Transcript Slide 1
Evidence to Improve Care Knowledge Transfer US study on research diffusion: • 9 clinical procedures • Calculated that on average it would take 15.6 years to reach a rate of use of 50% from a rate of use of 0 at time of landmark publication Balas & Boren, Yearbook of Medical Informatics, 2000 Knowledge Transfer • Minimum of 6.3 years for evidence to reach reviews, papers & textbooks • Estimated 9.3 years transition period to implement evidence from reviews, papers & textbooks Balas & Boren, Yearbook of Medical Informatics, 2000 RAND Study Appropriate health care is only provided about half the time Alcohol dependence Hip fracture Peptic ulcer Diabetes Low back pain Prenatal care Breast cancer Cataracts 11% 23% 33% 45% 69% 73% 76% 79% Percentage of time McGlynn et al, N Engl J Med, 2003 Improving Care Approaches – individual: • Educational courses, CPD • Evidence based medicine, CPGs, decision aids • Data, audit & feedback, reminder systems • Peer example – opinion leaders • Financial rewards Improving Care Approaches – individual: • Public reporting • Recertification • Sanctions Improving Care Patient centred approaches: • Patient involvement, patient centred care, empowering patients • Patient oriented interventions to change health care provides’ behaviour Improving Care Organisational & system approaches: • TQM & CQI Collaboratives • Financial incentives & sanctions • Accreditation • Public reporting History of Guidelines • 1980’s US College of Physicians begins publishing clinical guidelines • 1990’s guideline programs introduced in Scotland, England, Germany, France, NZ • 1995 Australia - NHMRC published the first Guidelines for Guidelines Handbook Number of Guidelines in Pubmed number of references 2500 2000 1500 1000 500 0 1966 1971 1976 1981 1986 1991 year of publication Search term [guideline*] limited to title and year 1996 2001 2006 Types of guidelines Consensus based guideline • Statements by a group of experts, with or without reference to evidence Explicit evidence-based guideline • Developed after the systematic retrieval & appraisal of literature • Separate opinion from evidence Do guidelines improve health care? Systematic review: • 14 countries • 1966 - 1998 • 235 studies (RCTs, CCTs, CBAs, ITS) • Primary care, outpatient, inpatient • Many studies of poor methodological quality Grimshaw et al, J Gen Intern Med 2006 Do guidelines improve health care? • 86.6% of studies reported improvements in care • Median improvement 10% • Moderate: Reminders • Modest: Educational materials, Audit & feedback, Educational outreach • Multifaceted interventions Grimshaw et al, J Gen Intern Med 2006 Australian Guidelines National or state 1993: • 32 organisations, 34 clinical practice guidelines 2007: • > 80 organisations, 305 current clinical practice guidelines Australian Guidelines Dissemination • NHMRC portal in development • Will link to systematically developed CPGs • Register of guidelines in development BMJ Clinical Evidence Randomised Controlled Trial • 14,000 Australian general practitioners • Letter offering 2yrs free access to BMJ Clinical Evidence • 7 strategies to encourage acceptance • Use monitored through electronic data capture NATIONAL INSTITUTE OF CLINICAL STUDIES BMJ Clinical Evidence Study NATIONAL INSTITUTE OF CLINICAL STUDIES Quality Improvement Collaboratives Short-term, multi-organisational projects: • Specific topic • Experts in topic & qi methods • Multi-professional teams from multiple sites • “Model for improvement” - PDSA • Structured meetings Widespread adoption worldwide Q.I. Collaboratives • 1999 RMH Emergency Dept • 2000 Victorian ED Collaborative (18 hospitals) • 2002 NICS Australian ED Collaborative (47 hospitals) • 2003 ACSQHC Medication Safety Collaborative (100 hospitals) • 2004 Australian Primary Care Collaborative (600 practices) Q. I. Collaboratives Do they work? Systematic review: Evidence for the impact of quality improvement collaboratives Schouten L, Hulscher M, van Everdingen J et al, BMJ 2008; 336: 1491-1494. Studies in English with data on effectiveness of care processes or outcomes Q. I. Collaboratives Do they work? • 72 papers meeting criteria • 60 (83%) used an uncontrolled study design • 12 papers (9 studies) controlled designs – 2 RCTs, 6 CB&A studies, 1 ITS Most had important methodological flaws Q. I. Collaboratives Do they work? • 88% of uncontrolled reports were positive • Most controlled studies showed mixed effects - moderate positive results • 2/9 controlled studies (incl.1 RCT) – no significant effects • ? Cost-effectiveness, sustainability Evidence to improve care Despite 30 years of research “Lack a robust, generalisable evidence base” Grimshaw et al, Health Technol Assess, 2004