionals follow clinical guidelines. We looked at changes in healthcare professionals’ actions – for example, whether they prescribed appropriate medicines or delivered the type of care recommended in the guidelines.
What did we do?
We searched for studies that compared tailored strategies with non-tailored strategies or no strategy. We summarised the findings and assessed how confident we could be in the results, based on how the studies were designed and carried out.
What did we find?
We found 79 studies that tested tailored strategies in healthcare settings. Most studies were in high-income countries, for example, the USA (19 studies) and the Netherlands (13 studies). Only eight studies were in low-income countries. Studies took place in a variety of healthcare settings, such as pharmacies, doctors' surgeries, nursing homes or hospital inpatient or outpatient departments. The healthcare professionals were also mixed and included mixed groups in 47 studies, physicians in 22 studies, nurses in 5, pharmacists in 1, and ‘other’ in 4 studies.
Most tailored strategies involved several activities. The most common included providing educational materials designed for doctors or nurses, running training sessions or educational meetings, and giving feedback to professionals about their performance. The strategies selected were used to tackle common barriers identified in the studies, including characteristics of health professionals (such as familiarity with the guidelines), aspects of the setting where the intervention was being implemented (the number of resources or incentives available to put best practice into action), and miscommunication between members of clinical teams (for example, from the lack of routine clinical meetings).
Overall, tailored strategies probably lead to small improvements in how well professionals follow clinical guidelines, compared to non-tailored strategies. The evidence indicates similar results for tailored strategies compared to no strategy.
What are the limitations of the evidence?
Our confidence in the evidence is moderate. Studies used different methods to measure the impact of tailored strategies on healthcare professional practice. Studies also applied tailoring in different ways. These differences make it difficult to say which tailoring approaches work best or under what circumstances. Most studies were done in high-income countries, so we cannot tell how well the findings apply in low- or middle-income countries.
How up to date is this evidence?
This is an update of a previous review. The evidence is current to 5 March 2024.
Read the full abstract
Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants.
Objectives
To assess the effect of tailored implementation strategies, compared with a non-tailored strategy or no strategy, in improving healthcare professional practice.
Secondary objectives were to assess whether the effects of tailored implementation strategies differ according to whether theory, evidence of the effectiveness of strategies, and input from stakeholders were involved in the tailoring process, and to assess whether the effects of tailored implementation strategies differ according to setting (high- or low-income country).
Search strategy
We searched CENTRAL, MEDLINE, Embase, two other databases and two trials registers from 2014 to 5 March 2024. We performed a forward citation search for papers citing the previous update. We did not apply any restrictions on date of publication, publication status or language.
Selection criteria
Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice.
Data collection and analysis
Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified.
Main results
We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression.
Authors' conclusions
Despite the increase in the number of new studies identified, our overall finding is like that of the previous review. Tailored implementation strategies probably result in a slight improvement in professional practice.
Funding
Dr Sheena McHugh received funding from the Irish Health Research Board (HRB-RL-2020-004) that helped to support the conduct of this review.
Registration
Registration: Zenodo, 7104299, via DOI: 10.5281/zenodo.7104299
Protocol available via DOI: https://doi.org/10.5281/zenodo.7104299
Previous versions available via: DOI: 10.1002/14651858.CD005470.pub3, DOI: 10.1002/14651858.CD005470.pub2, and DOI: 10.1002/14651858.CD005470
