A public lecture on the Science & Art of Implementing Evidence

1. Getting a Grip on Guidelines A public lecture on the Science & Art of Implementing Evidence Dave 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

2. If you don’t like that 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?

3. Vanessa 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’

4. 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

5. Definitions • “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

6. 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)...

7. What do CME & CPD mean?’any & all ways by which physicians learn & change’ AMA 1972 courses reminders patient ed mailed materials, guidelines outreach visits peers, consultants www search AV aids

8. Continuing professional development • “…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

9. Information overload

10. DEFINITIONS • 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

11. The clinical care gap Ideal, evidence-based practice clinical care gap Current practice

12. WARNING!!:this is the interactive part • Think about a gap in your practice, setting or experience • Define it • Figure out the why question – what are the barriers to full implementation of the guideline, evidence, whatever • (Figure out the ‘how to fix it’ question)

13. Exercise #1 Identify a clinical gap in practice/health care with which you’re familiar

14. 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 overuse

15. 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) Underuse

16. Exercise # 2 Describe the causes of the gap

17. What causes the gap?The evidence-to-practice puzzle The evidence/guideline The clinician The educational delivery system • Health Care • System issues • Patient • Team members

18. 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 problems with the learner-clinician

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

20. 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

21. 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!!

22. ….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

23. 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/dissemination

24. “Information managementis 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 literature every two weeks” Sharon Straus, KT program, University of Toronto Last week

26. …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

27. Three Reviews of ‘educational’ interventions 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

28. Educational materials Formal educational meetings Outreach visits Local opinion leaders Patient mediated strategies Audit/feedback Reminders Mass media Combination strategies Strategies

29. Other overall 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?

30. Others’ findings (1999 –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

31. Reason for the gap #4769: the ‘CME Process’A Database of Physician Education & Changewww.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

32. 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 Some comments on these reviews….

33. Implications ……..Exercise #3 What are the implications of this gap, and its causes, for us as practitioners?

35. What guidelines can’t do…

36. A CRITICAL LOOK AT GUIDELINE DEVELOPMENT The AGREE instrument – The Not-all-guidelines-are-equal Guideline

37. STAKEHOLDER INVOLVEMENT APPLICABILITY CLARITY and PRESENTATION RIGOR OF DEVELOPMENT EDITORIAL INDEPENDENCE SCOPE and PURPOSE www.agreecollaboration.org

38. 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

39. 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 relevantprofessional 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.

40. 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

41. 3. Rigor of development (continued) Item 11. The health benefits, side effects, and risks have been considered in formulatingthe 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

42. 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

43. 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 havebeen discussed. Item 20. The possible cost implications of applying the recommendations havebeen considered Item 21. The guideline presents key review criteria for monitoring and/or audit purposes

44. 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

45. Seems simple…So what’s all the fuss?

46. The clinical care gap: possible theory-to-practice solutions, probable research questions Ideal, evidence-based practice The information Interventions The learner-target knowledge translation strategies Current practice

47. 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

49. 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 Reminders Audit/ feedback 2) Solving the ‘CME’/Intervention Problem – a possible modelBMJ 2003

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