Life In The Slower Lane

Here is the structured PICO analysis for the sixty-first article you uploaded:

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Full Title (verbatim and exact):

“Implementing guidelines in nursing homes: a systematic review”

Diehl H, Graverholt B, Espehaug B, Lund H

BMC Health Services Research (2016); 16:298

DOI: 10.1186/s12913-016-1550-z

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Type of Article:

Systematic review (5 cluster-randomised controlled trials)

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PICO Analysis:

Population:

• Healthcare personnel and residents in nursing home settings, across five cluster-RCTs
• Total of 9750 residents from 184 nursing homes included
• Mean resident age: ~83 years
• Study locations: Belgium, Germany, USA, Netherlands, and Australia 

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Intervention:

• All studies used multifaceted implementation strategies to promote clinical guideline uptake
• Common components included:
  • Educational meetings
  • Printed educational materials
  • Audit and feedback
  • Academic detailing
  • Organisational support (e.g. project nurse, care teams) 

Six different guideline topics were targeted:

1. Oral health care
2. Physical restraint reduction
3. Antipsychotic prescribing
4. Pressure ulcer prevention
5. Falls prevention
6. Infection prevention

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Comparator:

• Usual care or passive dissemination of guidelines
• In most studies, control groups received minimal or no targeted implementation support 

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Outcome:

1. Person-centred outcomes (patient-level):

• Assessed in 3 of 5 studies:
  • Reduction in denture plaque (significant) but not tongue or dental plaque 
  • Reduction in pressure ulcers, UTIs, falls (mixed results; one study found a significant reduction of adverse events per patient-week, rate ratio 0.67)
  • Femoral neck fractures (no significant reduction)
• Overall quality of evidence: low to very low due to small sample sizes, single studies, and risk of bias 

2. Process outcomes (professional practice):

• Four studies assessed:
  • Use of physical restraints: decreased significantly in one study (RR 0.78; 95% CI: 0.63–0.97)
  • Antipsychotic prescribing: no significant change
  • Adherence to fall prevention or infection control measures: no consistent effects
  • Vitamin D and hip protector use: no change 
• High risk of contamination bias in 3 studies (e.g., simultaneous national campaigns, shared staffing between intervention and control units) likely diluted effects

3. Health system outcomes:

• Not directly measured, but studies referenced hoped-for impacts such as:
  • Reduced hospitalisations
  • Improved quality and safety indicators
  • More cost-effective care via better guideline uptake

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Summary Conclusion:

This systematic review identified only five high-quality studies evaluating the effectiveness of guideline implementation strategies in nursing homes. While some improvement in professional practice (e.g., reduced restraint use) and patient outcomes (e.g., reduced denture plaque, adverse event rates) was observed, the overall effects were small, inconsistent, and of low certainty. The review highlights a major evidence gap in the implementation science of aged care and recommends that future research:

• Use theory-informed approaches
• Address barriers to change
• Focus on measurable guideline uptake, not just clinical outcomes
• Improve methodological quality and reduce contamination

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