Turning guidelines into clinical practice : Findings from an implementation study

Sammanfattning: Aim: The general aim of this thesis is to describe factors of importance when implementing clinical guidelines in psychiatry, and more specifically contribute to a better understanding of the implementation process. The specific aims are: Study I, to investigate a tailored implementation programme for implementing clinical guidelines for depression and suicidal patients, and to evaluate the compliance to guidelines after 6 months. In Study II, to further investigate compliance after 12 and 24 months. In Study III, to more specifically investigate perceptions of clinical guidelines and to identify barriers to, and facilitators of, implementation. Finally, in Study IV, to evaluate clinical outcomes and patient costs comparing patients who received psychiatric care according to guidelines with those who received treatment as usual. Methods: Six psychiatric clinics in Stockholm, Sweden participated in implementing clinical guidelines for depression and suicidal patients. The guidelines were actively implemented at four clinics, and the other two only received the guidelines and served as controls. In Study I, 725 patient were included, 365 before implementation and 360 six months after. Compliance to guidelines was measured using quality indicators derived from the guidelines. In Study II, further data collection took place after 12 and 24 months and a total of 2,165 patients were included. Study III was qualitative and conducted at two of the psychiatric clinics. Data were collected using three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data. Study IV included the two clinics that implemented the clinical guidelines for depression and the control clinic that only received the guidelines. A cost analysis of guideline implementation was performed and patient outcomes were assessed after 12 months. Results: In Study I, the implementing clinics significantly improved their recording of quality indicators compared to the control clinics. No changes were found in the control clinics. In Study II, the difference between the implementation clinics and control clinics persisted over 12 and 24 months. In Study III, the practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction. In Study IV, the psychiatric outcome measures improved significantly at the clinics with an active implementation compared to the control clinic. The costs were also lower. Conclusion: Our results showed that compliance to the guidelines was better at the clinics with an active implementation than at the control clinics and that this difference was sustained after 12 and 24 months. Additionally, patients at the intervention clinics were significantly more likely to be clinically improved, and at a lower cost.