How to change physician, health system and pa4ent behavior: the knowledge to ac4on cycle and guideline implementa4on

BradenManns

KDIGO

DescribetheKnowledgetoAc6onCycleandGuideline

implementa6on

Overviewofhowtochangephysician

behavior

Outline:

ExamplesofClusterRCTstes6ngdifferentguidelineimplementa6onstrategies

KDIGO

Knowledge transla4on is ge>ng evidence into prac4ce……

CanadianIns6tutesofHealthResearch

KDIGO

Knowledge to Ac4on Cycle

KDIGO

1. Using albuminuria to assess risk and guide treatment in CKD-KDIGO CKD Guidelines

•  Albuminuriaincreasestheriskofdeath,cardiovasculardiseaseandESRD

•  Pa6entswithalbuminuriaaretheoneswhobenefitfromangiotensinblockade•  Butonly20%ofpeoplewithnondiabe5cCKD

haveameasureofalbu/proteinuriawithinoneyear

KDIGO

Howdowegetphysicianstomeasurealbuminuriaandactontheresults?KDIG

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2. Timely ini4a4on of dialysis

•  Ini6a6onofdialysisistheraisond'êtreofNephrology•  Priorguidelinesrecommendedini6a6ngdialysisatmean

eGFRof10.5mls/min•  Between2001and2010,“earlystartdialysis”increased

from27to41%

•  IDEALstudysuggestsnodifferenceinmortality,hospitaliza6onorqualityoflifeforpa6entsini6a6ngatlowereGFR

KDIGO

Howdoweprepare

our

systemforsmooth(later)

ini6a6onofDialysis

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How do you change Health care prac44oner behavior?

I don’t do requests,

It’s chopsticks or

nuttin “ ”KDIGO

•  TheCanadianSocietyofNephrology(CSN)createdguidelinesbuthadnoknowledgetransla6onplan/ac6vi6es

•  TheCSNcreated“CANN-NET”tocreatepriorityareasforKT,andtousetheknowledgetoac6oncycletoimprovecareandoutcomesinpriorityareasinkidneydisease

KDIGO

Knowledge to Ac4on Cycle Digging deeper KDIG

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Barriers to implementa4on of evidence

1. Professional2. Pa6ent3. Healthcareteam/organiza6on4. Prac6ceenvironmentKDIG

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Barriers to implementa4on of evidence: Professional

KDIGO

Physicianknowledge• Lackofawarenessofstudy/guideline• Medicaltraining/lackofskills/obsoleteknowledge

• Informa6onoverload• Unsurehowtoimplementtheinterven6on

KDIGO

Uncertainty• Clinicaluncertainty–poorqualityevidence

• Keyopinionleadersnotinagreement

KDIGO

Goingagainstthegrain:• Goingagainstusual“Standardofcare”

• Compulsiontoact(needtodosomething)KDIG

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Barriers to implementa4on of evidence: Pa4ent

KDIGO

Pa5ent’sexpecta5ons• Pa6enttypicallydoesn’tknowwhattheywant!

• Expressedwishesforprescrip6onKDIG

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Problemswithadherence• Lackofunderstandingregardingneedforadherence

• Lackof6me(i.e.exercise)• Financialbarrierstoadherence• Individualsexistwithinalargersocietyo Lifestylesarecollec6ve–dialysiseduca6oncampaignmoreeffec6ve?

KDIGO

Barriers to implementa4on of evidence: Health System KDIG

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Healthcareteam/organiza5on• Lackofreimbursementforserviceormedica6on

• Lackof6me• Percep6onofliability(riskofcomplaints)

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Prac5ceenvironment• Geographicloca6onofclinics/ameni6es• Advocacy(i.e.bypharmaceu6calcompanies)

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Now we know what the relevant barriers are…….

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So what works to change care?

Itdependsonwhattheiden6fiedbarrieris….

• Nooneinterven6oniseffec6veinallcircumstances

• Combina6onsofinterven6onsmaybemoreeffec6ve

KDIGO

In general….

• Preparewell• Iden6fythebarrierstoimplementa6onupfront

• Selectasetofstrategiesaimedatdifferentbarriers

• Defineindicatorsforsuccessandmonitorprogressregularly

KDIGO

If the Barrier is physician knowledge: 1.Distribu5onofeduca5onalmaterialstoprofessionals:mixedeffects

2.Guidelineimplementa5onstrategies:medianimprovementin“care”of8%

3.Con5nuingMedicalEduca5on:•  Largeconferencesanddidac6cteaching:No/minimaleffect

•  Smallgroup/interac6veeduca6onwithac6vepar6cipa6on:Posi6veeffectsonprac6ce,possiblyoutcomes

4.Educa5onaloutreachbyexperts:par6cularlyeffec6veforprescribing

KDIGO

Other Strategies

Auditandfeedback:• Mostevidenceisaroundtarge6ngoftestorderingorpreven6on

• Mixedresultswhenusedonitsown.• Possiblymoreeffec6vewhencombinedwithreminders,andeduca6on

Reminders(posters,pa6entsremindingstaff):•  largesteffectofanyofthestrategiesusedonitsown,butlargevaria6onacrossstudies

KDIGO

Subs5tu5onoftasks:•  Useofnurses/pharmacists•  Anemiaprotocols,clinicalpathways/ordersetswithimplementa6onguidedbynurse

• Canbesimilarlyeffec6veormoreeffec6vethanphysician-onlycare

Pa5ent-directedinterven5ons• Canbeeffec6ve;par6cularlyforimprovingpreven6on/vaccina6on•  Examplesincludeeduca6onorFacilitatedrelay

KDIGO

Example: Using albuminuria to assess risk in CKD

ThebarriersLackofunderstandingoftheresultsofthetestLackofunderstandingoftheprognos6csignificance

InCKDInnonCKD

?Clinicaldecisionsupport?KDIG

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Clinical decision support system

KDIGO

Applying the policy: Clinical decision support systems

•  Toiden6fyfeaturesofclinicaldecisionsupportsystemscri6calforimprovingclinicalprac6ce

•  Systema6creviewof70RCTs,68%ofwhich“improvedprac6ce”

•  Evaluatedforthepresenceof15decisionsupportsystemfeatures

Kawamotoetal,BMJ2005

KDIGO

Features of effec4ve decision support systems Characteris5c Example Adjusted

oddsra5o

Automa5cprovisionofdecisionsupportaspartofclinicianworkflow

Carerecommenda6onsprovidedwithinpa6entschart,sothatcliniciansdonotneedtoseekoutrecommenda6ons

112

Provisionofdecisionsupportat5meandloca5onofdecisionmaking

Carerecommenda6onsprovidedaschartremindersduringanencounter,ratherthanasmonthlyreportslis6ngallthepa6entsinneedofservices

15

Provisionofarecommenda5on,ratherthananassessment

CPGsrecommenduseofanACEinhibitorvsACEinhibitorsareeffec6ve…

7

KDIGO

CananeGFRmanagement-basedlaboratoryprompt,whichiden6fiesapa6entwithCKDasbeingathighriskforcardiovasculardiseaseandprogressiontokidneyfailure,improvethemanagementofcardiovascularriskfactorsandkidneydiseasebyphysicians?

KDIGO

Standardsofcare-appearingbelowtheeGFRforpa6entswithGFR<60mls/min

NewManagement-basedeGFRprompt-appearingbelowtheeGFRforpa6entswithGFR<60mls/min

Inoutpa6entswithstablekidneyfunc6on,es6matedGFRisamoreaccuratemarkerofkidneyfunc6onthanserumcrea6nine.ChronickidneydiseaseisdefinedbyGFR<60mls/min/1.73m2formorethan3months.Publishedguidelinesrecommendthatpa6entswithGFR<30ml/min/1.73m2bereferredtoaNephrologist(seewww.akdn.info)

Thispa6enthasreducedkidneyfunc6onandisatriskforcardiovasculareventsandprogressiontokidneyfailure.TheNa6onalKidneyFounda6onrecommends:

1.  Measurerandomurinealbumin-to-crea6ninera6o

2.  Ins6tuteanACEiorARBinpa6entswithdiabetes,orthosewithanAlb:Cr>35mg/mmol

3.  ReferraltoaNephrologistifGFR<30ml/min/1.73m2

4.  AssessandtreatmodifiableriskfactorsforCVandrenaldisease:a)targetBPlessthan130/80mmHg,b)targetLDL-C<2.5mmol/L,c)ifdiabe6c,targetHbA1C<7.0%

Theaboverecommenda6onsaregeneralinnatureandmaynotapplytoallpa6ents.Furtherinforma6onisavailableatwww.akdn.info

KDIGO

Cohort Subgroup StandardeGFRlaboratoryprompt,N(%)

ManagementbasedeGFRlaboratoryprompt,N9%)

Intra-classCorrela5onCoefficient(p-value)

UnadjustedRela5veRisk(95%CI)

Allpa5ents,GFR<60ml/min/1.73m2)

PrevalentCKDpa6ents

1,932(77.1) 2,260(76.9) 0.020(<0.001)

1.00(0.96to1.04)

IncidentCKDpa6ents

338(73.3) 337(68.9) 0.011(0.224)

0.94(0.86to1.02)

Allpa5entsGFR<30ml/min/1.73m2)

PrevalentCKDpa6ents

161(72.2) 208(80.0) <0.001(0.0497)

1.13(1.03to1.24)

IncidentCKDpa6ents

38(62.3) 57(73.1) <0.001(0.498)

1.17(0.91to1.50)

Results: Primary outcome: Use of ACEi/ARB in patients with diabetes/albuminuria KDIG

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Cohort Subgroup StandardeGFRlaboratoryprompt,N(%)

ManagementbasedeGFRlaboratoryprompt,N9%)

Intra-classCorrela5onCoefficient(p-value)

UnadjustedRela5veRisk(95%CI)

Allpa5ents,GFR<60ml/min/1.73m2)

PrevalentCKDpa6ents

550(6.3) 645(7.4) 0.050(<0.001)

1.29(1.03to1.62)

IncidentCKDpa6ents

162(6.0) 134(5.2) 0.083(<0.001)

1.06(0.75to1.49)

Allpa5entsGFR<30ml/min/1.73m2)

PrevalentCKDpa6ents

42(10.2) 69(14.7) 0.038(0.100)

1.50(1.02to2022)

IncidentCKDpa6ents

25(16.8) 36(20.6) 0.057(0.171)

1.35(0.81to2.25)

Results: Acquiring a measure of albuminuria KDIG

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Conclusion:

• Baselineuseofangiotensinblockadeishigh• Noaddi6onalimpactofamanagement-basedeGFRprompt,includingonclinicaloutcomes

• Physiciansmayresponddifferentlytothetreatment-basedlabpromptifeGFR<30mls/minKDIG

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KDIGO

Canadian Society of Nephrology 2014 Clinical Practice Guideline for Timing the Initiation of Chronic Dialysis   Gihad E. Nesrallah, Reem A. Mustafa, William F. Clark, Adam Bass, Lianne Barnieh, Brenda R Hemmelgarn, Scott Klarenbach, Robert R Quinn, Swapnil Hiremath, Pietro Ravani, Manish M. Sood, Louise M. Moist

CMAJ, Feb 2014

Timely ini4a4on of dialysis

KDIGO

CSN Guideline

• Recommenda6onfortheini6a6onofchronicdialysis•  “intent-to-defer”over“intent-to-start-early”approach•  Strongrecommenda6on;moderatequalityevidence

KDIGO

Barriers to implementa4on of evidence survey

• NorenalprogramacrossCanadahasapolicyon6mingofdialysisini6a6on

• Asignificantnumberofrespondentsfelturemicsymptomsoccurredearlierinpa6entswithadvancingageorco-morbidillness.

• ManyNephrologistsfelttherewasanabsoluteeGFRatwhichtheywouldini6atedialysisinanasymptoma6cpa6ent. KDIG

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Knowledge to Ac4on Cycle

KDIGO

Drarordersets

Posterforproviders

Educa6onforpa6ents

Decisionaid

KDIGO

Evaluate the impact of KT strategy

• What happened aVer publica4on of the IDEAL study – a 4me series analysis

•  The impact of our KT strategy – a cluster RCT using 55 predialysis clinics in Canada, tes4ng the impact on 4ming of dialysis and use of home dialysis KDIG

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Propor4on of pa4ents ini4a4ng dialysis early, before and aVer the IDEAL study KDIG

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Assesstoseeifyou’vemadeadifference

Selectyourguidelinetopriori6zebasedonimportanceandcaregaps

Localguidelines

Whydon’twedobeter

Whatstrategy/KTtoolwillworkbest?

KDIGO

KDIGO