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Making information useful for decision makersJeremy Grimshaw MD, PhDDirector of the Canadian Cochrane Centre and NetworkClinical Epidemiology Program, Ottawa Health Research InstituteDepartment of Medicine, University of Ottawa
Outline
• Background• Effectiveness of strategies targeting different
decision makers• Current knowledge translation concepts• Health technology applications
Background
• Health technology assessments aim to inform decision making at all levels of health care systems.
• Considerable development over last two decades in health technology methods.
• Health technologies are struggling to optimise the dissemination and implementation of health technology assessments to maximise their impact.
Background
Potential target audiences for HTA• Policy makers
– Macro (national/provincial)– Meso (organisational)
• Managerial• Provider• Consumer
Background
• Most of the approaches to dissemination and implementation are more often based on beliefs than on scientific evidence
• ‘Evidence based medicine should be complemented by evidence based implementation’
Grol (1997). British Medical Journal.
Effectiveness of strategies targeting different decision makers
Cochrane Effective Practice and Organisation of Care (EPOC) Group aims to undertake systematic reviews of interventions to improve healthcare delivery and healthcare systems including:
• Professional interventions (e.g. continuing medical education, audit and feedback)
• Financial interventions (e.g. professional incentives)• Organisational interventions (e.g. the expanded role of
pharmacists)• Regulatory interventions
Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Zwarenstein (2005). Cochrane Library.
EPOC progress to date - register and reviews• Register of 3500+ primary studies• 33 reviews, 26 protocols• Collaborating with over 180 researchers from 12
countries
Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Zwarenstein (2005). Cochrane Library.
Effectiveness of strategies targeting different decision makers
Effectiveness of strategies targeting policy makers and managers
• Health policy-makers perceptions of their use of evidence: a systematic review
• 24 studies involving 2014 interviews with health policy makers
• Most studies focused on hypothetical scenarios or retrospective perception of the use of evidence in relation to specific cases.
Innvaer, Vist, Trummald, Oxman (2002). Journal of Health Services Research and Policy
Effectiveness of strategies targeting different decision makers
• Facilitators– Personal contact (13/24)– Timely relevance (13/24)– Inclusion of summaries with policy recommendations
(11/24)• Barriers
– Absence of personal contact (11/24)– Lack of timeliness or relevance of research (9/24)– Mutual mistrust (8/24)– Power and budget struggles (7/24)
Innvaer, Vist, Trummald, Oxman (2002). Journal of Health Services Research and Policy
Effectiveness of strategies targeting health care professionals
Effective Health Care Bulletin (1999). Getting evidence into practice. Effective Health Care Bulletin, 5(1). London, Royal Society of Medicine Press.
Also available from:http://www.york.ac.uk/inst/crd/ehc51.pdf
Effectiveness of strategies targeting health care professionals
Multifaceted interventions
Educational outreachLocal opinion leadersDidactic educational session
RemindersAudit and feedbackDissemination of printed educational materials
Generally effectiveMixed effectsGenerally ineffective
Bero et al (1998). BMJGrimshaw et al (2002). Medical Care
Effectiveness of strategies targeting health care professionals
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C, Vale L et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess2004.
(Available from:http://www.hta.nhsweb.nhs.uk/)
Effectiveness of strategies targeting health care professionals
Results• Included 285 reports of 235 studies, yielding
309 separate comparisons• Overall methodological quality poor (eg unit
of analysis errors common)• Poor description of interventions• Only 27% of studies used theories and/or
psychological constructs • 29.4% comparisons reported any economic
data
Effectiveness of strategies targeting health care professionals
–1.0%, +34.0%
+1.3%, +16.0%
+3.6%, +17.0%
Range
+14.1%14Reminders
+7.0%5Audit and feedback
+8.1%5Educational materials
Median effect size
Number of CRCTs
Intervention
Single interventions
Effectiveness of strategies targeting health care professionals
16 28 46 63 56 N =
Absolute effect size
Number of interventions in treatment group
>4 4 3 2 1
80%
60%
40%
20%
0%
-20%
-40%
-60%
-80%
Multifaceted interventions
Effectiveness of strategies targeting health care professionals
Multifaceted interventions including educational outreach•13 CRCT
Range –4% to +17.4% (median +6.0%)
Effectiveness of strategies targeting health care professionals
• Improvements in direction of effect in 86% of comparisons
• Reminders most consistently observed to be effective
• Educational outreach only led to modest effects • Dissemination of educational materials may lead
to modest but potentially important effects (similar effects to more intensive interventions)
• Multifaceted interventions not necessarily more effective than single interventions
Effectiveness of strategies targeting patients
• Cochrane Consumers and Communication Review Group aims to undertake systematic reviews of interventions to improve communication with consumers
• Register of 4538 primary studies• 12 systematic reviews and 20 protocols
– Decision aids for people facing health treatment or screening decisions
– Interventions for helping patients to follow prescriptions for medications
– Recordings or summaries of consultations for people with cancer
Effectiveness of strategies targeting patients
• Decision aids for people facing health treatment or screening decisions
• Included 35 RCTs• Decision aids improved:
– knowledge – more realistic expectations– lower decisional conflict related to feeling informed– increased proportion of people active in decision making– reduced proportion of people who remained undecided post
intervention• Decision aids had a variable effect on which healthcare options
were selected.O'Connor AM, et al (2003). Cochrane
Effectiveness of strategies targeting different decision makers
Summary• Relatively sparse evidence base especially for
policy makers and managers• Health technology agencies need to use
considerable judgment about how to disseminate HTAs to different target audiences
Current knowledge translation concepts
• Knowledge translation is about ensuring that:– stakeholders are aware of and use research evidence
to inform their decision making – research is informed by current available evidence
and the experiences and information needs of stakeholders
Knowledge translation models
• Push• Pull• Linkage and exchange• Knowledge brokers
Push models (1)
• Improving dissemination by researchers• Five key questions
– What should be transferred?– To whom should research knowledge be transferred?– By whom should research knowledge be transferred?– How should research knowledge be transferred?– With what effect should research knowledge be
transferred?
Lavis JN, Robertson D, Woodside JN, Mcleod CB, Abelson J (2003) Milbank Quarterly
Push models (2)
• Multiple approaches targeting different stakeholder groups– Actionable messages– Policy briefings (1, 3, 25)– Policy seminar and workshops– Toolkits– Peer reviewed papers– Other – patient decision aids, guidelines
Pull models
• Increase demand from decision makers• Enhancing receptor capacity
– Critical appraisal skills– EXTRA training program– Policy maker secondments
Linkage and exchange
• Creating new relationships between HTA agencies and policy makers to enhance mutual understanding and develop partnerships for framing and conducting HTA.
Knowledge brokers
• Using knowledge brokers to build and nurture relationships between those involved in joint knowledge production (researchers and policy makers)
Making information useful for decision makers
• Health technology agencies need clarity on their role in dissemination and implementation activities and what they should be held accountable for.
Making information useful for decision makers
• Improving receptivity of stakeholder audiences– Developing relationships with key stakeholder
audiences– Knowledge brokers, regular workshops,
regular communications• Improving linkages with partner organizations
with complementary responsibilities
Making information useful for decision makers
• Development of a formative dissemination plan throughout all stages of HTA process including– Planning HTA– Conduct of HTA– Interpretation of HTA findings– Dissemination of HTA findings– Further KT activities
Making information useful for decision makers
• Five key questions– What should be transferred?– To whom should research knowledge be transferred?– By whom should research knowledge be transferred?– How should research knowledge be transferred?– With what effect should research knowledge be
transferred?
Lavis JN, Robertson D, Woodside JN, Mcleod CB, Abelson J (2003) Milbank Quarterly
Making information useful for decision makers
Planning and conduct of HTA• Identifying potential stakeholders (policy makers,
managers, health care professionals, patients)• Engagement in peer review of HTA protocol to ensure
that HTA questions and methods will address decision makers information needs
• Engagement of stakeholders in advisory group throughout HTA process to:– advise on conduct and interpretation of HTA – develop stakeholders as champions of HTA– sensitize stakeholders about forthcoming HTA
Making information useful for decision makers
Disseminating findings of HTA• Dissemination plans may vary depending on target
group and HTA findings• Base model
– Development of actionable messages– Use of multiple formats and channels
• Policy maker briefing papers (1,3,25)• Publications• Website
• Additional specific activities often with partner organizations
Example – horizon scanning
Regulatory Body
National Policy Makers
Local Policy Makers
Professional Organizations
Health Care Professionals
Patients Research Funders
Researchers Medical Insurers
Stop useStop use, promote researchPromote use for limited indicationsPromote use for new indicationPromote widespread use
Abbreviations: P = primary target audience for early warning message; S = secondary target audience for early warning message
Example - early warning message concerning a new drug
Regulatory Body
National Policy Makers
Local Policy Makers
Professional Organizations
Health Care Professionals
Patients Research Funders
Researchers Medical Insurers
Stop use P P S S S S PStop use, promote research P P S S S S P P PPromote use for limited indications P P P S P P PPromote use for new indication P P P S P S PPromote widespread use P P P S P P P
Abbreviations: P = primary target audience for early warning message; S = secondary target audience for early warning message
Example - early warning message concerning a new surgical procedure
Regulatory Body
National Policy Makers
Local Policy Makers
Professional Organizations
Health Care Professionals
Patients Research Funders
Researchers Medical Insurers
Stop use S P P P P PStop use, promote research S P P S S P P PPromote use for limited indications S P P P P PPromote use for new indication S P P P S PPromote widespread use S P P P P P
Abbreviations: P = primary target audience for early warning message; S = secondary target audience for early warning message
Summary
• Health technology agencies (and evidence based organizations) are struggling to optimise the dissemination and implementation of health technology assessments to maximise their impact.
• Limited but potentially informative evidence base about how to target different stakeholder groups
Summary
• Future activities should focus on:– developing relationships with key stakeholder
audiences– embedding knowledge translation throughout
planning and conduct of HTAs– tailoring KT activities to target audience and key
messages• Further research is needed to develop better
evidence base to support future dissemination and implementation activities
Contact details
• jgrimshaw@ohri.ca• EPOC – epoc@uottawa.ca• Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C,
Vale L et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004.(Available from: http://www.hta.nhsweb.nhs.uk/)
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