Transcript Slide 1

Research into Practice
– An evidence-based approach to
implementing evidence.
ACT Health Allied Health Symposium, 2014
Bridging the Gap: Translating Evidence into Practice
Dr Shelley Wilkinson AdvAPD
Queensland Health- Health Research Fellow, Maternal Health
Mater Health Services/Mater Research
Worries of a change agent..
• Many patients do not receive (evidence-based) care
– many tests ordered or medications prescribed are not evidence-based and
potentially harmful
• Many patients in hospitals (5-10%) harmed or die because of errors and
adverse events, many (40%) are preventable
• Large, unexplained differences in quality and safety between hospitals,
hospital wards, practices exist
• Improvement, even after well developed implementation programs, is
usually small and slow
Richard Grol, 2013
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
“After decades of improving the health care system, patients
still receive care that is highly variable, frequently
inappropriate, and too often, unsafe”
Braithwaite, 2013
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Knowledge Translation (KT) Terms - 1
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Applied health research
Capacity building
Complex interventions
Complexity science
Complexity studies
Co-optation
Diffusion of innovations
Diffusion(s)
Dissemination
Evidence based practice
Getting knowledge into practice
Implementation
Implementation research
Implementation science
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Information dissemination and
utilization
Innovation adaptation
Innovation adoption
Innovation diffusion
Knowledge communication
Knowledge cycle
Knowledge dissemination
Knowledge exchange
Knowledge management
Knowledge mobilization (mobilisation)
Knowledge transfer
Knowledge translation
Knowledge transformation
Knowledge uptake
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - Wikispaces
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Knowledge Translation (KT) Terms - 2
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Knowledge utiliz(s)ation
Linkage and exchange
Organizational change
Outcomes effectiveness research
Policy research
Popularization (popularisation) of
research
Research into action
Research into practice
Research mediation
Research transfer
Research transformation
Research translation
Research utiliz(s)ation
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Sociology of knowledge
Technology transfer
Third mission
Translation(al) research
Translating Research into Practice (TRIP)
Translation(al) science
Transmission
Utilization (utilisation)
Knowledge to action
Knowledge development and application
Knowledge diffusion
Applied dissemination
Effective dissemination
Research implementation
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - Wikispaces
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Implementation
Translation & application of
innovations, recommended
practices or policies. A process
of interaction between the setting
of goals & actions geared to
achieving them
Dissemination
Conscious efforts to spread new
knowledge, ideas, policies and
practices to specific target
audiences or to a public at large
Green et al 2009
Acknowledgements: NHMRC/NICS - Rosie Forster
T1
T1
Discovery to
health
application
Phase I and II
clinical trials
Observational
studies
T2
T2
T3
Health
application to
evidence-based
practice
guidelines
Practice
guidelines to
health practice
Phase III clinical trials
Dissemination research
Observational
Studies
Implementation research
Evidence synthesis and
guidelines development
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Diffusion research Phase
IV clinical trials
T4
Practice to
population
health impact
Outcomes research
(includes many
disciplines)
Population monitoring of
morbidity and mortality,
benefits and risks
Institute of Medicine, Clinical Research Roundtable Sung, JAMA 2003
Knowledge Discovery and Application Processes
T1
T2
T3
Discovery and Production
• Ideas
• Lab/bench science
• Animal testing
• Early human
Phase I
• Middle human
Phase II
• RCTs
Phase III
• Post marketing
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Application and
Implementation
• Aware
• Accepted
• Applicable
• Able
• Acted upon
• Agreed to
• Adhered to
T3
T4
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - Wikispaces
Knowledge Discovery and Application Processes
Discovery and Production
• Ideas
100,000
• RCTs
Application and
Implementation
• Aware
100%
100
• Adhered to 20%
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - Wikispaces
Introducing service/care changes
UK Medical
Research
Council
framework
(2000)
Acknowledgements: Centre for Clinical Effectiveness, Southern Health - Claire Harris
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
•..the scientific study of methods to promote the systematic uptake of research
findings and other evidence-based practices into routine practice, and, hence,
to improve the quality and effectiveness of health services. It includes the study
of influences on health care professionals and organisational behaviour
•Eccles Implementation Science 2006
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
The
evidencepractice
gap
Perceived quality problem or
emergence of new evidence
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Implementation improvements
New
knowledge,
guideline
Is this
knowledge applied
in practice?
Yes
Prevent
relapse,
monitor use
No
Implementation
interventions,
evaluation
Yes
Perceived
problem in
healthcare
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Is there
“evidence” on
best practice?
No
Richard Grol, 2013
Experimentation,
evaluation
Better GDM control
through improved
diet therapy and
BGLs
TEAM
APPROACH
1
 Less medication
use
 Fewer injections
 Improved QoL
 Patient satisfaction
 Better pregnancy
outcomes
 Decreased weight
retention
 Lower chronic
disease incidence
through improved
follow up
including
Endocrinologists
Obstetricians
Midwives
Diabetes
Educators
Dietitians
American Dietetic
Association Guidelines
MMH
2009
MMH
2010
MMH
2011
70.8%
94.7%
92.5%
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<1%
5.6%
5.3%
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0
0
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0
0
0
0
0
0
1 new visit
3 review visits (min)
1 postnatal visit
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
evidencepractice
gap
Personal costs/savings
Clinical costs costs/savings
Health system costs/savings
Public health costs/savings
Diet controlled GDM
(2009-2011)
MMH: 20-30%
RCTs: 70-80%
50% ‘unnecessarily’
on medication
The evidence
practice gap
Perceived quality
problem or
emergence of new
evidence
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Assessment of influencing
factors
Design of implementation
strategies
Evidence-based
Informed by theory
Optimal care/
Behaviour
change
Explicitly evaluating
your intervention
using a theory-driven
approach
Assessment of influencing factors
Design of implementation strategies
Evidence-based
Informed by theory
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
I always plan to, but
other things take up my
time
priorities
I’d prefer to exercise with others, but people
are often doing other things at the time I
want to go
I don’t have
the right
equipment
I’d like to do
a new sport
like rock
climbing or
kayaking but I
don’t know
how to get
started
Gyms are
expensive
Sustained improvement of patient care…
barriers
theory
intervention
..is usually influenced by a complex mix of factors related to:
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Proposal for change
Patient
Individual professional
Social context
Team and collaboration
Organisational context
Wider political and economical context
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Grol et al, Milbank Q 2006
Above the waterline
lie the observable
workplace
behaviours, practices
and discourse: this is
the way we do things
around here
Below the
waterline lie the
underlying beliefs,
attitudes, values,
philosophies and
taken-for-granted
aspects of
workplace life:
“how we think”
and “why we do
the things we do
around here”
The ‘iceberg
model’ of
culture
Braithwaite, 2011
Change strategies: a great variety on the market
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Evidence-based medicine and clinical
guidelines
Total quality management
Accreditation and certification
Continuous professional development
Portfolio and problem based learning
Patient empowerment and partnership
Organisational development
Performance indicators, accountability,
transparency
Public reporting and physician profiling
Business process redesign
Breakthrough collaboratives
Leadership development
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
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barriers
theory
intervention
Disease management, case
management, managed care
Balanced score cards
Risk management
Shared decision making
Complex adaptive systems thinking
Etc……..
If the only tool you have is
a hammer, it’s tempting
to treat every problem
you have like a nail
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
barriers
theory
intervention
Assessment of influencing factors
Consider:
1.Who needs to do what, differently?
2.Using a theoretical framework, which barriers and enablers need to be addressed?
3.Which intervention components (behaviour change techniques) and modes of delivery could
overcome the modifiable barriers and enhance the enablers?
4.How can behaviour change be measured and understood?
(French et al, Implementation Science, 2012, 7:38)
Tools/Readings
• Improving Patient Care
• NHMRC/NICS Barriers and Enablers tool
• Frameworks…including..
• PARIHS framework
• TDF (Theoretical Domains Framework)
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Assessment of influencing factors :The TDF
The Theoretical Domains Framework
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
barriers
theory
intervention
(Cane et al, Implementation Science, 2012, 7:37)
Design of implementation strategies
barriers
theory
intervention
• Requires a multi-level (theory-based) approach to change
• 3 essential conditions are required (Michie et al, Implementation Science, 2011)
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Design of implementation strategies
barriers
theory
intervention
SOURCES OF BEHAVIOUR – the green hub
… from the TDF
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Design of implementation strategies
INTERVENTION FUNCTIONS – the red circle
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
barriers
theory
intervention
Design of implementation strategies
INTERVENTION FUNCTIONS – the red circle
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
barriers
theory
intervention
Design of implementation strategies
POLICY FUNCTIONS – the grey circle
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
barriers
theory
intervention
Design of implementation strategies
POLICY FUNCTIONS – the grey circle
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
barriers
theory
intervention
Improving practice: the international evidence
barriers
theory
intervention
• No evidence that one of many, many (new) approaches to
improving clinical practice is superior for ALL problems
• Change, even after well prepared interventions is usually
moderate (5-10%), but potentially relevant for patients
• Most new, interesting strategies and approaches have not
been evaluated well (and are based on beliefs or good
experiences rather than evidence)
Grol & Grimshaw, Lancet 2003; Grimshaw et al 2004
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Slow change: the rule of Benedictus
There is only one speed in the improvement of things:
“conversio morum” … piecemeal quality management and
improvement or gradual, day-to-day change in small,
feasible and achievable steps, instead of “breakthrough
changes”
“steadily pushing in
the right direction”
barriers
theory
intervention
EPOC interventions
(Effective Practice and Organisation of Care Group – Cochrane)
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Clinical pathways; standardized protocols
Audit and feedback
Local opinion leaders
Local consensus processes
Small group interactive continuous education
Electronic patient management systems
http://epoc.cochrane.org/epoc-reviews
N trials
Median change
Printed education material
23
+4%
Educational materials
56
+6%
Educational outreach visits
34
+5%
Audit and feedback
118
+5%
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Aim: To translate GDM model of
care appointments in the MMH
GDM TRIP
Step 1: Who needs to do
what differently?
Step 2: Using a theoretical
framework, which barriers and
enablers need to be addressed?
Step 3: Which intervention components
could overcome the modifiable barriers
and enhance the enablers?
Step 4: How will we measure
behaviour change?
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
barriers
theory
intervention
Clinicians (dietitians, O&G, Obs Med
physicians, midwives, diabetes
educator); Women
Knowledge; Beliefs about
consequences, Social/professional role
and identity, Social influences,
Intentions, Memory, attention, decision
processes, Environmental context and
resources
Training re NPG (w/ outcomes),
Audit & feedback , Clinical
Champions, Local opinion leaders,
Care pathways Women’s
engagement, $$, and rooms
Clinical practice measures and patient
outcome measures
barriers
theory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
The evidence
practice gap
Perceived quality
problem or
emergence of new
evidence
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Assessment of influencing
factors
Design of implementation
strategies
Evidence-based
Informed by theory
Optimal care/
Behaviour
change
Explicitly evaluating
your intervention
using a theory-driven
approach
Optimal care/
Behaviour change
Explicitly evaluating your
intervention using a theorydriven approach
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Evaluating the intervention
outcomes
(process,
clinical)
• Research is different from the real (TRIP) world
• Research = defined boundaries/structures vs real world = messy/complex
• Can’t control everything, but you can monitor and describe
• Outcomes should link with your intervention strategies
• Try to use routinely collected data, where possible
– Process measures, including fidelity (adherence and moderators)
– Good to have clinical measures as well, but you’re not re-validating or reproving your guidelines!
– Economic measures
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Study design: 9 months pre/post
implementation study
GDM TRIP
outcomes
(process,
clinical)
Process outcomes:
Primary: uptake of the new dietetic schedule, as measured by adherence to the
NPG appointment schedule
Secondary: clinician (i) awareness,
(ii) knowledge and
(iii) acceptance
Clinical outcomes:
Primary: effect of the NPG schedule on requirement for pharmacotherapy
(insulin/metformin)
Secondary: (i) rate of maternal weight gain,
(ii) diet quality, physical activity and pt satisfaction
(iii) birth weight.
+ cost-benefit analysis and other clinical outcomes
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
GDM TRIP: IMPLICATIONS
& RELFECTIONS
• Increased proportion of women receiving best practice care, but no
change in medication use
• Await clinical outcomes, diet, activity and satisfaction measures
• Data shortcomings influence findings
• Reality of health service research – messy, complex, real world
• Potentially didn’t influence prescribing behaviour
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Model of care ‘integration’ required four, rather than one month…
• slower than expected process could have been overcome by wider
(higher) clinician and management engagement
• Who else needs to be involved? Who else needs to know?
• Prepare for, but don’t guess your barriers
• Visit clinic/ward at least once a week for entire project
Where to next?
• Dissemination
• Scaling up and rolling out
• Sustainability
Queensland Health - Health Research Fellowship (2014-2016)
Study 3
Aim: to improve the nutritional management of women with GDM in Qld
•
build on implementation findings from the MMH GDM NHMRC TRIP project
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Acknowledgements
• NHMRC/NICS
– Fellowship funding, Masterclass training, Slides/images
- Project team @ Mater Health Services/Mater Mothers:
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David McIntyre, Director Obstetric Medicine
Sally McCray, Director Nutrition & Dietetics
Mike Beckmann, Director Obstetrics & Gynaecology
Annette Parry, Diabetes Educator/Midwife
Sam Drew, Midwifery Unit Manager, ANC
- Mentors:
- David McIntyre (Project);
- Adele Green (TRIP)(Deputy Director, QIMR)
- My eyes and ears on the ground:
- Debbie Tolcher, Elin Donaldson
& Ellen Heads, MMH dietitians
[email protected]
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Transformation isn’t a matter of intent,
it’s a matter of alignment
Peter Fuda