A public lecture on the A public lecture on the Science & Art of Science & Art of

Implementing EvidenceImplementing EvidenceDave Davis, MD, CCFP, FCFP, FRCPC (hon) University of Toronto Faculty of Medicine

– Associate Dean, Continuing Education

– Principal Investigator, Knowledge Translation Program Ontario Guidelines Advisory Committee, Chair

If you don’t like If you don’t like thatthat title…title… Translating Guidelines into Practice Putting Guidelines in Place Using Evidence-based educational

principles to help clinicians put evidence into practice

Knowledge Translation:– old concept + new tools = better effect?

Vanessa Young, 1985-2000Vanessa Young, 1985-2000

Mild eating disorder (early satiety) diagnosed in 1998, in Oakville, Ontario

Seen by child psychiatrist and family doc., prescribed cisapride, with excellent results

1990; massive drug launch, all the bells & whistles 1992-98; subsequent, sporadic findings of cardiac

arrhythmias released by drug company bulletins, federal warnings (via print materials)

2000; Vanessa dies suddenly 2001; coroner’s inquest: family doctor especially

expresses inability to ‘keep up with the information overload’, like an ‘avalanche’

An outline; knowing when to nap

Definitions The Care Gap

– evidence for the gap in care – its extent & nature Causes of the gap

– problems with the learner, the message, the system

A Possible Solution – The creation and best use of guidelines– the question of translating knowledge into practice

“Knowledge translation is the effective and timely incorporation of evidence-based information into the practices of health professionals in such a way as to effect optimal health care outcomes and maximize the potential of the health system”

– Adapted from the Canadian Institutes for Health Research definition, 2001

Diffusion: distribution of information and the practitioners’ natural unaided adoption of policies and practices

Dissemination: communication of information to clinicians to improve their skills

Implementation: putting a guideline in place, involves effective communication, overcomes barriers by administrative and educational techniques

(after Lomas)...(after Lomas)...

What do CME & CPD mean?What do CME & CPD mean?’any & all ways by which physicians learn & change’ AMA

1972 courses

mailed materials,guidelines

peers,consultants

AV aids

patient ed

outreach visits

wwwsearch

reminders

Continuing professional Continuing professional developmentdevelopment

“…broader than ‘CME’, continuing professional development permits a consideration of many non-clinical topic areas, allows for a broader range of methods and settings. Further, it is more adult-learner centered….”

» Davis, Barnes, Fox, eds., The Continuing Professional Development of Physicians, AMA Press, 2003

Information overload

DEFINITIONSDEFINITIONS

Clinical practice guidelines are consensus and/or evidence-based statements of care intended to provide direction and assist decision-making in clinical care for both patients and clinicians..

• Adapted from the Institute of Medicine, 1990

Current practice

Ideal, evidence-based practice

clinical care gap

The clinical care gap

WARNING!!WARNING!!: this is the this is the interactive partinteractive part

1. Think about a gap in your practice, setting or experience

2. Define it

3. Figure out the why question – what are the barriers to full implementation of the guideline, evidence, whatever

4. (Figure out the ‘how to fix it’ question)

Exercise #1

Identify a clinical gap in practice/health care with which

you’re familiar

overuse

Acute pharyngitis– Fahey 1998

Acute Otitis Media– Delmar 1997

Acute bronchitis– 65-80% vs 20%– Gonzales 1997

?PSA screening ?Mammography for

low risk women age 40-50– Gotzsche, 2000

Others……(Ministry of Health, Ontario

data, 2001-04):

– Hysterectomies– Repeat C-Sections– Modified radical

mastectomy in breast CA

– Routine, pre-op chest X-rays, EKGs

– Lumbosacral X-rays for acute low back pain

– *Routine q6-12month echocardiograms in stable CHF

– *? Sleep studies

Underuse Pap Smears: Pirkis, 1998 CHF & ACE inhibitors

Hickling 2001– and beta blockers in the

elderly; McAlister 1999 Post MI patients

• Lipid lowering: Kong, 1998; Aronow, 1998

• ASA• Beta blockers

Atrial Fib & anticoagulation• Mendelson, 1999

Diagnosis of mental disorders• Craig and Boardman,

1997 ?Screening for colorectal cancer

>50

…and misuse– Beta blockers in

diabetics, asthmatics– Tricyclic

antidepressants in the presence of cardiac arrhythmias

– Cisapride (knowing what we know today)

Exercise # 2

Describe the causes of the gap

What causes the gap?What causes the gap? The evidence-to-practice puzzle

The educational deliverysystem

The clinicianThe evidence/guideline

Health CareSystem issues

•Patient•Team members

problems with the learner-clinician

age, experience, time (dis)incentives training

– emphasis on knowledge, not knowledge management

– inability to detect needs, evaluate performance

– self-directed learning– critical appraisal

type of practice competence motivation too narrow a definition

of ‘learner’ learning cycle:

awareness, agreement, adoption, adherence

No time…

No, Thursday’s out. How about never-is never good for you?

Dave’s top 10 reasons for not buying into CPGs 10) They change all the time 9) Guidelines, what guidelines? 8) I am too busy to adopt this

new stuff 7) Patient problems don’t fit

neatly into those little boxes 6) They were made in

Washington (Ottawa, Saskatchewan), wouldn’t apply here

Dave’s top 10, cont’d 5) I don’t trust all this EBM stuff 4) There were no family docs (left-

handed psychiatrists, etc) on the panel

3) MY patients expect ME to make decisions!

2) I already DO abide by the guidelines, yup, yessirree, 100%, all the time; that’s me - Mr. Guidelines.....and

1) MY patients are different!!

….problems with the guideline, evidence itself

– compatibility– complexity– cost– relative advantage– accessibility– format– patency of evidence, process of development– opportunity; trial-ability– Note the AGREE instrument

Producing & disseminating guidelines

1) selection of clinical question 2) literature searching 3) distillation/synopsis of literature 4) agreement by consensus, review 5) development of statement 6) endorsement of statement

7) distribution/dissemination7) distribution/dissemination

“Information management is like having your mouth to a firehose”

David Naylor, Dean, Faculty of Medicine, University of Toronto

2002

“It’s pretty simple, really: just review the world It’s pretty simple, really: just review the world literature every two weeks”literature every two weeks”

Sharon Straus, KT program,

University of TorontoLast week

…problems with the ‘Delivery System’ for CME

& CPD: does it work?

“Does CME work, Dave?

All these short courses - do they change how physicians practice?” Fraser Mustard

(not the guy in CLUE)

Dean, Faculty of Health Sciences, McMaster University

July 1977

Three Reviews of Three Reviews of ‘educational’ ‘educational’ interventionsinterventions

INCLUSION CRITERIA:– Randomized Controlled Trials– Replicable, educational interventions:

meetings, feedback, audiotapes, reminders, lectures, etc

– >50% practicing physicians/professionals– Objective outcomes of physician

performance or patient/health care status

StrategiesStrategies Educational materials Formal educational

meetings Outreach visits Local opinion leaders Patient mediated

strategies Audit/feedback

Reminders Mass media Combination

strategies

Other overall Other overall findings…findings… Needs Assessment (‘social

marketing’) appears to be important – the more the better (subjective needs, objective, gaps and barrier analysis)

No evidence much about long-term effects

Enabling materials – helpful?

Others’ findings (1999 –Others’ findings (1999 –2004):2004):[Cochrane Reviews- Thompson-O’Brien, Grimshaw, others] Most effects pretty much small to moderate at best,

INCLUDING– Multiple methods – Mailed materials

Reminders still mostly moderate-large effects, but few/no long-term studies

Methodology better understood, but studies often very messy, lack details, poorly designed

And… Quantitative methodology necessary but not sufficient

to understand change NO common theoretical base – mostly kitchen sink

research

Reason for the gap #4769: the ‘CME Process’

A Database of Physician Education & Change

www.cme.utoronto.ca/rdrbwww.cme.utoronto.ca/rdrb

The Research and Development Resource Base in CME

– educational, clinical & health services literature

– supported by the AMA, ACME, SACME,

Royal College of Physicians and Surgeons of Canada, the University of Toronto

Some comments on Some comments on

these reviews….these reviews…. CAUTIONS

– publication bias– screening bias– reporting gaps– very narrow,

quantitative, EBM-ish RCT bias

– focus of this review - change, not learning

– but.........

COMMENTS– size/scope/

nature of field– What we do

doesn’t work– What we don’t

do does

……..Exercise #3

What are the implications of this What are the implications of this gap, and its causes, for us as gap, and its causes, for us as

practitioners?practitioners?

What guidelines can’t do…

A CRITICAL LOOK AT A CRITICAL LOOK AT GUIDELINE GUIDELINE

DEVELOPMENTDEVELOPMENT

The AGREE The AGREE instrumentinstrument – –

The Not-all-guidelines-The Not-all-guidelines-are-equal Guidelineare-equal Guideline

SCOPE and PURPOSESCOPE and PURPOSE

RIGOR OF DEVELOPMENT

RIGOR OF DEVELOPMENT

EDITORIAL INDEPENDENCE

EDITORIAL INDEPENDENCE

CLARITY and PRESENTATION

CLARITY and PRESENTATION

APPLICABILITY

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www.agreecollaboration.org

1. Scope and purpose

concerned with the overall aim of the guideline, the specific clinical questions and the target patient population.

Item 1. The overall objective(s) of the guideline is (are) specifically described

Item 2. The clinical question(s) covered by the guideline is(are) specifically described

Item 3. The patients to whom the guideline is meant to apply are specifically described

2. Stakeholder involvement

focuses on the extent to which the guideline represents the views of its intended users.

Item 4. The guideline development group includes individuals from all relevant professional groups

Item 5. The patients’ views and preferences have been sought

Item 6. The target users of the guideline are clearly defined.

Item 7. The guideline has been piloted among target users.

3. Rigor of development

relates to the process used to gather and synthesize the evidence, the methods to formulate the

recommendations and to update them.

 Item 8. Systematic methods were used to search for evidence

Item 9. The criteria for selecting the evidence are clearly described

Item 10. The methods used for formulating the recommendations are clearly described

3. Rigor of development (continued)

 Item 11. The health benefits, side effects, and risks have been considered in formulating the

recommendations

Item 12. There is an explicit link between the recommendations and the supporting evidence

Item 13. The guideline has been externally reviewed by experts prior to its publication

Item 14. A procedure for updating the guideline is provided

4. Clarity and presentation

deals with the language and format of the guideline.

 Item 15. The recommendations are specific and unambiguous

Item 16. The different options for management of the condition are clearly presented

Item 17. The key recommendations are easily identifiable

Item 18. The guideline is supported with tools for application

5. Applicability

pertains to the likely organizational, behavioral and cost implications of applying the guideline.

Item 19. The potential organisational barriers in applying the recommendations have been discussed.

Item 20. The possible cost implications of applying the recommendations have been considered

Item 21. The guideline presents key review criteria for monitoring and/or audit purposes

6. Editorial independence

concerned with the independence of the recommendations and acknowledgement of

possible conflict of interest from the guideline development group.

Item 22. The guideline is editorially independent from the funding body

Item 23. Conflicts of interest of guideline development members have been recorded

Seems simple…So what’s all the fuss?

                      

Current practice

Ideal, evidence-based practice

The clinical care gap: possible theory-to-The clinical care gap: possible theory-to-practice solutions, probable research practice solutions, probable research

questionsquestions

The informationInterventions The learner-target

knowledge translation strategies

1) ‘Solving’ the information problem – one example The Guidelines Advisory Committee,

Ontario – Joint body of the Ontario Medical Association and the Ministry of Health

and Long term Care, Ontario– Chooses a topic area; reviews all guidelines in that area; scores them

by the Cluzeau/AGREE instrument– Mounts them on a website

– Quick, 30 second synopsis– Parallel patient synopsis– Other links to QA tools, algorithms

– Simultaneous distribution/dissemination/implementation through medical schools, licensing body, professional associations, hospitals, etc

Other Efforts: Skolar, Cochrane, Ovid, Bandolier

 

2) Solving the ‘CME’/Intervention Problem – a 2) Solving the ‘CME’/Intervention Problem – a

possible modelpossible model BMJ 2003

Methods/ Stages

Awareness Agreement Adoption Adherence

Predisposing - Print material,- Lectures, - Academic detailing - Media campaigns

   

Enabling   -Small groups,- Opinion leaders

- Pt. Education,- Opinion leaders

 

Reinforcing     Reminders, Audit/ feedback

RemindersAudit/ feedback

NHS Consumer Health Information Web Site December 2001 5.2 million hits – 171,900 visitors (Powell & Clarke, 2002)

Fifty-eight per cent of GPs have been approached by patients with Internet healthcare information. Sixty-five per cent of the information presented by patients was new to GPs. (Wilson, 1999)

NOTE: communication skills

Solving the learner problem #3: Consumers can drive change, too: why not educate them?

A few final wordsA few final words– Large body of educational/change literature – largely unused

in guideline implementation – NO single effective change agent (except maybe

reminders); multiple methods may work best if they include the awareness-to-agreement continuum; methods work at different levels of change - predisposing, enabling & reinforcing

– Need to re-conceptualize ‘CME’, in order to incorporate models of ‘knowledge translation’, or guideline implementation; need to re-think targets

– Hope for the future: better models, more practical tools, information systems,Commonwealth initiatives in health, NICS, others, and

– Remember Vanessa

www.ktp.utoronto.ca

www.cme.utoronto.ca

www.gacguidelines.ca

For more For more information…….information…….