Barriers to the implementation of clinical evidence in primary care
Clinical research can only benefit patient and population health if findings are incorporated into routine care. There are delays and inappropriate variations in the uptake of evidence-based care and withdrawal of low-value or even harmful treatments.5 This translation gap limits the health, social and economic impacts of clinical research. Persistent inappropriate variations in care undermine efforts to achieve equity of outcomes; their magnitude cannot be explained away by population and casemix factors.
Primary care presents particular implementation challenges. In the UK, these include growing demand, increasing complexity of care and limited workforce capacity, against a background of recurrent organisational reconfigurations. There are also multiple competing priorities for attention, such as a steady stream of new guideline recommendations and quality indicators for performance management.6
Active strategies are needed to promote effective, efficient and equitable primary care. Addressing deficits in knowledge and resources is important, but insufficient by itself to bring about significant change.7 There is a substantial and growing evidence base to inform implementation strategies. For example, rigorous evaluations of interventions such as audit and feedback, computerised decision support and local opinion leaders all demonstrate improvements in patient care and outcomes.8
However, there are pitfalls in applying this evidence base to improvement efforts. First, it is hard to predict with confidence whether a given implementation strategy will work for a given targeted evidence-based practice. Some degree of judgement and acceptance of risk is inevitably required. Second, the effectiveness of most implementation strategies is typically modest, although still potentially important at a population level. This is partly because new randomised trials often test implementation interventions against control (no intervention) conditions rather than actively exploring how to enhance effectiveness through head-to-head trials of different interventions; this contributes to research waste.9 Third, there is limited evidence on the cost-effectiveness of implementation strategies and uncertainty about which targeted priorities would yield the greatest returns on investment, thereby handicapping decision-making in the face of competing priorities.