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From Knowledge to Action: Bridging the Gap Between Theory and Practice in Clinical Practice Guidelines
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摘要: 随着循证医学和临床实践指南的快速发展以及转化医学与实施科学的兴起，加强证据的转化与利用，促进高质量指南的传播与实施，已在国内外学者中引起广泛关注。本文对当前指南传播与实施的现状、基本步骤、阻碍与促进因素进行分析和总结，对其与实施科学之间的关系展开论述，并在此基础上就我国如何提升指南传播与实施效果提出思考和建议。Abstract: With the rapid development of evidence-based medicine and clinical practice guidelines, as well as the rise of translational medicine and implementation science, strengthening the translation and utilization of evidence, and promoting the dissemination and implementation of high-quality guidelines has received more and more attention worldwide. In this article, we analyzed and summarized the current status, basic procedures, barriers, and facilitators of guideline dissemination and implementation. Then, we discussed its relationship with the implementation science and how the existing theories, frameworks, models and study designs in the field of implementation science can be used to promote the dissemination and implementation of high-quality guidelines. In the end, we put forward some thoughts and suggestions on how to improve the dissemination and implementation of guidelines in China.作者贡献：陈耀龙、史乾灵负责统计数据并撰写文章初稿；赵俊强、徐东、李慧、邵瑞太、陈彤、刘恩梅、马艳芳、周奇、商洪才、杨克虎负责初稿修改；陈耀龙负责文章审校。利益冲突 无
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表 1 2010—2020年部分专业领域指南依从性情况系统评价结果
领域 指南依从性情况 医务人员层面 颅脑损伤领域 遵循指南可降低严重创伤性脑损伤患者的死亡率并改善预后，但对于手术管理、药物及非药物治疗等不同方面的指南推荐，医务人员的依从性差异较大(0~100%)[20] 心脏病领域 遵循指南可降低非ST段抬高型急性冠状动脉综合征患者的死亡率，但对于患者危险分层、药物治疗、冠状动脉造影等方面的指南推荐，医务人员的依从性差异较大(0.5%~98%)[21] 预防性使用抗生素领域 围手术期适当预防性使用抗生素可降低手术部位感染率，但由于医务人员对指南的依从性差异较大，导致接受不恰当抗生素使用的患者比率差异较大(2%~100%)[22] 卒中领域 遵循指南可有效改善卒中患者的预后，降低医疗费用，但医务人员对卒中患者一般护理和特殊护理指南的依从性均较低且差异较大[23] 手卫生领域 医务人员对手卫生指南的整体依从性仅为40%，其中重症监护室医务人员的依从性低于医院其他科室，临床医师的依从性低于护理人员[24] 患者层面 加速康复外科领域 术后早期经口进食可促进成人患者术后恢复并减少并发症，但仅40%的患者报告第一次进食时间，22%的患者报告第一次进食固体食物时间符合当前指南的推荐[25] 慢性疾病领域 体育锻炼可有效预防和治疗慢性疾病，但癌症、心血管疾病和糖尿病患者对指南中推荐的体育锻炼平均依从性为77%[26] 癫痫领域 对于癫痫持续状态患者的治疗，当前实践与指南推荐的苯二氮卓类药物服用、院前治疗、治疗场所及时机等方面存在较大差异(11%~66%)[27] 营养领域 营养指南在当前实践中的依从性较低，且差异较大。谷物、蔬菜、水果、乳制品、蛋白质的摄入比例分别为17%~61%、8%~70%、5%~62%、4%~60%、26%~54%，儿童与老年人的依从性较低，成人的依从性相对较高[28] 痛风领域 大部分痛风患者需长期或终生服用药物以控制病情或缓解症状，但痛风患者的间断服药率为54%~87%，患者服药依从性有待改善[29] 
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表 2 国内外部分主要指南制订组织对指南传播与实施的管理方法
组织 指南传播 指南实施 具体要求 步骤* 具体要求 步骤 WHO[30] 制订者应同出版社协商费用，免费发行范围应至少涵盖图书馆、公共卫生院校、医学院校、WHO国家办事处及日内瓦驻外使团；使用监测与评估系统收集并分析数据，并对指南实施效果和影响进行评估 (1)在线出版
(2)信息共享机构档案库存档
(3)进行多语言翻译，特别是6种官方语言
(4)期刊发表制订初期对指南实施予以考虑；实施策略应符合地方具体情况；提供一系列衍生文件或工具以促进指南实施，这些工具可与指南一起发表，或由当地实施者制定 (1)召开多学科工作组会议，分析本地需求和优先顺序
(2)确定潜在的阻碍与促进因素
(3)明确可利用的资源与政治支持
(4)通知实施相关的各级合作伙伴
(5)设计实施策略NICE[32] 制订初期对指南传播予以考虑；目标人群应包括医疗服务提供者、护理人员、实践者及公众；不同类型的指南，采取不同的传播方式 (1)将指南发表告知利益相关者
(2)通过新闻通讯或通知发布
(3)通过社交媒体(新闻稿或简报)发布
(4)通过培训、讲座、会议及研讨会发布制订初期对指南实施予以考虑；提供基本情况与资源影响评估工具，用以判断当前实践是否符合指南推荐并评估指南实施的成本；NICE团队与指南制订委员会协作研发指南实施工具，制定实施策略 考虑以下选择：
(1)基本情况与资源影响评估工具
(2)可视化总结与快速推荐
(3)患者决策辅助工具
(4)与其他组织开展合作
(5)其他可获得的支持工具G-I-N[33] 制定多维、主动的传播计划 (1)在线与期刊发表
(2)与卫生保健系统相关部门建立联系
(3)举行新闻发布会
(4)通过社会媒体发布
(5)通过专业学会会议发布
(6)授权第三方进行多语言翻译开发或改编相关工具、支持系统和衍生产品；帮助目标用户采用系统透明的方法改编指南，以适用于当地情况 考虑以下选择：
(1)研发手机应用程序
(2)将指南整合至临床决策支持系统
(3)针对目标人群开展教育
(4)基于当地资源和风险修改推荐意见，不受指南专家组的影响IOM[1] 采用主动策略进行指南传播，指南的传播与实施并非相互独立 (1)通过社交媒体发布
(2)分发印刷材料
(3)发布快速推荐指南组织机构和卫生系统提供必要的实施资源和帮助，促进利益相关者的参与；实施者与制订者、临床决策支持系统设计者加强合作，采取主动、多维的实施策略 考虑以下选择：
(1)审计与反馈
(2)临床监测提醒系统
(3)电子健康病历
(4)共享决策辅助系统
(5)开展专业教育
(6)确定意见领袖SIGN[31] 与包括当地指南传播委员会在内的组织机构保持密切联系，及时通知新指南和指南最新版的发表；扩大指南获取途径，注重在线传播，包括在线免费发行SIGN指南、快速推荐及患者手册 (1)期刊发表指南摘要
(2)获取强大的临床支持
(3)举办会议、研讨会及教育活动
(4)同时发布患者及护理版本指南制订初期对指南实施予以考虑；在指南中报告实施内容，提供或研发相应的工具；明确实施障碍，构建基于证据的实施策略；与现有专业网络或项目结合，可考虑的实施资源包括临床路径、电子决策支持工具等 (1)组建多学科实施团队，确定领导与合作者，明确利益相关者
(2)确定指南实施前的基本情况
(3)做好人员和环境准备
(4)确定潜在阻碍，采取有效的技术
(5)加强团队协作
(6)定期评估进度并向团队反馈中华医学会[34] 在中华医学会平台进行指南的统一发布与传播 (1)在线发表
(2)期刊发表
(3)其他方式(新闻发布会、通讯稿、召开会议等)通过相关“学组”“协作组”对某一领域进行专题范围内的前瞻性及回顾性应用，对指南改善结局的有效性进行验证 未提及具体实施步骤，一般以“工作坊”的形式深入指南相关临床验证工作 *均未提及具体步骤，可考虑以下选择；WHO：世界卫生组织；NICE：英国国家卫生与临床优化研究所；G-I-N：国际指南联盟；IOM：美国医学科学院；SIGN：苏格兰校际指南网络
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分类 阻碍因素 促进因素 指南本身 (1)推荐意见不够清晰明确，可实施性不强 (1)提供指南实施工具(如执行总结、小册子) (2)指南可信度不高 (2)吸纳使用者参与指南制订、传播与实施、后效评估 (3)指南可及性较差 (3)以简短形式呈现指南 (4)推荐意见与当前实践兼容性较差 (4)以数字化形式呈现指南 (5)仅关注单病种患者 (6)缺乏明确的干预目标 医务人员 (1)对指南或推荐意见知晓率低 (1)对指南持积极的认可态度 (2)对指南或推荐意见不信任 (2)具有良好的沟通反馈能力 (3)缺乏实施推荐意见的资源(时间、知识、技能) (3)具有良好的行为改变能力 (4)缺乏实施推荐意见的信心 (4)接受指南方面相关培训 (5)担心影响医患关系 (6)拒绝改变 患者 (1)对身体特征或自身疾病不了解 (1)具有健康意识，理解不遵循指南或推荐意见的后果 (2)对指南或推荐意见不了解 (2)具有遵循指南的兴趣或动机 (3)对指南或推荐意见缺乏信心 (3)获取良好的同伴支持与反馈 (4)对指南或推荐意见接受度低 (4)接受指南方面的教育 (5)期望与医生意见或指南相反 (5)使用患者决策辅助工具 (6)缺乏实施的资源(时间、财力、家庭支持) (6)加强医患沟通 (7)渴望更大的自主权 外部环境 (1)缺乏有效的领导或意见领袖 (1)推荐意见与现行政策或制度相符 (2)团队协作与沟通能力较差 (2)获取管理者或上级领导的支持 (3)资源与设备短缺 (3)组建多学科实施团队 (4)缺乏本土证据 (4)将指南整合至临床决策或监测系统
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