1

Dissemination and Implementation

Paul K. Whelton MD, MSc

for the

ALLHAT Collaborative Research Group

ALLHATU.S. Department of Health and Human

Services

National Institutes of Health

National Heart, Lung, and Blood Institute

22

Selected Factors that Influence Dissemination and Selected Factors that Influence Dissemination and Implementation of New Treatment Trial FindingsImplementation of New Treatment Trial Findings

System of CareSystem of Care– Access to careAccess to care– Insurance coverageInsurance coverage– Marketing influencesMarketing influences

ProviderProvider– KnowledgeKnowledge– ConvictionConviction– Recall of resultsRecall of results– Interest in innovationInterest in innovation– Marketing influencesMarketing influences

Patient levelPatient level– PreferencesPreferences– SymptomsSymptoms– Marketing influencesMarketing influences

ALLHAT

33

ALLHATTraditional Approaches to Dissemination& Implementation of Clinical Trial Results

Press release/press conference

Short burst of media coverage

Presentations at scientific meetings

Publications in peer-reviewed journals

44

Recommendations Lag Behind EvidenceRecommendations Lag Behind Evidence

19721972 10 RCTs; >2,500 patients.10 RCTs; >2,500 patients. Not recommended in anyNot recommended in any Benefit in Benefit in meta-analysis; meta-analysis; textbook/review articletextbook/review article p < 0.01p < 0.01

19821982 27 RCTs; >8,000 patients.27 RCTs; >8,000 patients. Only 1 of 13 Only 1 of 13 textbooks/reviewstextbooks/reviews Benefit in Benefit in meta-analysis;meta-analysis; (Special (Special settings only)settings only)

p < 0.001 p < 0.001

19861986 43 RCTs; >21,000 patients.43 RCTs; >21,000 patients. Only 7 of 10 Only 7 of 10 textbooks/reviewstextbooks/reviews Benefit in meta-analysis;Benefit in meta-analysis;

p < 0.00001p < 0.00001

Antman et al, JAMA 1992;268:240-248.

RecommendationsKnowledge

Use of Fibrinolytic Therapy Following Acute MI

55

Knowing is Not the Same as DoingKnowing is Not the Same as Doing

35%

7%

61%

76%

0% 20% 40% 60% 80% 100%

Visits with SBP< 150 mm Hg

Visits with SBP< 140 mm Hg

Satisfied withBP control

Aware, Agreewith JNC-VI?

Oliveria et al, Arch Intern Med 2002;162:413-420

Survey of 21 physicians and 270 associated patient visits

PhysicianReport

PhysicianPractice

66

ALLHATRationale for Dissemination & Implementation of the ALLHAT Results

Large body of important information

Provide strong scientific basis for clinical decision-making in pharmacotherapy of hypertension

Important that practitioners and public benefit from time, effort, resources and care devoted to conduct of ALLHAT

77

ALLHAT Approach to Dissemination & ALLHAT Approach to Dissemination & Implementation of Knowledge in Clinical PracticeImplementation of Knowledge in Clinical Practice

Dissemination & implementation into clinical Dissemination & implementation into clinical practice given priority statuspractice given priority statusDissemination Committee formedDissemination Committee formedConsultation with experts in disseminationConsultation with experts in disseminationImplementation planned in two phasesImplementation planned in two phases– InitialInitial– Long-termLong-term

ALLHAT

88

ALLHATDelineation of Core Messages

Because of the superiority of thiazide-type diuretics in preventing one or more major forms of CVD and their lower cost, they should be the drug of choice for first step antihypertensive therapy.

For the patient who cannot take a diuretic (which should be an unusual circumstance), CCB’s and ACEI’s may be considered.

Most hypertensive patients require more than one drug. Diuretics should generally be part of the antihypertensive regimen. Lifestyle advice should also be provided.

99

ALLHAT

Media training for national & regional Media training for national & regional spokespersons spokespersons Press conference & intensive media coveragePress conference & intensive media coveragePresentations & publicationsPresentations & publications– Research-oriented venuesResearch-oriented venues– Practice-oriented venuesPractice-oriented venuesGeneration & distribution of dissemination aidsGeneration & distribution of dissemination aids

Initial Strategies for Dissemination & Implementation in Clinical Practice

1010

ALLHAT

Pocket reference cardPocket reference card

Prototype letter to colleaguesPrototype letter to colleagues

Aid in identification of opinion leadersAid in identification of opinion leaders

Aid in creation of site specific Aid in creation of site specific dissemination plan dissemination plan

Web sites for easy access to Web sites for easy access to information and dissemination aidsinformation and dissemination aids

Study slidesStudy slides

Frequently asked Frequently asked questionsquestions– ProvidersProviders– Patients & publicPatients & public

Study newslettersStudy newsletters– ProvidersProviders– Study participantsStudy participants

Case studiesCase studies

Initial Strategies for Dissemination& Implementation in Clinical Practice

1111

ALLHATOngoing Strategies for Dissemination & Implementation in Clinical Practice

Provision of information for practice Provision of information for practice guidelines committeesguidelines committees

Continued facilitation of professional Continued facilitation of professional education opportunitieseducation opportunities– ALLHAT Steering Committee membersALLHAT Steering Committee members– ALLHAT investigatorsALLHAT investigators

Ongoing media coverageOngoing media coverage

1212

ALLHATPlanned Strategies for Dissemination& Implementation in Clinical Practice

Health care providersHealth care providers-- Face-to-face colleague contactFace-to-face colleague contact-- Physician contact through NHBPEP member Physician contact through NHBPEP member

organizationsorganizations

Formulary system approachFormulary system approach

Patient-oriented approach throughPatient-oriented approach through public service announcementspublic service announcements

1313

Results as of June 2004Results as of June 2004>240 presentations>240 presentations

ManuscriptsManuscripts-- 25 published25 published-- 48 in process48 in process

Distribution of Dissemination aidsDistribution of Dissemination aids– Main results, core messages, slides, newsletters, Main results, core messages, slides, newsletters,

and pocket cards distributed to more than 600 and pocket cards distributed to more than 600 clinical site investigators and through them to their clinical site investigators and through them to their colleagues in “Dear Colleague” letterscolleagues in “Dear Colleague” letters

– Frequently asked questions and newsletter Frequently asked questions and newsletter distributed to more than 42,000 participants distributed to more than 42,000 participants through clinical sitesthrough clinical sites

ALLHAT

1414

Results as of June 2004Results as of June 2004MediaMedia– Millions reached through print, radio, television, and Millions reached through print, radio, television, and

internet messagesinternet messages

WebsitesWebsites– ALLHATALLHAT

134,405 users134,405 users2,872,734 hits2,872,734 hits

– NHLBINHLBI– NHBPEP Coordinating Committee member NHBPEP Coordinating Committee member

organizationsorganizations

Guidelines AssistanceGuidelines Assistance– NHLBI JNC 7NHLBI JNC 7– Canadian BP GUIDELINESCanadian BP GUIDELINES– NKF GUIDELINESNKF GUIDELINES

ALLHAT

1515

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

Q1-02 Q2-02 Q3-02 Q4-02 Q1-03 Q2-03 Q3-03

ACEIs TotalACEIs Total

CCBs TotalCCBs Total

Diur TotalDiur Total

Tota

l Pr

escr

iptio

nsTo

tal

Pres

crip

tions

ALLHATIMS Health, National Prescription Audit, 2003IMS Health, National Prescription Audit, 2003

Drug Utilization by ClassDrug Utilization by Class

2002 2003

1616

SummarySummary

Traditional strategies for dissemination and Traditional strategies for dissemination and implementation of clinical trial results have had limited implementation of clinical trial results have had limited and delayed impact on clinical practiceand delayed impact on clinical practice

ALLHAT has utilized a new proactive approach to ALLHAT has utilized a new proactive approach to dissemination and implementation of its findingsdissemination and implementation of its findings

Success in influencing antihypertensive treatment Success in influencing antihypertensive treatment decisions is being evaluateddecisions is being evaluated

Experience to date suggests success in achieving our Experience to date suggests success in achieving our objectivesobjectives

ALLHAT