Transcript Evidence based implementation of evidence based guidance

Knowledge translation for professionals
Jeremy Grimshaw MD PhD
Director, Clinical Epidemiology Program, OHRI
Director, Canadian Cochrane Centre
Potential barriers to KT
Information management is
necessary but not sufficient
to ensure knowledge
translation
The new tower of Babel?
Hibble, Kanka, Pencheon, Pooles. BMJ
(1998)
Potential barriers to KT
• Structural (e.g. financial disincentives)
• Organisational (e.g. inappropriate skill mix, lack
of facilities or equipment)
• Peer group (e.g. local standards of care not in
line with desired practice)
• Professional (e.g. knowledge, attitudes, skills)
• Professional - patient interaction (e.g. problems
with information processing)
• Patient (e.g. knowledge, attitudes, skills)
Planning change
Assess
barriers & supports
+
Monitor
+
strategy application
& degree of use
outcomes
Practice Environment
• structural
• social
• patients
• economic
Potential Adopters
• attitudes
• knowledge
• skill
Evidence - Based
Recommendations
• development process
• innovation attributes
Strategies
• barrier
management
• transfer
• uptake
Evaluate
Adoption
• intention
• use
Outcomes
• patient
• practitioner
• system
Ottawa Model of Research Use
Logan & Graham, 2002
Planning change
Choosing interventions
• Need to identify potential barriers relating to behavior,
potential adopters and practice environment.
• Need to distinguish between modifiable and non
modifiable
• Need to prioritize which are key barriers based on
consideration of:
• Identification of mission critical barriers
• Potential for addressing barriers through interventions
Towards evidence based implementation
• Most approaches to changing clinical practice
are more often based on beliefs than on
scientific evidence
• ‘Evidence based medicine should be
complemented by evidence based
implementation’
Grol (1997). British Medical Journal.
Cochrane Effective Practice and
Organisation of Care (EPOC) Group
EPOC aims to undertake systematic reviews of
interventions to improve practice including:
• Professional interventions (e.g. continuing
medical education, audit and feedback)
• Financial interventions (e.g. professional
incentives)
• Organisational interventions (e.g. the
expanded role of pharmacists)
• Regulatory interventions
Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Zwarenstein (2006). Cochrane Library.
Cochrane Effective Practice and
Organisation of Care (EPOC) Group
Progress to date - register and reviews
• Register of 5000+ primary studies
• 39 reviews, 34 protocols
• Collaborating with over 300 researchers globally
Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Shepperd, Tavender, Zwarenstein (2007). Cochrane Library.
Overview of reviews of professional
behaviour change strategies
• Identified over 150 systematic reviews of professional
behaviour change interventions
• For COMPUS, we summarised approx 50 systematic
reviews judged to be likely highest quality and most upto-date
Overview of reviews
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Educational materials (1)
Educational meetings (1)
Educational outreach (1)
Audit and feedback (2)
Opinion leaders (1)
Mass media (1)
Reminders – general (4)
Reminders – Computer
assisted drug dosage (3)
• Reminders – CPOE (1)
• Tailored interventions (1)
• Multifaceted interventions
(1)
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Prescribing – general (10)
Prescribing - safety (2)
Changing roles – nursing (1)
Changing roles – pharmacy (7)
Financial (4)
Regulatory (1)
• General (10)
Educational materials
• Distribution of published or printed recommendations for
clinical care, including clinical practice guidelines, audiovisual materials and electronic publications. The
materials may have been delivered personally or through
mass mailings.
• Target knowledge, skills barriers at individual health care
professional/peer group level
• Relatively low cost, feasible
Educational materials
Farmer (2007) Cochrane Library (in preparation)
• High quality review
• 21 studies (RCTs, CCTs, CBAs, ITS)
• 9 studies included prescribing data
• Distribution of education materials may be effective for
appropriate care including prescribing.
• (Median effect across 6 RCTs +4.9% absolute
improvement)
Educational meetings
• Health care providers who have participated in
conferences, lectures, workshops or traineeships
• Didactic meetings – largely target knowledge barriers at
individual health care professional/peer group level
• Interactive educational meetings – can also target skills
(if simulation/rehearsal involved) and attitudes at
individual health care professional/peer group level
Educational meetings
Thomson O’Brien (2001) Cochrane Library
• High quality review
• 32 studies (RCT, CCT)
• 5 studies included prescribing data
• Interactive workshops and mixed interactive-dogmatic
activities were generally ineffective for improving
appropriate care. Mixed effects were observed for
didactic sessions.
• Insufficient evidence on prescribing.
Educational outreach
• Use of a trained person who met with providers in their
practice settings to give information with the intent of
changing the provider’s practice. The information given
may have included feedback on the performance of the
provider(s).
Educational outreach
• Derives from social marketing approach
• Use social persuasion methods to target individual’s
knowledge and attitudes
• Typically aim to get maximum of 3 messages across in
10-15 minutes using approach tailored to individual
health care provider
• Typically use additional strategies to reinforce approach
• Typically focus on relatively simple behaviours in control
of individual physician eg choice of drugs to prescribe
Educational outreach
• Relatively expensive although may still be
efficient
• May be less effective for complex behaviours
requiring team or system change
Educational outreach
Thomson O’Brien (1997) Cochrane Library
• Medium quality review
• 18 studies (RCT, CCT)
• 12 studies included prescribing data
• Multifaceted educational outreach visits were generally
effective for improving appropriate care including
prescribing
• (Grimshaw 2004 – median effect across 13 RCTs of
multifacted educational outreahc interventions +6.0%)
Local opinion leaders
• Use of providers nominated by their colleagues as
‘educationally influential’. The investigators must have
explicitly stated that their colleagues identified the
opinion leaders.
• Target peer group knowledge, attitudes
• Resources required include survey of target group,
resources to recruit and support opinion leaders.
Local opinion leaders
Doumit (2007) Cochrane Library
• Medium quality review
• 12 studies (RCT, CCT)
• 7 studies included prescribing data
• Generally effective for improving appropriate care.
Insufficient evidence on prescribing.
• Median effect across studies +10% absolute
improvement
Local opinion leaders
• Appear to be condition specific
• Likely coverage of target group difficult to assess
Grimshaw et al (2006). Implementation Science
• Stability over time uncertain – Doumit re-surveyed
surgeons 2 years after initial survey to identify opinion
leaders. Only 4/16 original opinion leaders re-identified
Doumit (2006) Masters thesis
Audit and feedback
• Any summary of clinical performance of health care over
a specified period of time. The summary may also have
included recommendations for clinical action. The
information may have been obtained from medical
records, computerised databases, or observations from
patients.
• Adams et al demonstrated that self reported behaviour
likely to overestimate actual performance by 27%
Adams et al (1999) Int Journal for Quality in Health Care
• Target health care provider/peer groups’ perceptions of
current performance levels
• Aim to develop cognitive dissonance to motivate
physicians to change
Audit and feedback
• Resources required include data abstraction and
analysis costs, dissemination costs (postal or personal)
• Feasibility may depend on availability of meaningful
routine administrative data for feedback
Audit and feedback
Jamvedt (2005) Cochrane Library
• High quality review
• 118 studies (RCT, CCT)
• 55 studies included prescribing data
• Audit and feedback alone, audit and feedback with
educational meetings, audit and feedback as part of
multifaceted intervention generally effective.
• Median effect across studies +10% absolute
improvement
• Larger effects were seen if baseline compliance was low.
Reminders
• Patient or encounter specific information, provided
verbally, on paper or on a computer screen, which is
designed or intended to prompt a health professional to
recall information. This would usually be encountered
through their general education; in the medical records
or through interactions with peers, and so remind them
to perform or avoid some action to aid individual patient
care. Computer aided decision support and drugs
dosage are included.
• Focus on professional – patient interaction, prompting
professional to remember to do important items
Reminders
• Resources vary across deliver mechanism
• Increasing interest in computerised decision support but
evidence tends to come from a few highly computerised
US academic health science centres
• Insufficient knowledge about how to prioritise and
optimise reminders
Reminders
Garg (2005) JAMA
• Medium quality review
• 100 studies (RCT, CCT)
• 49 studies included prescribing data
• Mixed effects were observed for computerised clinical
decision support systems (CDSS) for appropriate care
including prescribing
Multi faceted interventions
• Any intervention including two or more components
• Multi-faceted interventions are more likely to target
different barriers in the system
• Likely more costly than single interventions
• Need to carefully consider how components likely to
interact to maximise benefits
Effectiveness of strategies targeting
health care professionals
Multifaceted interventions
Absolute effect size
80%
60%
40%
• Grimshaw et
al (2004).
Health
Technology
Assessment
20%
0%
-20%
-40%
-60%
-80%
N=
56
63
46
28
16
1
2
3
4
>4
Number of interventions in treatment group
Conclusions
• Imperfect evidence base to support choice of
interventions to improve prescribing
• Choice of intervention should be based upon
consideration of:
• likely barriers
• evidence of effectiveness of intervention
• mechanism of action of intervention
• resources available
• other feasibility issues
Contact details
• Jeremy Grimshaw - [email protected]
• EPOC – [email protected]