TRANSLATING EVIDENCE INTO CLINICAL PRACTICE: WHAT WORKS

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TRANSLATING EVIDENCE INTO CLINICAL PRACTICE
WHAT WORKS?

• David A. Katz, MD, MSc
• University of Iowa
• March 28, 2006

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Outline

• Barriers to guideline implementation
• Attributes of effective interventions
• Chronic Care Model (CCM)
• Questions for future research

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Barriers to implementation

• Patient-related factors
• Low health literacy
• Low self-efficacy
• Lack of social support
• Competing demands (work, family, etc.)
• Multiple chronic conditions

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Barriers to implementation (contd)

• Clinician-related factors
• Knowledge
• Lack of awareness
• Lack of familiarity
• Attitudes
• Low self-efficacy
• Lack of outcome expectancy
• Clinical inertia
• Other barriers (lack of time, reimbursement)

Cabana, 1999
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Barriers to implementation (contd)

• Practice-related factors
• Inadequate resources
• Lack of leadership (e.g., champion)
• Lack of organizational commitment to support
  quality improvement
• Lack of effective teamwork
• Shortell, 2004

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Qualitative review Attributes of effective
interventions for implementing guidelines

• Create a process of continuous improvement at the
  individual and organizational level
• Provide face-to-face instruction, feedback
• Provide practical support (facilitators,
  resources)
• Use a combination of methods directed to specific
  barriers to change
• Grol, 1992

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Meta-analysis Interventions used in disease
management programs

• Definition of DM An intervention designed to
  manage or prevent a chronic condition using a
  systematic approach to care and potentially
  employing multiple treatment modalities.
• Published articles from 1987-2001
• Experimental or quasi- experimental study design
• Sufficient data to estimate effect size
• Weingarten, 2002

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Meta-analysis (contd)

• 102 articles describing 118 intervention programs
• 59 of DM programs used 2 or more interventions
• The most commonly used interventions were
• patient education (92 studies)
• provider education (47 studies)
• provider feedback (32 studies)
• patient reminders (28 studies)
• Weingarten, 2002

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Meta-analysis Effects of interventions on
provider adherence to guidelines
Weingarten, 2002
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Meta-analysis Effects of provider-targeted
interventions on disease control
Weingarten, 2002
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Meta-analysis Effects of patient-targeted
interventions on disease control
Weingarten, 2002
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Meta-analysis Limitations/caveats

• Great variation in patients, providers, and types
  of interventions used
• Few studies directly compared the effectiveness
  of different interventions
• Relatively few studies examined cost
• Reduced cost 1/7 (14)
• Reduced hospitalizations 3/28 (11)
• Ofman, 2004

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Chronic Care Model
Guidelines
Practice redesign
Self-management support
Decision support
Clinical information system
Organizational change
Community resources
Wagner, 1996
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Example 1 Depression

• Barriers to implementation of depression
  guidelines
• Patient ambivalence
• Confidence and skill of PCP
• Access to psychiatric care
• Poor communication between primary care and
  mental health specialists
• Potential solution 3-component model for
  depression care

Dietrich, 2003
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Example 1 Depression

• Design Cluster RCT in 60 primary care practices
• Patients Major depression or dysthymia
• Intervention
• Office systems approach to assessment
  monitoring of depression (practice redesign)
• Telephone f/u at 1, 4, and 8 wks from care
  manager (self management support)
• Use of psychiatrist to supervise care managers
  and assist PCP as needed (decision support)

Dietrich, 2004
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Example 1 Process measures
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Example 1 Outcome
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Example 2 Smoking cessation

• Barriers
• Organization of care around the patient-initiated
  15 minute visit
• Solution Use of non-physician personnel to
  handle routine preventive tasks and pt education
• Problem Limited staffing by nurses

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Example 2 Smoking cessation

• Design RCT in 8 primary care practices
• Patients Cigarette smokers
• Intervention
• Training of nursing staff in identification and
  brief counseling of smokers (practice redesign)
• Free NRT and proactive telephone counseling by
  cessation nurse (self-management support)
• Interim feedback to clinic staff
• Katz, 2004

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Results Adherence to guidelines
Recommended activity
Control
Intervention
(n499)
(n642)
Ask about smoking,
67
87
Assess willingness to quit,
30
73
Advice to quit,
38
47
Set quit date,
1
27
Discuss
pharmacotherapy,
14
39

p
lt
0.001, p0.06
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Results Cessation outcomes
Control
Intervention
Adj OR
(n499)
(n642)
(95 CI)
Any quit attempt,
50
57
1.4 (1.0-1.9)
2-mo quit rate,
5.8
16.4
3.5 (2.0-6.0)
6-mo quit rate,
9.8
15.4
1.8 (1.2-2.7)
Plan to quit w/in 6-mo,
35
43
1.3 (0.9-1.8)

p
lt
0.05
Applies only to
pts who were still smoking at 6-mo follow-up
contact
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Example 3 Diabetes

• Barriers
• Lack of patient-specific data to inform decision
  making
• Data needed to plan care is scattered across
  several different parts of the medical record
• Solutions
• Registry for identification of patients with
  chronic illness
• Real-time reminders and feedback that are
  specific for individual patients

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Example 3 Diabetes

• Design RCT of 58 family physicians
• Intervention
• Based on ADA care guidelines
• Local consensus with minor revisions
• Computer-generated recommendations on which
  studies were due
• Recommendations appeared on chart
• Lobach, 1997

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Example 4 Asthma

• Design RCT of 42 primary care pediatrics
  practices (MCO-affiliated)
• Patients children with mild-mod persistent
  asthma
• Planned care intervention
• Peer leader MD trained to champion the asthma
  guideline (organizational change)
• Nurse case manager to provide planned asthma
  visits (self-management support)
• Feedback to PCPs using registry based reports
  (information systems)
• Compared to 1) peer leader alone, 2) usual care

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Example 4 Implementation
Lozano, 2004
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Example 4 Outcomes
Lozano, 2004
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Teamwork

• Fundamental assumption of the CCM is the presence
  of effective teams
• Few studies have examined the relationship
  between clinical teams and delivery of
  guideline-recommended care

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Characteristics of effective teams

• Define clear goals with measurable outcomes
• Build clinical and administrative systems that
  facilitate getting the work done
• Divide labor by assigning tasks and roles
• Train individuals to perform these roles
• Develop clear structures and processes for
  communication

Grumbach, 2004
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Summary

• Implementation of evidence in practice is more
  likely to occur when
• Clinicians receive education, feedback, and/or
  reminders
• Workload is shared with ancillary staff
• Communication between primary care and specialty
  physicians is enhanced
• Multiple practice-change strategies are combined
• Guideline implementation and DM strategies can
  significantly improve disease control and HRQOL,
  but effects tend to be modest

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Summary (contd)

• Chronic care model is a coherent framework for
  implementing evidence-based care
• Need to know more about the effectiveness of
  certain components of chronic care model
  (organizational change, community resources)
• Need to figure out how to best integrate single
  disease strategies for implementing guidelines
  into the overall care of the patient

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Questions for future research

• What strategies improve the cohesiveness and
  overall effectiveness of practice teams?
• Do financial incentives for clinicians improve
  the delivery of guideline-recommended counseling
  and educational activities in support of patient
  self-management?
• Does improving access to and collaboration with
  medical specialists improve the delivery of
  evidence-based care?
• What is the incremental cost-effectiveness of
  strategies for guideline implementation relative
  to usual care?