Development, implementation, and evaluation of clinical practice guidelines, protocols, and pathways used in rural and remote Australia, Canada, and Aotearoa New Zealand: a scoping review

OBJECTIVE: This scoping review examines the extent and type of evidence describing the development, implementation, and evaluations of clinical practice guidelines (CPGs), protocols, and pathways used in the rural and remote areas of Australia, Canada, and Aotearoa New Zealand (NZ). INTRODUCTION: Given the role that clinical guidance resources (CGRs) can play in reducing health disparities, it is useful to understand what resources are being utilized in rural and remote health contexts and the robustness of the processes that underpin them. ELIGIBILITY CRITERIA: Records were included from 3 high-income countries with rural or remote regions and First Nations populations. Eligible records clearly identified a CGR, demonstrated its endorsement or implementation in a rural or remote health service, and had the CGR as a primary focus of the evaluation. All health topics were considered. METHODS: Following JBI methodology, searches were conducted in November 2024 with a research librarian across MEDLINE (Ovid), CINAHL (EBSCOhost), Emcare (Ovid), Scopus, ProQuest Dissertations and Theses, and Google for English-language records. Data were extracted using an author-developed charting tool and reported using descriptive statistics, tables, graphics, and a narrative summary. RESULTS: Fifty-six studies met the eligibility criteria encompassing Australia (82%), Canada (13%), and NZ (5%). Publication types were journal articles (86%), conference proceedings (7%), institutional reports (5%), and 1 thesis (2%). The CGRs examined were CPGs (50%), protocols (27%), pathways (21%), and 1 study examined both protocols and pathways (2%). Twenty-one studies (38%) evaluated CGR development, 52 (93%) evaluated implementation, and 17 evaluated both. Study approaches were mixed methods (32%), experimental or quasi-experimental (30%), qualitative (20%), descriptive observational (16%), and analytical observational (2%). The most common study designs were before-and-after studies (39%) and qualitative case studies (32%), which were often combined within mixed methods studies. CGRs were most commonly adopted (36%) from national guidelines and used without alteration. Other CGRs were newly developed (25%), adapted from other contexts (23%), or updated (16%) from previous versions, meaning 64% of studies contextualized CGRs for rural and remote contexts prior to implementation. Among the 21 development studies, 14% used a recognized guideline development tool, 52% conducted a systematic review, and none reported a quality assessment of the resulting CGR. All 52 implementation studies employed more than 1 implementation strategy, 48% matched strategies to pre-identified determinants, and 44% were designed to address barriers at all levels considered (individual, organizational, and broader systems). The most common strategy categories were training and educating stakeholders (92%) and adapting and tailoring to context (85%). Implementation studies measured implementation outcomes (96%), health service outcomes (81%), and patient health outcomes (42%). The most common outcomes measured in each category were feasibility (52%), efficiency (90%), and clinical or health status (29%). Most implementation studies (88%) did not report using any theory, model, or framework. CONCLUSIONS: This is the first comprehensive review of CGR development, implementation, and evaluation in rural and remote regions of Australia, Canada, and NZ. Findings highlight the need for more rigorous CGR development and quality assessment, along with theory-informed implementation and evaluation to strengthen their design and utility. REVIEW REGISTRATION: OSF https://osf.io/6em32/overview.