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