Transcript IMPROVING CARE: KNOWING WHAT TO DO

Moving evidence into clinical practice:
Bridging the gap between what we know and what we do.
Scott Bennetts
A/g Director Effective Practice Program
NHMRC National Institute of Clinical Studies
WORKING TO BUILD A HEALTHY AUSTRALIA
www.nhmrc.gov.au/nics
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Overview
– What is an evidence practice gap?
– Why is life so hard?
– Improving evidence uptake
• What do we know?
• How can we do it?
– Example and tips
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RAND Study (US)
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
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Defining evidence based practice…
‘Evidence based practice is the conscientious, explicit and
judicious use of current best evidence in making decisions
about the care of individual patients. To practice (in an evidence
based way) means integrating individual clinical expertise
with the best available external clinical evidence from
systematic research’.
Sackett, Rosenberg, Gray, Haynes, Richardson BMJ 1996
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Evidence Based Practice is…
EVIDENCE
ACTION
IMPLEMENTATION SCIENCE (T2)
KNOWLEDGE TRANSLATION
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Research Continuum
T2
T1
Basic
Biomedical
Research
Translation
from basic
science to
human studies
Clinical
Science and
Knowledge
Translation of
new knowledge
into Clinical
Practice
Adapted from
Sung et al
JAMA, 2003
Improve
d Health
Care
T1 is the translation of new understandings of disease mechanisms into new
methods of diagnosis, therapy and prevention, and their first testing in humans.
T2 is the translation of results from clinical studies into everyday clinical practice.
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Research Continuum
T1
Basic
Biomedical
Research
Translation
from basic
science to
human studies
Clinical
Science and
Knowledge
Improve
d Health
Care
E.P. GAP
Evidence practice gap - The difference between what is known from best
available research evidence and what actually happens in day to day practice
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Knowledge Translation – the issues
US study on research diffusion:
• 9 clinical procedures
• Assumed a rate of use of 0 at time of landmark publication
• How long to reach a rate of use of 50%?
15.6 years
Balas & Boren
Yearbook of Medical Informatics, 2000
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Knowledge Translation – the issues
Volume of evidence
• 20,000 – 30,000 Health Care Journals publish well over 2 million
articles each year
Varying quality of evidence
Lack of evidence in some areas
Complexities of change
• Training, policy, systems, legislation
• Clinician habits / preferences, biasing
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Number of Guidelines
in Pubmed
number of references
2500
2000
1500
1000
500
0
1966
1971
1976
1981
1986
1991
1996
2001
2006
year of publication
Search term [guideline*] limited to title and year
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Role of NICS
To improve health care by getting the
best available evidence
from health and medical research
into
everyday health care practice
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Planning for change
5
not so
EASY STEPS
Identify practice
gaps (audit data
and evidence
comparison)
1.
Identify why the
gap exists
(barriers
analysis)
2.
Intervention
Planning
Intervention
Report
&
Publish
Evaluation
3.
4.
5.
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1
Identify the gap
In order to improve practice we need to be aware of:
1. What the current practice is (audit)
2. What best practice is (the evidence, standards)
To do this you need:
• Standards / Clinical indicators
• A measurement tool / regular monitoring
• A leader, a team, and a clinical champion
Identify practice
gaps (audit data
and evidence
comparison)
1
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CASE STUDY
NATIONAL EMERGENCY CARE
PAIN MANAGEMENT INITIAITIVE
2008 - 2010
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Why pain – the background
• Emergency care clinicians identified ED pain management as an
area for improvement. They were concerned that:
- appropriate pain relief is not consistently provided in EDs
- pain is a cause of significant distress for patients in EDs
- inadequate pain management is a key issue identified in
healthcare research literature, patient surveys and complaints.
• There are over 7 million ED presentations in Australia annually
- The literature states that for 70%-80% of those presentations,
pain is the primary complaint
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• 2007 audit of practice in Australian ED’s
- 1966 patients from 36 EDs
- chart review of compliance with NHMRC approved guidelines
- audit of organisational policies and processes
- data from cohorts where pain on presentation is common
• The evidence-practice gap
-
fractured neck of femur - 10% received femoral nerve block
migraine - 12% received IV narcotics
abdominal pain - 29% received IV morphine
Average time to analgesia - Migraine 62min, # NOF 110min
Abdo pain 88min,
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Proportion of patients whose pain was reassessed after
each administration of an analgesic, by cohort
100
90
80
Percent
70
Peer Group
60
Your ED
50
40
30
20
10
0
Migraine
Abdo Pain
Fractured NoF
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• Compare audit findings with national standards / the evidence
• Set goals / clinical indicators
– Involve staff and management
– Ongoing monitoring
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Our targets
• Assessment of pain
- 80% of patients presenting to the emergency department in
pain have a documented pain score
• Timeliness of analgesia
- median time to analgesia of 30 minutes from triage
• Effectiveness of pain management
- 80% of patients with severe pain (7 or greater) decrease
their pain score by 3 or more points within one hour
Macintyre PE, Schug SA, Scott DA, Visser EJ, SM; W, APM:SE
Acute Pain Management: Scientific Evidence (3rd edition)
Melbourne: ANZCA & FPM; 2010.
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2
Barriers and enablers
• While clinical data (audit) informs us what the problem is and
how big the clinical issue may be, it doesn’t necessarily tell us
why there is an issue
• An understanding of the barriers to quality pain management
assists in choosing appropriate interventions that have been
shown to be effective to the identified barriers
Identify why the
gap exists
(barriers
analysis)
2
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Consider…
Clinical practice and change is influenced at four levels
1. System-wide
2. Organisational
3. Departmental
4. Individual (clinician / consumer)
Ferlie, E. & Shortell, M. (2001)
Improving the Quality of Health Care in the United Kingdom and the United States:
A Framework for Change. The Milbank Quarterly, 79.
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Barriers/enablers. . .
Consider . . .
Level of knowledge
Education session
Decision aids
Perception / reality mismatch
Audit and feedback
Reminders
Level of motivation
Incentives / sanctions
Beliefs / attitudes
Peer influence
Opinion leaders
Systems of care
Process redesign
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Investigating barriers
• Focus groups, brainstorming, interviews, surveys, observational
studies.
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CASE STUDY
How did we study barriers and enablers?
Three parts
1. Audit of pain management in Australian ED’s (June - August
2007)
2. Focus groups (Nov – Dec 2007)
3. Literature review (July 2008)
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FINDINGS - Barriers
Workforce issues
• Staffing levels / staff shortages / turn over
• Rotating staff
• Staffing skill mix
Time constraints
Organisational culture
•“Cultural change" for some staff
• Leadership
• Lack of supportive policy and procedures
• Lack of ownership by any individual or group
Resource issues
Guideline issues
• Availability of guidelines
• Lack of dissemination of evidence based guidelines
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FINDINGS – Enablers
Interest/Motivation
•
•
•
Staff motivation
Local champions and leadership e.g. nurse educator
A genuine desire to deliver quality care
Resources/Policies
•
•
•
Clear, short, concise policies, pain management policies
Standing orders
Web based intranet/internet access to resources
Recognised need for better practice
•
•
Audit data and research showing need for improvement
Understanding of best practice
Dedicated pain management role
Education
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3Intervention planning
Effective implementation programs include:
• strategies at all levels (individual and system)
• an appropriate implementation team
• understanding of local barriers and enablers
• interventions aimed at overcoming barriers
• planned change
• system changes to support and maintain best practice
• use of current practice data for feedback
• local data for monitoring performance
Intervention
Planning
3
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Project Planning
•
•
•
•
Form a team
Identify resources required – budget, business case, tools, time,
equipment
Consider constraints (limitations) – budget, resource, time,
competent staff, legal or ethical restrictions, availability of data,
'political' considerations
Set Priorities - Consider clinical data, chose your battles (barriers
and enablers), quick wins, be opportunistic. Consult your teams,
staff, management, executive.
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Project Planning (cont)
•
•
•
•
Set a time line / schedule to determine which intervention takes
place when
Division of tasks is made (who does what at what time)
Identify your stakeholders – organisational, executive and other
leadership, other departments, clinicians.
Communication plan
Getting buy in - how are you going to sell it?
Dissemination – advise and inform the target group about
the practice to stimulate uptake. Getting the message out
there.
Consider existing resources and forums - staff meetings,
existing newsletters, email, web etc
Opinion leaders, champion.
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Project Planning (cont)
The Intervention
•
Develop resources
What is already out there?
What has been done before in our ED?
What has worked?
What hasn’t worked?
What is the evidence?
Busy test…’will this work on a busy ward?’
Draft
Get feedback (engage staff / stakeholders)
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Project Planning (cont)
Pilot
•
Brief test run (one week / month)
Collect data
get staff feedback
•
Adjust
•
Test
•
Repeat cycle
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Building on rapid cycles of change
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What do we know about influencing clinicians
to adopt best practice?
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Interventions directed at influencing clinicians
(EPOC)
•
Distribution of targeted educational materials
•
Participation in conferences, workshops, training sessions
•
Local consensus processes
•
Educational visits
•
Opinion leaders
•
Patient-mediated intervention
•
Audit and feedback
•
Reminders
•
Tailored interventions
•
Multiple combined strategies
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Printed Educational Materials
Printed educational materials - including guidelines, guideline
summaries, and articles – are frequently used to disseminate
information.
•
•
Small effects on process outcomes, compared with no intervention
No effect on patient outcomes, compared with no intervention
Unclear what factors improve effectiveness of printed educational
materials.
Farmer et al, Cochrane Database of Systematic Reviews, 2008 (4)
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Opinion Leaders / Clinical Leaders
“Opinion leaders are people who are seen as likeable, trustworthy
and influential.”
•
Opinion leaders improve evidence-based practice, either on their
own or as part of a multi-faceted intervention
•
No clear preferred method for using opinion leaders: e.g. informal /
formal education, meetings, small group visits
•
Some evidence to suggest opinion leaders identified by survey
(“Who are the opinion leaders?”) are more likely to improve
compliance than those chosen from a pre-selected list
Doumit et al, Cochrane Database of Systematic Reviews, 2007 (2)
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Audit & Feedback
“Any summary of clinical performance of healthcare over a given
period of time”
•
•
Small to moderate effects on practice, generally bigger when
baseline adherence is low
More intensive feedback results in bigger effect.
“The effects of audit and feedback might be larger when health
professionals are actively involved and have specific and formal
responsibilities for implementing change”
Jamtvedt et al, Cochrane Database of Systematic Reviews, 2006 (2)
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Reminders
Reminders can be printed (e.g. stickers or forms) or electronic
(e.g. computer based)
•
•
Systematic review of reminders found that they significantly
improved performance (13% improvement)
Effectiveness did not vary by type of reminder.
(Balas, Arch Int Med, 2000)
(Dexter, NEJM, 2001)
The method you choose needs to fit your system!
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4
Intervention / evaluation
• The ‘doing’ part of Step 3’s planning
– Be flexible
• Project evaluation
– Audit data
– Staff consultation
– Patient consultation
– Other sources?
Intervention
Evaluation
4
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5
Report and publish
• Consider who needs to know – executive, staff, community.
• Use your communications dept
• Consider writing a journal paper…share your experience!
Report
&
Publish
5
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Take home messages
1. Don’t assume that because the evidence exists, that it will
automatically find its way into clinical practice
2. Seek understanding of current practice (study / audit)
3. Consider barriers to proposed change  target
intervention to these barriers
4. Gain support (high level and ground support)
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For more information
www.nhmrc.gov.au/nics
Scott Bennetts
[email protected]
GPO Box 4530, Melbourne 3001
t +61 3 88660400
www.nhmrc.gov.au/nics
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