It is imperative that we improve, or seek new ways of promoting guideline use, but there are many possible ways to do this. To identify the most productive avenue for ongoing investigation it is essential to first analyze related issues, and select an approach that is relevant and actionable. Many factors influence whether and how guidelines are used, including guideline characteristics (quality of format and content), and individual (provider characteristics), institutional (capacity to collect, adapt, share and apply evidence), and health system (policies, resources) attributes [9-12]. While these factors may challenge use of guidelines, it appears that a number of issues may be influential further upstream of the setting in which guidelines are meant to be applied.

Repeat survey of Canadian guideline developers in 1994, 2002 and 2008, and a survey of organizations in Africa, Asia, Europe, Latin America, the United States, and United Kingdom found that few actively implemented their guidelines [13,14]. There may be several reasons for this. Evidence on the impact of different guideline implementation strategies is unclear. Educational (materials, meetings), social engagement (opinion leaders, educational outreach), embedding (clinical support systems, reminders), and incentive (audit & feedback, pay-for-performance) approaches had a small to moderate impact either alone or in combination, but not consistently, and many of these studies did not include economic analyses [15-22]. Most strategies are not routinely applied outside of experimental studies and few program evaluations are published which would provide information about the impact and implications of these strategies in a variety of contexts. By systematic review we found no studies evaluating implementation of breast cancer management guidelines [23], and only two studies evaluating implementation for colorectal cancer management guidelines [24]. Therefore, little data about cost and contextual effectiveness is available to guide decisions about which implementation strategies are most useful in the real world.

Guideline implementation is quite complex, involving multiple stages including creating actionable products, adapting them to local context, assessing barriers, selecting and applying interventions, monitoring use, evaluating outcomes, and sustaining use [25]. Interviews with health professionals in the United Kingdom revealed they had difficulty in acquiring resources to fund implementation, often turning to “soft” money from pharmaceutical companies or charities for more traditional passive (mailing, posting on web site) or educational (meetings) strategies [17]. Thus implementation capacity, which could be defined as the knowledge, resources, infrastructure and practices required to implement guidelines may be lacking, and therefore limits use of, or successful application of existing strategies for promoting guideline uptake.

We learned that not all guideline development organizations are mandated to implement their guidelines. Those with an implementation mandate featured widely inconsistent funding and staffing models, differing approaches for choosing implementation strategies most often dependent on guideline characteristics, and a range of dissemination and implementation activities including access (web sites, publications), alerts (newsletters, media campaigns), distribution (regular mail, email), education, champions, and organizational partnerships. These findings highlight variable implementation practices and emphasize the lack of insight on how to optimize implementation capacity. While implementation approaches and strategies need not be standardized across organizations, the findings suggest that even if we learn more about how to tailor implementation strategies to enhance their effectiveness, it is not clear who would apply these strategies, and how, given variable mandates, lack of frameworks to guide implementation decision making, and limited resources.

It is well recognized that producing guidelines does not improve the quality of health care, yet the issue of how to achieve implementation of guidelines remains. Participants were asked to comment on the pros and cons associated with three implementation approaches that differed by responsibility, and to recommend an optimal approach. Most participants selected the option of including information within guidelines that would help users to implement them. Given variable mandate and resources for guideline implementation, it was considered the most feasible and cost-effective approach, and therefore most likely to have impact due to potentially broad use. Participants referred to this as “more bang for the buck”. While the other two strategies considered were perceived to have some merit, their feasibility and application were questioned, so it is not surprising that an innovative approach was preferred. Many research studies have found that implementation capacity is a key barrier of guideline implementation [1,7], and that, quite reasonably, as a result of limited mandate and resources many developers do not implement their guidelines [13,14,17]. While intermediaries were commonly viewed as an effective mechanism for promoting use of guidelines, uncertainty about their characteristics and roles as expressed by participants was similar to that described in published research [16,17,30].

We are investigating how to tailor guidelines with information that supports user implementation. A review of the medical literature identified features desired by different users, or associated with guideline use [33]. The Guideline Implementability Framework included 22 elements organized within eight domains: adaptability, usability, relevance, validity, applicability, communicability, resource implications, implementation and evaluation. Subsequent analysis of 20 high quality guidelines on various clinical indications found that most did not contain implementability elements, highlighting numerous opportunities to potentially improve guideline development and use by integrating one or more of these elements [33]. We have identified and described tools that could be included in guidelines to help users address Resource Implications (equipment or technology needed; industrial standards; policies governing their use; type and number of health professionals needed to deliver services; education, training or competencies needed by staff to deliver services; anticipated changes in workflow or processes during or after adoption), Implementation (identifying barriers associated with adoption; selecting and tailoring implementation strategies that address barriers) and Evaluation (tools based on performance measures to assess baseline and post intervention compliance with guidelines). These tools will populate an open directory to which others can contribute. This is a core activity of the Guideline Implementability Research and Application Network (GIRAnet), and may lead to a sustainable effort where guideline developers, implementers and researchers contribute to, and draw from this shared resource on an international basis [34].

Interpretation of study results may be confounded by several issues. The limitation most commonly associated with exploratory or qualitative research is transferability or relevance to other settings. We attempted to mitigate this through purposive sampling of 30 guideline development agencies from seven different countries that produced guidelines for a variety of disciplines and clinical indications. While we achieved thematic saturation, meaning that no further unique ideas emerged with successive interviews, and we found no trends by country, type of guideline developer organization, or guideline clinical indication, we sampled only from industrialized, English-speaking countries, which may have introduced selection bias. The notable exception was the World Health Organization which produces guidelines for non-industrialized countries and therefore provided opinions based on relevance of strategies for implementing guidelines in those settings. Another possible limitation is that participants were prompted to discuss only three differing approaches for guideline implementation. While there are many strategies for implementing guidelines, we chose these three high level approaches specifically because they represented a diversity of responsibility for guideline implementation, but each still encompassed a range of possible implementation strategies. Finally, even if capacity were improved to optimize these approaches, a number of contextual barriers challenge guideline use in the settings where health care is delivered. While this is true, the approach of creating implementable guidelines, thought to be most promising by guideline developers and which we are investigating, is meant to help users overcome those contextual barriers. Tailoring of guideline products in this manner may be complementary to tailoring of strategies to implement those guidelines, but further research is needed to develop these approaches, and more rigorously evaluate their individual and combined impact.