the translational toolbox · theory of planned behavior preparation self - efficacy beliefs...

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TheTranslational Toolbox

Ralph Gonzales, MD, MSPH

Henry Lee, MD, MSJune 2011

Henry Lee• Assistant Professor of

Pediatrics, Division of Neonatology

• Associate Director of Data Analysis, California Perinatal Quality Care Collaborative

Ralph Gonzales• Professor of Medicine,

Epidemiology & Biostatistics

• Director, UCSF Program in Implementation and Dissemination Sciences (IDS)Collaborative

• UCSF CTSI KL2 Scholars Program

(IDS)

• Associate Director, CTSI KL2 Scholars Program

Background Taxonomy

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Translating “Evidence”…

1. Level of “evidence”; establishing “evidence”

Efficacy, effectiveness, systematic reviews, guidelines/recommendationsg /

;

Translating “Evidence”…

1. Level of “evidence”; establishing “evidence”

Efficacy, effectiveness, systematic reviews, guidelines/recommendations

2. Translating “evidence” into practiceg p

Innovations that improve health/outcomes2a. Processes of Care

• Influence health outcome– Behaviors, tests, treatments, procedures, etc

2b. Health Care Interventions

• Influence processes of care– Translational Tools; Implementation strategies; Policies

• Decision support tools

• Health coaches

• Prenatal vitamins

• Electronic health records

Which are Processes of Care?


• Telemedicine

• Antiretroviral therapy

• Cognitive behavioral therapy

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• Decision support tools

• Health coaches

• Prenatal vitamins


Processes of Care vs. Tools


• Telemedicine

• Antiretroviral therapy

• Cognitive behavioral therapy

Implementation Strategies

TranslationalTranslational Tools

Evidence

Processes of Care

OUTLINE

• Classifying Tools– 3 Dimensions

• Exemplars– Patients: Decision Support

– Clinicians: Practice Guidelines

– Community: CBPR

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Translational Tool

• A strategy, program, mechanism, tool used to translate evidence into practice.

– Evidence = processes of care directly linked to health outcomeshealth outcomes

• Although final process always involves patients/persons, behavior change targets of translational tools can vary.

ICE

TH

Tool Dimension #1: Target

NCE Stakeholders

li

• Government

• Payors/Insurers

• Societies

• Hospitals

PRACTI

HEA

LT

EVIDEN

Delivery Systems

Individuals

• Hospitals

• Clinic/Practices

• Health Depts

• Providers

• Patients

• Public

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ENVIRONMENT

B h i l

Contemplation

Pre‐ Contemplation

PREDISPOSING REINFORCINGENABLING

Behavioral Intention

Action Maintenance

Theory of Planned Behavior

Preparation

Self -Efficacy

Beliefs Attitudes

Social Norms

Motivation and Persuasion

REFS-Prochaska-Azjen-Green

Phase 1Social

assessment

HealthProgram

Phase 4a

Predisposing

Phase 3Educational &

ecologicalassessment

Phase 4b

Phase 2Epidemiological

Assessment

Genetics

PRECEDE-PROCEED

InterventionAlignment

• Predisposing,

• Reinforcing, &

• Enabling

• Constructs in

• Educational/Ecological

• Diagnosis &

• Evaluation

• Policy,

• Regulatory &

• Organizational

• Constructs in

• Educational &

• Environmental

• Development

Phase 7Impact & Outcome evaluation

Quality of Life

Health

Educational strategies

Policyregulation

organization

Phase 5Implementation

Phase 6Process evaluation

Enabling

Reinforcing

Behavior

Environment

Administrative &Policy Assessment

Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.

Tool Dimension #2: PRECEDE

1. Predisposing Factors – Rx=Why you should change

– Examples: Media Campaigns; Education; Guidelines

2 R i f i F t2. Reinforcing Factors– Rx=Align rewards/penalties

– Examples: Incentives; Feedback; Opinion Leaders; Laws/Regulations

3. Enabling Factors (make it easy to do it)

– Rx=Make it easy to do it

– Examples: Skills; Decision Support; Authorization; Registries; Reminders

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Tool Dimension #3: Platform

Examples…

‐Education• Brochures; Computerized; Video; Mass Media; In‐Person

D i i t‐Decision support• Computerized; HealthCoach; Action Plans; Telephone Advice Nurse

‐Laws and regulations• Federal/state laws; work‐place regulations; school regulations; licensing

The Translational Toolbox‐individual behavior change tools

Community• Health fairs• Mass media• Advice lines• Support

Patient• Education

– Printed– Computer– Internet– Video/multi-media

Clinician• Education

– CME– Detailing

• Guidelines• Prior Auth’npp

groups• Conditional

payments• Taxes

• Decision Aids• Disease

management– Coaches– Action plans

• Copayments• P4P• Motivational

interviewing

• Prior Auth n• Decision

support• Registries• Reminders• Audit &

feedback• P4P• Opinion leader

KeyPredisposingReinforcingEnabling

OUTLINE



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Patient Behavior Change‐van de Meer V et al. Ann Intern Med 2009;151:110‐120

Background• Despite the availability of monitoring tools and effective therapy, asthma

control is suboptimal and long‐term management falls far short of the goals set in the guidelines

• Self‐monitoring, education, and specific medical care are important aspects in improving the lives of patients with asthma

• However, many patients with mild or moderate persistent asthma do not attend checkups regularly or visit their physician with symptoms of the disease.

• Internet technology is increasingly seen as an appealing tool to support self‐management for patients with chronic disease.

Patient Behavior Change‐van der Meer V et al. Ann Intern Med 2009;151:110‐120

Problem and Intervention

What is the evidence? Medical management

What is the quality gap? “under‐utilization”

Is the quality gap linked to the outcome gap? yes

Tool: decision support tool

Target:

PRECEDE:

Platform:

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Patient Behavior Change‐van der Meer V et al. Ann Intern Med 2009;151:110‐120


What is the evidence? Medical management

What is the quality gap? “under‐utilization”


Tool: decision support tool

Target: patients with asthma/internet access

PRECEDE: knowledge; skills; feedback

Platform: internet

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Patient Decision Aids“Informed Decision Making”g

Patient Decision Aid SpecsO’Connor AM et al. Cochrane Reviews 2003

• What is it?

– An adjunct to counseling that

• explains options

• clarifies personal values for the benefits vs. harms

• guides patients in deliberation and communication

• Outcomes– Improve Decision Quality

• Decisions are informed (knowledge; risk perception)

• Decisions based on personal values (congruence)’

• Most common conditions• Breast, prostate and colon cancer screening & treatment• Menopause options• Cardiovascular disease management• Prenatal testing

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Patient Decision Aid SpecsO’Connor AM et al. Cochrane Review 2003

• Cost:• Feasibility:• Complexity:• Efficacy/Effectiveness:

Patient Decision Aid SpecsO’Connor AM et al. Cochrane Review 2003

• Cost: development… low‐medium—person‐hours• Feasibility: very feasible• Complexity: potential for high complexity• Efficacy/Effectiveness:

– Most RCTs measured process/intermediate outcomes (knowledge; realistic expectations; decisional conflict)realistic expectations; decisional conflict)

• Main effects are on knowledge and realistic expectations, with OR about 1.4‐1.6.

• Reductions in decisional conflict appear modest• 5/9 studies showed improvement in satisfaction with decision

Patient Behavior Change Tools

Predisposing

• Patient education

Reinforcing

Enabling

• Decision support

• Action plans

Reinforcing

• Reminders

• Coaches

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OUTLINE




Clinician Behavior Change‐Campbell SM et al. N Engl J Med 2009;361:368‐78

Background

• In 2004, the U.K. government introduced a pay‐for‐performance scheme with 136 indicators for family practices.

• Payments make up approximately 25% of family practitioners’ income, and 99.6% of family practitioners participated in the pay‐for‐performance scheme, which is voluntary.



What is the evidence? Asthma, diabetes, CHD care

What is the quality gap? underperformance

Is the quality gap linked to the outcome gap? Yes

Tool: Financial Incentives/P4P

Target:

PRECEDE:

Platform:

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What is the evidence? Asthma, diabetes, CHD care

What is the quality gap? underperformance

Is the quality gap linked to the outcome gap? Yes

Tool: Financial Incentives/P4P

Target: Family Practices

PRECEDE: Reinforcing

Platform: Governance

Results

Clinical Practice Guidelines

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Practice Guideline Specs

• What is it?– Cost: person‐hours

– Feasibility: buy‐in; participation

– Complexity: varies

• S mmar of e idence i ff ti i i l ti• Summary of evidence ineffective in isolation

Practice Guideline Specs

• What is it?– Cost: person‐hours

– Feasibility: buy‐in; participation

– Complexity: varies

• S mmar of e idence i ff ti i i l ti• Summary of evidence ineffective in isolation

• Ideal uses– Target behaviors single, simple actions

– Target barriers knowledge/attitudes

• Conclusion: it’s all about ‘implementation’

Practice Guidelines seem to be most effective…

• for acute care conditions

• when quality of evidence is superior

• when compatible with existing values

• when decision making complexity is low

• when desired performance/behavior is clearly understood

• when new skills or organizational support is not necessary for behavior change

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The influence of intervention strategy and organisational factors on practice guideline effectiveness.

Adapted from Dijkstra et al, BMC Health Services Research 2006;6:53

PLATFORM

Educational Meeting

Educational Material

Consensus Meeting

Reminders

SETTING

Inpatient

Outpatient

OUTCOMESReminders

Feedback

Patient-Mediated

Outreach

Opinion Leader

Revision of Prof Roles

Financial

Organisational

ORGANISATIONAL EFFECT MODIFIERS

Leadership (Management Support)

Learning Environment (Academic)

Physician Type and Specialty

Local Consensus (Development)

-behavioral

-clinical

SUMMARYCPG Interventions

• Development– identify clinician knowledge and behavior gaps

– identify barriers to change

– evidence‐based “best practice”

– quantify benefit of CPG compliance on system, practice and patient

– local input & endorsement

• Implementation– opinion leader; clinical champion

– point‐of‐service reminders

– feedback/profiling

Clinician Behavior Change Tools

Predisposing

• Guidelines

• CME

Enabling

• Decision support

• Teams

Reinforcing

• Opinion Leaders

• Financial Incentives

• Penalties

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OUTLINE




– Community: CBPR

Public Behavior Change‐Manandhar DS et al. Lancet 2004;364:970‐79

Background

• In India, neonatal mortality accounts for up to 70% of infant mortality. Most deaths happen at home, and many could be avoided with changes in antenatal, delivery, and newborn care practicespractices.

• Primary and secondary health‐care systems have difficulties in reaching poor rural residents. In Makwanpur district, Nepal, for example, 90% of women give birth at home, and trained attendance at delivery is uncommon .

Translational Tool: CBPR

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Public Behavior Change‐Manandhar DS et al. Lancet 2004;364:970‐79


What is the evidence being translated? Prenatal/postnatal care

What is the quality gap? see Table 4 control group


Tool: CBPR

Target: pregnant women

PRECEDE: knowledge; decision support; social support

Platform: CBPR; “facilitators”

Results

Public Behavior Change Tools

Predisposing

• Health Fairs

• Mass Media

• Outreach

Enabling

• Built Environment

• Self‐Efficacy

• Outreach

• Health Coaches

Reinforcing

• Reminders

• Opinion Leaders

• Conditional Payments

• Co‐Payments

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SUMMARY

• Guidelines/Knowledge/Awareness is a necessary starting point, but rarely sufficient to create behavior change

• Think about an intervention strategy that uses multiple tools across the spectrum of predisposing, reinforcing and enabling factors depending on the relevant theory

• Tools don’t work by themselves. Implementation is the key

Translational Tool ResourcesAHRQ Innovations Exchange (http://www.innovations.ahrq.gov)

Cochrane Effective Practice and Organisation of Care Group (EPOC) (http://www.epoc.cochrane.org)

National Guidelines Clearinghouse (www.guideline.gov)

References

1. Prochaska JO, DiClemente CC. Stages and processes of self‐change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology 51(3): 390–395, 1983.

2. Azjen I, Driver BL. Prediction of leisure participation from behavioral, normative, and control beliefs: an application of the theory of planned behavior. Leisure Science 13:185–204, 1991.

3. Green LW, Kreuter MW. Health Program Planning: An Educational and Ecological Approach. 4th edition. NY: McGraw‐Hill Higher Education, 2005.

4. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice (4th Edition). San Francisco, Calif.: Jossey‐Bass, 2008.

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Appendix

CASE STUDY:The IMPAACT Trial

Supported by AHRQ (1 R01 HS013915) and VA HSR&D (AVA‐03‐239)

• Emegency Department Intervention:

1. Provider education (practice guidelines) delivered by local opinion leadersdelivered by local opinion leaders

2. Group audit and feedback

3. Patient education

• Sites provided individualized adaptation of components

IMPAACT Intervention Sites

Northwestern Memorial Hospital Chicago VAMC

Lincoln Medical CenterBronx VAMC

UNM Health Sciences CenterAlbuquerque VAMC

Medical College of GeorgiaAugusta VAMC

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60

80

100

escr

ipti

on R

ate

EMNet Average year 1 Truman year 1Truman year 2 EBM Target

Group Audit and Feedback

*

0

20

40

URI Bronchitis Pharyngitis AECB

Ant

ibio

tic

Pre

URI, Bronchitis, Pharyngitis: excludes COPD, and antibiotic-responsive secondary diagnosesAECB: as 1st diagnosis, or URI/bronchitis 1st diagnosis in patient with PMHx COPD* < 5 visits

*

Patient Education

• Waiting Room Patient Education– Pamphlets/Cards

– Informational KioskInformational Kiosk

• Examination Room Materials– Bronchitis Posters

Exam Room Poster

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KIOSK

• Waiting room signs directed patients to kiosk

• Patients were encouraged to use kiosk by ED staff

• Rotating messages on screen suggested content

• All text on screen could be heard through speakers

• Bilingual educational printout at end of program

Kiosk Care Plan(Spanish and English)

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Adjusted Abx Rx Rates for URI/AB

5

10

15

p = .04

tib

ioti

cs:

Per

iod

s

-15

-10

-5

0

Control Sites Intervention Sites% V

isit

s P

resc

rib

ed A

nt

Inte

rven

tio

n -

Bas

elin

e P

Adjusted Abx Rx Rates for all ARIs

5

10

15

p= .17

d A

nti

bio

tic

s:

lin

e P

eri

od

s

-15

-10

-5

0

Control Sites Intervention Sites

% V

isit

s P

res

cri

be

dIn

terv

en

tio

n -

Ba

se

l

ABx Treatment of URIs/Bronchitis Decreased at Intervention Sites

Metlay et al, Ann Emerg Med, 2007.

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References & Resources1. Azjen I, Driver BL. Prediction of leisure participation from behavioral, normative, and control beliefs: an

application of the theory of planned behavior. Leisure Science.1991;13:185–204.

2. Campbell SM et al. Effects of pay for performance on the quality of primary care in England. N Engl J Med. 2009;361:368‐78.

3. Dijkstra R et al. The relationship between organisational characteristics and the effects of clinicalguidelines on medical performance in hospitals, a meta‐analysis. Bio Med Central Health Services Research. 2006;6:53. doi:10.1186/1472‐6963‐6‐53.

4. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice 4th

Edition. San Francisco, California: Jossey‐Bass, 2008.h5. Green L, Keuter M. Health Program Planning An Educational and Ecological Approach 4th Edition. NY,

London: McGraw‐Hill, 2005.

6. Manandhar DS et al. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster‐randomised controlled trial. Lancet. 2004;364:970‐79.

7. Metlay et al. Cluster‐randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments. Annals of Emergency Medicine. 2007;50(3):221‐230. doi:10.1016/j.annemergmed.2007.03.022.

8. O’Connor AM et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2003;1. doi: 10.1002/14651858.CD001431.

9. Poses RM, Cebul RD, Wigton RS. You can lead a horse to water – Improving physicians’ knowledge of probabilities may not affect their decisions. Medical Decision Making. 1995;15:65‐75.

10. Prochaska JO, DiClemente CC. Stages and processes of self‐change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology.1983;51(3): 390–395.

References & Resources11. US Department of Health and Human Services, National Institutes of Health. Theory at a glance: a guide

for health promotion practice. National Cancer Institute. Available at http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf. Accessed on January 19, 2012.

12. Van der Meer V et al. Internet‐based self‐management plus education compared with usual care in asthma: a randomized trial. Annals of Internal Medicine. 2009;151(2):110‐20.

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