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Table 1 Previous studies—improving guideline concordance in the field of CR

From: Evaluating the effect of a web-based quality improvement system with feedback and outreach visits on guideline concordance in the field of cardiac rehabilitation: rationale and study protocol

Study Description of the studies
I. Tackling internal barriers: CDS To stimulate the implementation of the Dutch CR Guidelines, an EPR with CDS functionalities named CARDSS (cardiac rehabilitation decision support system) was previously developed [5]. After entering patient data, CARDSS provides its users with a patient-specific, guideline-based rehabilitation program, consisting of recommended rehabilitation goals and therapies. The effect of the system was evaluated in a cluster-randomized trial in 21 CR clinics, which showed that the system increased concordance to the CR guideline: CR professionals using the system better adapted the CR therapy to patients’ needs [7]. Data from the same trial however pointed out that there remained to exist a large variation in CR practice across clinics. For instance, the percentage of patients participating in exercise training varied from 41% in one clinic to 100% in another and the percentage of patients participating in education and counseling programs varied from 39% to 96%.
II. Persisting barriers after introduction of CDS After the trial a qualitative study was conducted to investigate which barriers were reduced and which barriers persisted after introduction of the CDS system [8]. Results from semi-structured interviews with 29 CR professionals showed that the system succeeded in overcoming professional knowledge barriers. For instance, professionals were more aware of the need to use objective instruments to assess patients’ needs and of the therapy decision rules as described in the guidelines. However, two remaining barriers for guideline concordance frequently mentioned were organizational and guideline-related barriers; both can be classified as external barriers according to Cabana et al. [9].
III. Tackling external guideline-related barriers: revision of the guidelines To overcome guideline-related barriers, the clinical algorithm for assessing patient needs in CR was revised [23]. We combined patient data collected by CARDSS and input from academic and practical experts. Assessment of patient needs based on clinical judgment was found to be a source of practice variation and was therefore avoided in the revised algorithm by adding several standardized assessment instruments.
IV. Tackling external organization-related barriers: pilot study with feedback To address the remaining organizational-related barriers, a once-only benchmark-feedback loop was introduced in a pilot study in 21 clinics [22]. Data from the CDS system at different clinics were collected, stored in a central data registry, and used to generate paper feedback reports with benchmark information for each of the clinics. The reports aimed to steer discussions in team meetings, encouraging them to formulate QI plans. Although the reports were positively received by the clinics, many were unable to create time to discuss and actually act upon the report.
V. Developing quality indicators For providing quality feedback to CR clinics, we developed a national preliminary set of quality indicators. This was performed in close collaboration with an expert (representatives from all disciplines involved in CR) and patient panel using a modified Rand method [24]. Within this method, results from both panels were combined with results from a literature search and guideline review in an extensive rating and consensus procedure. Table 3 shows the final set including 18 quality indicators regarding guideline concordance (e.g., complete data collection during needs assessment) and other quality aspects perceived relevant by both panels (e.g., patients participate in satisfaction research). Based on user experiences during this trial, we aim to select a subset of quality indicators to be rolled out on a national level.