Knowledge translation for professionals

1
Knowledge translation for professionals

• Jeremy Grimshaw MD PhD
• Director, Clinical Epidemiology Program, OHRI
• Director, Canadian Cochrane Centre

2
Potential barriers to KT

• Information management is necessary but not
  sufficient to ensure knowledge translation
• The new tower of Babel?
• Hibble, Kanka, Pencheon, Pooles. BMJ (1998)

3
Potential barriers to KT

• Structural (e.g. financial disincentives)
• Organisational (e.g. inappropriate skill mix,
  lack of facilities or equipment)
• Peer group (e.g. local standards of care not in
  line with desired practice)
• Professional (e.g. knowledge, attitudes, skills)
• Professional - patient interaction (e.g. problems
  with information processing)
• Patient (e.g. knowledge, attitudes, skills)

4
Planning change
Assess Monitor
Evaluate barriers supports
strategy application
outcomes
degree of use

• Practice Environment
• structural
• social
• patients
• economic

• Outcomes
• patient
• practitioner
• system

• Strategies
• barrier
• management
• transfer
• uptake

• Adoption
• intention
• use

• Potential Adopters
• attitudes
• knowledge
• skill

• Evidence - Based Recommendations
• development process
• innovation attributes

Ottawa Model of Research Use
Logan Graham, 2002
5
Planning change

• Choosing interventions
• Need to identify potential barriers relating to
  behavior, potential adopters and practice
  environment.
• Need to distinguish between modifiable and non
  modifiable
• Need to prioritize which are key barriers based
  on consideration of
• Identification of mission critical barriers
• Potential for addressing barriers through
  interventions

6
Towards evidence based implementation

• Most approaches to changing clinical practice 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.

7
Cochrane Effective Practice and Organisation of
Care (EPOC) Group

• EPOC aims to undertake systematic reviews of
  interventions to improve practice 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 (2006). Cochrane Library.

8
Cochrane Effective Practice and Organisation of
Care (EPOC) Group

• Progress to date - register and reviews
• Register of 5000 primary studies
• 39 reviews, 34 protocols
• Collaborating with over 300 researchers globally
• Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew,
  Oxman, Shepperd, Tavender, Zwarenstein (2007).
  Cochrane Library.

9
Overview of reviews of professional behaviour
change strategies

• Identified over 150 systematic reviews of
  professional behaviour change interventions
• For COMPUS, we summarised approx 50 systematic
  reviews judged to be likely highest quality and
  most up-to-date

10
Overview of reviews

• Educational materials (1)
• Educational meetings (1)
• Educational outreach (1)
• Audit and feedback (2)
• Opinion leaders (1)
• Mass media (1)
• Reminders general (4)
• Reminders Computer assisted drug dosage (3)
• Reminders CPOE (1)
• Tailored interventions (1)
• Multifaceted interventions (1)

• Prescribing general (10)
• Prescribing - safety (2)
• Changing roles nursing (1)
• Changing roles pharmacy (7)
• Financial (4)
• Regulatory (1)
• General (10)

11
Educational materials

• Distribution of published or printed
  recommendations for clinical care, including
  clinical practice guidelines, audio-visual
  materials and electronic publications. The
  materials may have been delivered personally or
  through mass mailings.
• Target knowledge, skills barriers at individual
  health care professional/peer group level
• Relatively low cost, feasible

12
Educational materials

• Farmer (2007) Cochrane Library (in preparation)
• High quality review
• 21 studies (RCTs, CCTs, CBAs, ITS)
• 9 studies included prescribing data
• Distribution of education materials may be
  effective for appropriate care including
  prescribing.
• (Median effect across 6 RCTs 4.9 absolute
  improvement)

13
Educational meetings

• Health care providers who have participated in
  conferences, lectures, workshops or traineeships
• Didactic meetings largely target knowledge
  barriers at individual health care
  professional/peer group level
• Interactive educational meetings can also
  target skills (if simulation/rehearsal involved)
  and attitudes at individual health care
  professional/peer group level

14
Educational meetings

• Thomson OBrien (2001) Cochrane Library
• High quality review
• 32 studies (RCT, CCT)
• 5 studies included prescribing data
• Interactive workshops and mixed
  interactive-dogmatic activities were generally
  ineffective for improving appropriate care.
  Mixed effects were observed for didactic
  sessions.
• Insufficient evidence on prescribing.

15
Educational outreach

• Use of a trained person who met with providers in
  their practice settings to give information with
  the intent of changing the providers practice.
  The information given may have included feedback
  on the performance of the provider(s).

16
Educational outreach

• Derives from social marketing approach
• Use social persuasion methods to target
  individuals knowledge and attitudes
• Typically aim to get maximum of 3 messages across
  in 10-15 minutes using approach tailored to
  individual health care provider
• Typically use additional strategies to reinforce
  approach
• Typically focus on relatively simple behaviours
  in control of individual physician eg choice of
  drugs to prescribe

17
Educational outreach

• Relatively expensive although may still be
  efficient
• May be less effective for complex behaviours
  requiring team or system change

18
Educational outreach

• Thomson OBrien (1997) Cochrane Library
• Medium quality review
• 18 studies (RCT, CCT)
• 12 studies included prescribing data
• Multifaceted educational outreach visits were
  generally effective for improving appropriate
  care including prescribing
• (Grimshaw 2004 median effect across 13 RCTs of
  multifacted educational outreahc interventions
  6.0)

19
Local opinion leaders

• Use of providers nominated by their colleagues as
  educationally influential. The investigators
  must have explicitly stated that their colleagues
  identified the opinion leaders.
• Target peer group knowledge, attitudes
• Resources required include survey of target
  group, resources to recruit and support opinion
  leaders.

20
Local opinion leaders

• Doumit (2007) Cochrane Library
• Medium quality review
• 12 studies (RCT, CCT)
• 7 studies included prescribing data
• Generally effective for improving appropriate
  care. Insufficient evidence on prescribing.
• Median effect across studies 10 absolute
  improvement

21
Local opinion leaders

• Appear to be condition specific
• Likely coverage of target group difficult to
  assess
• Grimshaw et al (2006). Implementation Science
• Stability over time uncertain Doumit
  re-surveyed surgeons 2 years after initial survey
  to identify opinion leaders. Only 4/16 original
  opinion leaders re-identified
• Doumit (2006) Masters thesis

22
Audit and feedback

• Any summary of clinical performance of health
  care over a specified period of time. The
  summary may also have included recommendations
  for clinical action. The information may have
  been obtained from medical records, computerised
  databases, or observations from patients.
• Adams et al demonstrated that self reported
  behaviour likely to overestimate actual
  performance by 27
• Adams et al (1999) Int Journal for Quality in
  Health Care
• Target health care provider/peer groups
  perceptions of current performance levels
• Aim to develop cognitive dissonance to motivate
  physicians to change

23
Audit and feedback

• Resources required include data abstraction and
  analysis costs, dissemination costs (postal or
  personal)
• Feasibility may depend on availability of
  meaningful routine administrative data for
  feedback

24
Audit and feedback

• Jamvedt (2005) Cochrane Library
• High quality review
• 118 studies (RCT, CCT)
• 55 studies included prescribing data
• Audit and feedback alone, audit and feedback with
  educational meetings, audit and feedback as part
  of multifaceted intervention generally effective.
• Median effect across studies 10 absolute
  improvement
• Larger effects were seen if baseline compliance
  was low.

25
Reminders

• Patient or encounter specific information,
  provided verbally, on paper or on a computer
  screen, which is designed or intended to prompt a
  health professional to recall information. This
  would usually be encountered through their
  general education in the medical records or
  through interactions with peers, and so remind
  them to perform or avoid some action to aid
  individual patient care. Computer aided decision
  support and drugs dosage are included.
• Focus on professional patient interaction,
  prompting professional to remember to do
  important items

26
Reminders

• Resources vary across deliver mechanism
• Increasing interest in computerised decision
  support but evidence tends to come from a few
  highly computerised US academic health science
  centres
• Insufficient knowledge about how to prioritise
  and optimise reminders

27
Reminders

• Garg (2005) JAMA
• Medium quality review
• 100 studies (RCT, CCT)
• 49 studies included prescribing data
• Mixed effects were observed for computerised
  clinical decision support systems (CDSS) for
  appropriate care including prescribing

28
Multi faceted interventions

• Any intervention including two or more components
• Multi-faceted interventions are more likely to
  target different barriers in the system
• Likely more costly than single interventions
• Need to carefully consider how components likely
  to interact to maximise benefits

29
Effectiveness of strategies targeting health care
professionals
Multifaceted interventions

• Grimshaw et al (2004). Health Technology
  Assessment

30
Conclusions

• Imperfect evidence base to support choice of
  interventions to improve prescribing
• Choice of intervention should be based upon
  consideration of
• likely barriers
• evidence of effectiveness of intervention
• mechanism of action of intervention
• resources available
• other feasibility issues

31
Contact details

• Jeremy Grimshaw - jgrimshaw_at_ohri.ca
• EPOC epoc_at_uottawa.ca