Institutionen för folkhälsovetenskap / Department of Public Health Sciences
Abstract
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