Effectiveness of Discrete Strategies and Implementation Bundles for Improving Clinician Prescription of Clinical Practice Guideline-Recommended Medications for Atherosclerotic Occlusive Disease: A Systematic Review and Meta-Analysis

BACKGROUND: We sought to determine the effectiveness of discrete strategies and implementation bundles for improving clinical practice guideline (CPG) strongly recommended medication prescription to adults with atherosclerotic occlusive disease. METHODS: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (inception to December 9, 2025) for randomized controlled trials evaluating discrete strategies or implementation bundles for improving CPG strongly recommended medication prescription to adults with atherosclerotic occlusive disease. Two investigators screened titles/abstracts and full texts, extracted data, assessed risk of bias, and classified discrete strategies and implementation bundles. Random-effects models were used for meta-analysis. Grading of Recommendations Assessment, Development and Evaluation was used to assess certainty. RESULTS: We included 31 randomized controlled trials studying 29 unique discrete strategies and implementation bundles. The implementation bundle with the largest effect size for improving CPG strongly recommended medication prescription combined case management, team changes, continuous quality improvement, audit/feedback, and clinician and patient education (relative risk, 2.62 [95% CI, 2.08-3.29]; moderate certainty). Meta-regression analyses suggested that discrete strategies and implementation bundles using patient education were more effective at improving statin (P=0.037) and all CPG strongly recommended medication (P=0.006) prescription. Combining case management, team changes, facilitated relay of information, and audit/feedback reduced all-cause death and new vascular event risk. Team changes improved prescription of all CPG strongly recommended medications (relative risk, 1.23 [95% CI, 1.11-1.36]; moderate certainty) and reduced major adverse cardiac event risk. CONCLUSIONS: Combining case management, team changes, continuous quality improvement, audit/feedback, and clinician and patient education had the largest effect size for improving CPG strongly recommended medication prescription and improved patient outcomes. Team changes improved CPG strongly recommended medication prescription and reduced major adverse cardiac event risk.