Enhancing Guidelines Dissemination & Implementation for Respiratory Diseases

1. Guideline implementation… …challenges in KT… Louis-Philippe Boulet MD FRCPC FCCP Valentine’s day 2013

2. Guidelines implementation • Are guidelines needed ? implemented ? • Barriers and facilitators: how to improve guidelines dissemination & implementation • Canadian Respiratory Guidelines: production, D& I and evaluation • Some local initiatives: Laval University KT Chair in Respiratory and Cardio-Vascular Health • What is next ?

3. The need for good guidelines Amir Qassem, G-I-N North-America

4. Guidelines in respiratory diseases* • Despite major advances in the understanding of respiratory diseases, treatment is often sub-optimal = high morbidity & unacceptable mortality • Priority is to undertake research that leads to improvements in the use of existing treatments through public health and primary care initiatives • Guidelines represent an important component of this approach, with recommendations imbedded within respiratory guidelines that can be implemented • This approach offers the best opportunity to close the gap between what is currently achieved in disease management and that which is potentiallyachievable*Asthma in original documentAdaptedfromHancox et al. Respiration 2011

5. Respiratory diseases in Canada ASTHMA 2,500,000 COPD 500,000 SLEEP APNEA 1,000,000 LUNG CANCER 18,500 TUBERCULOSIS 1800 « Gross estimates » from various sources including CIHI/CLA/Health Canada/Stats Canada 2001

6. Knowledgeand use of guidelines - 2002 Release of NZ guidelines for Dx and Tx of adult asthma - 2 wks later Fax-back questionnaire to all NZ GPs (n=729) - Response rate : 422 (58%) Have you ? J NZ Med J 2003;116(1168)

7. ASTHMA PPAQ Physicians Practice Assessment QuestionnaireN. Physicians: 31 Mean n.pts seen per month: 45 Boulet et al. Resp Med 2010

8. ASTHMA PPAQ(N. Physicians: 31 Mean n.pts seen per month: 45) Boulet et al. Resp Med 2010

9. Primary Care Respiratory Journal 2009 Aware of it ? Useful ? Audit % Recommendation 1 Objective tests to 95.3% 72.6% 67.0%confirm asthma Recommendation 2 Trial of other meds before 100% 85.9% 67.1% increasing the dose of ICS over 800 mcg/day (adults) Recommendation 3 Self-management education 98.4% 79.7% 22.8%offered, including a written action plan

10. How to improve implementation of guidelines recommendations? Research findings Research Findings

11. Bringingevidence to bedsidethroughefficient guidelines • Production • Valid, evidence-based, credible, unbiased guidelines • Adequate format • Summaries, algorythms, practice tools • Dissemination • Presentations, publications • Slide kits • Awareness program • Media • Etc.

12. Canadian Respiratory Journal 2006

13. Recommendations • The main targets of guidelines should be general practitioners and allied health professionals • The process of implementation should use proven and cost-effective methods for transmission of guideline recommendations • These methods cover the spectrum – from electronic and hard copy reminders, to algorithms, to data for hand-held computers • Academic detailing also can have an important role, as can complementary interventions from health educators and pharmacists.

14. Recommendations • Some of the programs also should be directed at the patients themselves and their families (High-quality education and regular follow-up promoting effective self-management) • Implementation of guidelines can best be done by multipronged, multipartner programs. National programs should be developed • The various interventions should be scrutinized to confirm their effectiveness and to continue to optimize integration of guideline recommendations into daily care

15. BMJ 2010

16. 2012

17. (www.respiratoryguidelines.ca) Canadian Thoracic Society Canadian Respiratory Guidelines Committee (CRGC) Chair: Louis-Philippe Boulet KT Co-Chairs: Samir Gupta and Chris Licskai CRJ 2009

18. Canadian Lung Association Board of Directors Canadian Respiratory Health Professionals Leadership Council Canadian Thoracic Society Board of Directors Canadian Respiratory Guidelines Committee (CRGC) CRGC D&I Committee Review D&I activities and advise on best practices CTS Guideline Committees - report guidelines activities to CRGC for approval Asthma Chair: Diane Lougheed COPD Chair: Paul Hernandez Sleep Disorders Chair: John Fleetham Pulmonary Vascular Diseases Chair: Sanjay Mehta Home Mechanical Ventilation Chairs: Jeremy Road & Doug McKim Research Steering Committee charged with setting research priorities Pediatric Assembly Represented on CTS Clinical Cttees in pediatric priority areas Education Committee charged with CME, Accreditation, etc. Other partners and organizations (GARD, GINA, Guidelines International Network, etc.

19. The Guideline agenda Developing the Question (PICO) Looking at the Evidence (GRADE) Adapting other Guidelines (ADAPTE) Ensuring or Appraising Quality (AGREE) Ensuring Implementability (GLIA)

20. www.respiratoryguidelines.ca

23. Bringingevidence to bedsidethroughefficient guidelines • Implementation • National initiatives • Local initiatives • Bedsideimplementation • Evaluation • Highlyneeded • Rarelydone • Required to improvestrategies

24. Knowledge Creation Knowledge inquiry Knowledge synthesis Knowledge tools/ products Tailoring knowledge Knowledge to Action from: Graham et al: Lost in Knowledge Translation: Time for a Map? Monitor knowledge use Select, tailor implement interventions Evaluate outcomes Assess barriers to knowledge use Sustain knowledge use Adapt knowledge to local context Identify Problem Identify, Review Select knowledge http://www.jcehp.com/vol26/2601graham2006.pdf

25. Barriers to guidelines implementation • Cultural/social Factors • Culture & belief systems • Norms, institutionalized habits • Leadership • Politics & personalities • Peer influence Structure Factors • Work pressure • Information overload • Competing demands/ time • Chaotic environment • Human resources • Decision-making • Policies, rules, laws • Available technology • Equipment, testing • Physical layout • Other Factors • Patients/Consumers • Case mix, behavior, attitudes, preferences & demands • Economic Considerations • Resources, remuneration, funding systems • Medical/Legal Issues • Other Organizational/System Factors Ian Graham, 2005

26. Effectiveness of Interventions Generally Effective • Educational outreach visits • Reminders • Interactive educational meetings • Multifaceted interventions including two or more of: • Audit and feedback • Reminders • Local consensus processes • Social marketing Bero et al. 1998, Grimshaw et al. 2001

27. Annual CRGC Cycle Guideline Evaluation (Oct - Dec) Revise new evidence Select topics to review Methodology training workshop Guideline Production (Jan - April) Generate updates or new guidelines Report at Annual Guidelines Meeting Document approval by CTS Dissemination & Implementation (Aug - September) Engage in D&I activities Publish an update in the CRJ Post documents and KT tools to the CTS website Concurrent research to measure effectiveness Post-Production Planning(May - July) Finalize all new documents Plan dissemination and implementation (D&I) Prepare budget

28. CTS Implementation and Evaluation Framework Goal 1 – Adopt an Overarching Methodology for Guiding KT Initiatives Adopt the CIHR Knowledge-To-Action (KTA) framework as a method for guideline implementation (page 5). Provide continuing educational support to individual assemblies as required. Goal 2 – Create an Implementation/KT Registry of Existing Resources, Programs and Projects Identify existing national guideline implementation / KT initiatives, programs, projects, and knowledge tools (environmental scan) with demonstrated value where possible (strategies with evaluation processes). Goal 3 – Create a mechanism for the exchange of KT priorities, possible approaches, and achievements between key stakeholders (For example: decision-makers, provincial lung associations, fellow implementers, existing networks, communities of practice)

29. CTS Implementation and Evaluation Framework Goal 4 – Each CTS Clinical Assembly will adopt/identify/create and/or support or align itself with existing implementation projects In situations where there are ongoing implementation projects that have overlap with the CTS Clinical Assembly goals, the Clinical Assembly may choose to align itself with one or more of these existing projects (as listed in the inventory created by Goal 2), in order to maximize efficient use of resources. Goal 5 – Support applications for funding to undertake and evaluate KT/Implementation Projects Create an inventory of program and research funding sources. Assist with proposal development. Link with knowledge translation experts on the CRGC for collaborative research. Goal 6 – Develop a practical framework to support project implementation development and evaluation

30. The Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE) Initiative A powerful tool for guideline implementation

31. PRESTINE: Objectives (1) • To collaborate with stakeholders across jurisdictions responsible for the implementation and sustainability of respiratory best practice guidelines for a pan-Canadian interoperable electronic health record • Broad stakeholder engagement to include clinicians, researchers, administrators, and information technology management, others as needed • To identify data elements for inclusion in EMR/EHRs, beginning with asthma in the primary care setting.

32. PRESTINE: Objectives (2) • It is anticipated that a common template will help inform further development of data elements for other respiratory diseases across the continuum of care • To develop criteria to evaluate select data elements for inclusion in the EMR/HER • To ensure that respiratory elements are coded to standardized terminology in the electronic health record. • To create a proposal to implement and evaluate the effectiveness of respiratory data definitions and standards in select primary care locations. • To secure funding for the pilot project.

33. A plan for a guideline implementation strategyAdapted from Boulet et al. Eur Resp J 2012 • Select guideline to be implemented • Identify stakeholders and form a working group • Determine whether the guideline needs to be adapted (ADAPT tool) • Perform a needs assessment/review current status of care • Assess barriers and facilitators to care and priorize gaps to be addressed • Select implementation strategies • Agree on specific indicators of change and targets for each outcome • Assess resources available to support the initiative • Produce a step-by-step implementation plan • Plan initial interventions & evaluate how the strategy was successful • Review the project in light of pilot projects and information gathered • Plan continuation/expansion of the initiative and its long-term evaluation

34. Patients’ Guidelines… « Even the best medical practice will not improve patient’s outcomes if this last does not implement physician’s recommendations… »

35. How to improve guidelines recommendations uptake by patients • Patient education • Improve monitoring of asthma control • Promote adherence to treatment • Shared-decision making • Adapt recommendations to patient’s characteristics and background • Regular review/follow-up

36. Definition: Shared decision making (SDM) is defined as a process by which a healthcare choice is made by a health professional together with a patient. (Towle and Godolphin, 1999).

37. Shared-decision Management and asthma • As a result of both their medication choices and better adherence, patients with SDM received a higher cumulative dose of anti-inflammatory medication over a 1-year period. • Compared to usual care, SDM was associated with significantly… • better asthma-related quality of life • fewer asthma-related medical visits • lower use of rescue medication • higher likelihood of well controlled asthma • better lung function Wilson S et al, Am J Respir Crit Care Med. 2010

38. Prevalence of high decisional conflict (≥2/5) = 71% Table 1. Mean and median scores of the questionnaires *SD= standard deviation Table 2. Decisional conflict’s correlations Descormiers et al. 2012

39. Means of decisional conflict according to independent variables DesCormiers A et al. 2012 • In the asthmatic population, decisional conflict (DC) is high which means asthmatics did not totally agree with recommendation for their asthma control • Mean DC are significantly higher in people who having no follow-up by a physician for their asthma • No follow-up by a physician might result in poorer understanding of possible options to treat asthma

40. Laval University KT Chair in Respiratory and Cardio-Vascular Health Mandate • Develop interventions to improveguideline implementation/KT intocurrent care • Evaluate the effects of these interventions Targets • Primary care partitionner and otherhealthprofessionals • Medicalstudents • Patients and theirfamily

42. Interventions • Practitioners/Medical students • Synthesis of disease management guidelines • Practice tools – CME – Web-based interventions • Evaluation of strategies • Patients • Interactive public conferences • Films for TV diffusion • Mini-clips /youtube clips • Web-site: information and materials • Books and written materials

43. Laval University KT Chair in Respiratory and Cardio-Vascular Health Development of a medical practice tool assessment model Saliha Ziam, Louis-Philippe Boulet (submitted)

44. Guidelines implementation tools –what should they look like? • USER FRIENDLY!!! • Pocket cards • Concise pamphlets- one page!!! • Journal articles • VISUAL! • Algorithms/ Flow diagrams • Internet/ Palm From A. Kaplan

45. Tools for medical practice • STAMP on main recommendations of the Asthma Guidelines • Results • Increase in knowledge • Better asthma control • Reduction of ED visits Renzi et al. CRJ 2006

46. Tools for guidelines implementation

47. Examples of tools produced by the Laval University KT Chair

48. Assessment of the tools: COUGH YES NO Q1 : Is the format adequate ? ( colors, illustrations, graphs, etc.); Q2 : Contains examples about how to implement the knowledge transfered; Q3 : Provides synthesis and summaries about specific questions; Q4 : Discusses relevant issues for patient management; Q5 : Provides « real-life » examples linked to the practice and how to utilize the knowledge transfered; Q6 : Discusses the effects of the use of the knowledge transfered for their practice.

49. Intent to use the asthma tool

50. Intent to use the coughtool