Transcript Evidence based implementation for quality and health

Evidence based implementation for quality
and health promotion in hospitals
Professor Jos Kleijnen
Director
Centre for Reviews and Dissemination
University of York
United Kingdom
State of affairs in the UK at the end of the
20th Century
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Variable uptake of new health technologies or management
programmes, without adequate evidence of clinical and/or
cost-effectiveness
Variable persistence of outdated technologies and
programmes
Slow introduction of new methods, even if they were
proven effective and value for money
Different local decisions about available healthcare in the
context of budgetary constraints
Inequalities in health and health care: ‘postcode
prescribing’
Problems related to evidence based health
care
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Availability of evidence
Accessibility of evidence
Assessment of evidence (systematic reviews and health
technology assessments)
Appraisal of evidence leading to guidance
Applicability of evidence and guidance
Availability of evidence
Good:
• A lot of guidelines are available
• A lot of (systematic) reviews are available
Not so good:
• Quality of primary research evidence is generally poor
• Many more good studies are needed
• Often guidelines and reviews do not cover specific,
practical problems or settings
Searching the TRIP database for
“prevention” and “falls” (25 May 2004)
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Evidence based 79
Guidelines 63
Query-answering services 8
E-textbooks 420
Medical images 2
Patient information leaflets 51
Peer reviewed journals
• Therapy articles 201
• Diagnosis articles 32
• Etiology articles 300
• Prognosis articles 104
Evans D, et al. Fall prevention: a
systematic review. Clinical Effectiveness in
Nursing 1999; 3: 106-111.
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Authors' conclusions
Despite the importance of patients falls in hospitals, and
the large amount of published information, there is
currently little evidence on which to base clinical practice.
Accessibility of evidence
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National electronic Library for Health
Turning Research into Practice
Centre for Reviews and Dissemination (CRD)
Cochrane Library (free for 116 HINARY countries, only
abstracts free for others)
www.freemedicaljournals.com
Most Health Technology Assessment agencies (via HTA
database at CRD)
Health Development Agency (public health and health
promotion)
Accessibility of evidence
Good:
• A lot of information is accessible free
Not so good:
• Difficult to know who/what you can trust
• You need easy access to the internet
• Printed copies usually attract a charge
Assessment
Good:
• Processes for assessment in place in many Western countries
• International collaboration is increasing: WHO Health Evidence
Network, Cochrane Collaboration, Guidelines International Network,
INAHTA etc.
• Many resources with assessed information
Not so good:
• Not easy for busy decision makers and practitioners
• Ideally by independent academic groups with appropriate
methodological and clinical expertise
• Takes a lot of time to do, whereas you need it by tomorrow
• Is expensive: one systematic review at £70,000, one technology
assessment report £80,000 – 160,000
Appraisal
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Assessment is scientific work by independent academics,
appraisal is decision making by appropriate bodies such as
the National Institute for Clinical Excellence and the
Health Development Agency
Appraisal takes more factors into account such as needs,
resources, priorities, innovation and others
Assessed evidence should inform appraisal just as
evidence should be integrated with clinical experience in
individual patient care
Appraisal
Good:
• If it takes best available evidence into account
• If it takes views of all relevant stakeholders into account
• If it takes affordability and practical barriers into account (sorry
we can’t do this because we would need to train 300,000
nurses….)
Not so good:
• If the process is not transparent
• If information is used that is not in the public domain
• When evidence is lacking and strong different opinions are
prevalent
Applicability
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JM Grimshaw et al. Effectiveness and efficiency of
guideline dissemination and implementation strategies.
Health Technology Assessment 2004;8:6.(84 pages –
download free from www.ncchta.org).
“There is an imperfect evidence base to support decisions
about which guideline dissemination and implementation
strategies are likely to be efficient under different
circumstances”
“Decision makers need to use considerable judgement
about how best to use the limited resources they have for
improving the quality of care and related activities to
maximise population benefits”
Applicability
Good:
• There is evidence that some dissemination and implementation
strategies work in some circumstances
• Simple single interventions may be as effective as complex
multifaceted interventions
• Dissemination of educational materials may lead to modest but
potentially important effects
Not so good:
• Decision makers need to exercise considerable judgement about what
may be effective in their circumstances
• There rarely is a budget for implementation
• Guidance may not be applicable to individual patients
• There are too many guidelines and there is too little time to implement
the recommendations
Further information
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www.york.ac.uk/inst/crd
www.cochrane.org
www.nice.org.uk
www.sign.ac.uk
www.nelh.nhs.uk
www.tripdatabase.com
www.hda.nhs.uk