“Turning Evidence into Action”

1. “Turning Evidence into Action”

2. National Institute of Clinical Studies Improving health care by: • Providing practical help to increase routine use of existing research knowledge • Identifying & testing effective ways to increase uptake of sound research

3. National Institute of Clinical Studies • Commonwealth owned company • Board of Directors appointed by Minister • Offices in Melbourne • $3.5 M per year funding agreement • Brief covers all health care

4. Evidence & Quality Why all the fuss? Approaches to change Example

5. Why all the fuss? • Huge variation in practice • Delays in introducing treatments of proven effectiveness • Delays in withdrawing ineffective &/or harmful treatments • Costly decisions made in the absence of evidence

6. Variation in practice • Very common – between countries, between states, within small areas • Geographical & population • Medical & surgical • Documented extensively for over 60 years

7. Delays in introduction • Steroids for women in premature labour • Thrombolysis for acute myocardial infarction • Warfarin for patients with atrial fibrillation • Anticoagulants in patients having orthopedic surgery • Recognition & management of hypertension

8. Scurvy • 1754 • James Lind • “A Treatise of the Scurvy” • “On the 20th May, 1747, I took 12 patients in the scurvy on board the Salisbury at sea. Their cases were as similar as I could have them.” • 1795 • Regular rations of lemon juice in the British navy

9. Delays in withdrawal • Bloodletting • Routine episiotomy • Prolonged bed rest • Routine pregnancy ultrasound

10. Costly decisions • Antibiotics for sore throats • Choice of prosthetic hips • Hyperbaric oxygen for sports injuries • Specialist outreach clinics

11. Angioplasty “It is very lucrative, patients are mostly self-referred and it is fun to perform” Nicod P, Scherer U Money, Fun & Angioplasty Letter, Ann Int Med, 1992.

12. “There is also nothing wrong with having fun at work – it may be one of the best insurances for doing a good job. Parts of coronary angioplasty are very similar to video games. One must advance a guide in small tortuous branches of a coronary tree. When a difficult lesion has been opened or an impossible turn has been taken by the balloon, the skills of the operator are immediately praised and rewarded by the applause of the cathetorisation laboratory crew. Physicians who have to work weeks or months for results and reward may envy interventional cardiologists.”

14. Driving forces • Loss of knowledge monopoly • Rise of consumerism • Increase in choice of care providers • Increased accountability requirements • Cultural “fit”

16. Diffusion of innovation “The part of the diffusion curve from about 10% to 20% adoption is the heart of the diffusion process. After that point, it is often impossible to stop the diffusion of a new idea, even if one wished to do so.” Everett Rogers

17. Increasing the use of research knowledge • Available • Accessible • Accepted • Adopted • Audited

18. Accessibility of research knowledge • Cochrane library • Clinical Evidence • Clinical information services

19. Diffusion research traditions • Anthropology • Agricultural economics • Communication • Education • Geography • General economics • Industrial engineering Everett Rogers

20. Diffusion research traditions • Marketing & Management • Public Health • Psychology • Public Administration & Political Science • Sociology • Statistics • Others Everett Rogers

21. Approaches to Change (1) Grol & Grimshaw

22. Approaches to Change (2) Grol & Grimshaw

23. Approaches to Change (3) Grol & Grimshaw

24. Approaches to Change (4) Grol & Grimshaw

25. Effective Change Use & adapt different approaches: • Issue • Target group • Change proposal • Setting • Obstacles to change

26. Hospital-acquired infection • 7-10% hospitalised patients • Hospital stay incr. 4-10 days • Mortality • Morbidity • Cost

27. Handwashing!

28. Semmelweiss (1818 – 1865)

29. Obstacles Care provider • Doesn’t believe evidence • Rarely sees complications • Importance underestimated • Believes performance better than it is • Habit

30. Handwashing “If, as the authors claim, there is such compelling evidence for the need to wash hands between each patient contact then why do I and the vast majority of my colleagues not do it? “ Specialist O& G Registrar BMJ 1999 319:518 (letter)

31. Handwashing “I have never seen any convincing evidence that washing between each patient contact reduces infection rates Washing hands between each contact would take on average 1-2 hours. Where will this come from & who will fund it?” Specialist O& G Registrar BMJ 1999 319:518 (letter)

32. Handwashing - doctors See study by J Tibballs in MJA, 1996.

33. Obstacles Social context • Habits of peers • Lack of interest from management • No guidelines

34. Obstacles Organisational context • Damage to hands • Equipment inadequate • Workload & time constraints

35. Possible Plan Brochure with evidence / Formal protocol Group/unit meeting to discuss guideline implementation problems Commitment of management/ clinical leaders New soap/tissues Reminders, observation by heads of units Performance feedback – individual/group Patient mediated interventions

36. NICS - Key tasks • Identifying important gaps • Identifying available, effective methods for changing practice • Stimulating change • Evaluating effectiveness of our approach

37. Initial Project Priority Areas • Improving clinical care in emergency departments • Management of cardiac failure • Management of pain

38. National Institute of Clinical Studies www.nicsl.com.au