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Translating Research Into Practice: Theory, Evidence, Planning

Translating Research Into Practice: Theory, Evidence, Planning. Ralph Gonzales, MD, MSPH UCSF April 1, 2008. Course Overview (1). Course Goals Learn how to design & evaluate interventions Learn some of the evidence base for specific types of interventions

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Translating Research Into Practice: Theory, Evidence, Planning

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  1. Translating Research Into Practice:Theory, Evidence, Planning Ralph Gonzales, MD, MSPH UCSF April 1, 2008

  2. Course Overview (1) • Course Goals • Learn how to design & evaluate interventions • Learn some of the evidence base for specific types of interventions • Develop and refine an intervention protocol • Deconstruct Interventions-- Who Changes? • Population/Community/Public • Patients • Providers • Systems/Organizations

  3. Sequential Approach to Intervention Design

  4. Health Care Interventions Understanding Behavior Intervening on Behavior Theory Evidence Planning

  5. Course Overview (2) • Homework • Required Reading before class • Protocol development • Exercise assigned after each class • Due following Sunday night (earlier is better) • Grades • Based on homework; participation in seminars; final protocol and final presentation (equally-weighted)

  6. Course Schedule • April 1 – May 13: patient, physician and system; and program evaluation lectures (n=7) • May 20: peer review and feedback of protocols (small groups using class time) • May 27: analytical designs and power • June 3: final protocol presentations • 15 minutes x 14 = 7 + 7… two separate groups… • Funding agencies • CHCF (M Laws); RWJF (?Disparities for Change Agent?); AHRQ ( ); UCSF Medical Center (Adler)

  7. Introductions • Name • Division/Department • Health Outcome you want to (ultimately) improve

  8. Translating Research Into Practice: The Birth of T2

  9. T1 NIH Roadmap Initiative-translating discoveries into health “I think that we have to ask ourselves whether much of the output of biomedical science is getting lost in translation?” –C.Lenfant, NEJM 2003;349:868-74. Former Director NHLBI. T2

  10. NIH Roadmap Initiative-translating discoveries into health Zerhouni E. Science 2003.

  11. NIH Roadmap Initiative-translating discoveries into health Westfall JM et al, JAMA 2007

  12. T2 = Quality

  13. Condition (n=25) Recommended Care, % Senile Cataract 79% Breast Cancer 76% Prenatal Care 73% …. Dyspepsia/Ulcer Disease 33% Atrial Fibrillation 25% Hip Fracture 23% Alcohol Dependence 11% Overall Average 55%

  14. Quality of Health Care • Donabedian A. JAMA 1988;260:1743-8 Structure Process Outcomes Community Characteristics Health Status Health Care Providers -Technical Processes -Interpersonal Processes Functional Status Delivery System Characteristics Satisfaction Public & Patients -Access -Acceptance -Adherence Provider Characteristics Mortality Cost Population Characteristics

  15. Provider Behavior is at the Core… System Knowledge judgment Technical Processes of Care Behavior -testing -diagnosis -treatment -procedures -referrals skill Health Care Provider Outcome (in future) Interpersonal Processes of Care empathy sensitivity Patients

  16. Institute of MedicineSix Dimensions of Health Care Quality Health Care That Is… • Safe • Timely • Effective • Efficient • Equitable • Patient-Centered Institute of Medicine, Committee on Quality Health Care in America. Crossing the quality chasm: a new health system for the 21st century. 2001. Washington DC, National Academy Press. Priority areas for national action: transforming health care quality. Adams K and Corrigan JM. 2003. Washington DC, National Academy Press.

  17. 1st Order Strategies to Improve Health Care Quality-measurement

  18. Practice Variation = Poor Quality

  19. http://www.dartmouthatlas.org/ Overuse Underuse Misuse

  20. 1st Order Strategies to Improve Health Care Quality-accountability

  21. National Committee for Quality Assurancewww.ncqa.org HEDIS Effectiveness of Care Measures 2003, comm • Beta-blocker post MI 94% • Cancer screening • Breast 75% • Cervical 82% • Colorectal 47% • Chlamydia screening 30% • Cholesterol screening 79% • HbA1c testing 85% • Eye exams in diabetes 49% • Controlling hypertension (<140/90) 62% • LDL < 100 after 60 days of MI 48%

  22. CMS/JCAHOHospital Quality Measures • Management of AMI • Aspirin on arrival and discharge • Beta-blockers on arrival and discharge • Lysis within 30 min of arrival • PCI within 90 min of arrival • ACE or ARB for LVSD • Management of CHF • ACE-inhibitor at discharge • Management of CHF • ACE or ARB for LVSD • LVSD evaluation (echo) • Discharge counseling • Tobacco cessation • Management of Pneumonia • Surgical Care Improvement • Antibiotics within 1 hour of surgery; appropriate abx; d/c after 24 hours • DVT prophylaxis

  23. Hospital Comparewww.hospitalcompare.hhs.gov Percent of Surgery Patients Who Received Treatment To Prevent Blood Clots Within 24 Hours Before or After Selected Surgeries to Prevent Blood Clots

  24. Link Quality Gap to “Outcome Gap”

  25. What is the Patient’s Role?

  26. T1 You can invest large NIH $$ to develop new drugs… but they are no good if patients don’t have access [structure], physicians prescribe [process], and patients accept and comply with treatment [process] T2

  27. Cross-Sectional Model of Health Care Behavior -adapted from Kleinman et al, and Donabedian

  28. Translating to Whom? Green L et al. NEJM 2001;344:2021-25

  29. Getting Started-Just Do It?

  30. Impact of CMS/JCAHO on Quality Improvement Activities • Why was CMS/JCAHO measures so much more effective at stimulating QI action than NCQA/HEDIS? • CMS linked to reimbursement/accreditation • vs. HEDIS was voluntary • little/no evidence that employers paid much attention to HEDIS in determining health plans • Hospital vs. health plan control over providers and QI investment • Stimulated lots of measurement and investment, but no methods/roadmap

  31. Book Ends “Just as in the rest of medicine, we must pursue the solutions to quality and safety problems in a way that does not blind us to harms, squander scarce resources, or delude us about the effectiveness of our efforts.” –Auerbach A et al, NEJM 2007;357:608-13 “The effectiveness of these systems is sensitive to an array of influences: leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.” –Berwick D. JAMA 2008;299:1182-84

  32. 2nd Order Strategies to Improve Health Care Quality

  33. Continuous Quality Improvementand PDSA Cycles Don Berwick; Institute for Healthcare Improvement

  34. A Roadmap for Designing Theory-Based Interventions • Needs Assessment • Understanding the Problem within a Theoretical Framework • Designing Multifaceted Intervention within a Theoretical Framework • Process and Outcome Evaluation of Intervention’s Impact • Refine and Repeat

  35. PRECEDE-PROCEDE

  36. Donabedian = QualityRogers = Adoption/Uptake Which innovations in health care get spread and adopted into practice? • Better than status quo. • Compatible with current values and needs of potential adopters. • Gain exposure to potential adopters, ideally from a trusted and respected source. • Time for “S-curve” to materialize. i.e., early adopters  early-late majority  laggards • Consistent social norms and opinion leaders. Rogers EM. Diffusion of Innovations, 4th ed. New York (The Free Press), 1995. Bodenheimer T. The Science of Spread. California Health Care Foundation. 2008.

  37. Needs Assessment

  38. Generic Approach to Needs Assessment • What behavior to measure/assess? • Is it important? Strong evidence for association with outcomes? • Use judgment and experts… FINER • Frequency? • Are there trends over time? • Distribution? • Does it vary by patient, physician or system factors? • Use theory or conceptual framework… • Quality? • Case-mix and risk adjustment? • Do you conclude underuse, overuse or misuse?

  39. IOM Priority Areashttp://www.iom.edu/?id=19752 Asthma Care coordination Children with special health care needs Diabetes End of life Cancer screening Frailty associated with old age Hypertension Immunization Ischemic heart disease Major depression Medication management Nosocomial infections Obesity (emerging area) Pain control in advanced cancer Pregnancy and childbirth Self-management/health literacy (cross-cutting area) Severe/persistent mental illness Stroke Tobacco-dependence treatment in adults

  40. Ralph’s Research Questions c. 1995 “We need to decrease overuse of antibiotics for acute respiratory infections” c. 1997 “How often are antibiotics prescribed for adults with uncomplicated acute bronchitis?”

  41. Penicillin-Resistant S. pneumoniae, 1979-2000 (US) 1979-1994: CDC Sentinel Surveillance Network 1995-2000: CDC Active Bacterial Core Surveillance (ABCS) System Emerging Infections Program

  42. European Surveillance of Antimicrobial Utilization -Goosens et al. Lancet 2005;365:579-87.

  43. Correlation Between Antibiotic Utilization and Antibiotic Resistance in Community Bacteria

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