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Research into Practice– An evidence-based approach to
implementing evidence.
ACT Health Allied Health Symposium, 2014
Bridging the Gap: Translating Evidence into Practice
Dr Shelley Wilkinson AdvAPDQueensland Health- Health Research Fellow, Maternal Health
Mater Health Services/Mater Research
Worries of a change agent..
• Many patients do not receive (evidence-based) care– many tests ordered or medications prescribed are not evidence-based and
potentially harmful
• Many patients in hospitals (5-10%) harmed or die because of errors and adverse events, many (40%) are preventable
• Large, unexplained differences in quality and safety between hospitals, hospital wards, practices exist
• Improvement, even after well developed implementation programs, is usually small and slow
Richard Grol, 2013
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
“After decades of improving the health care system, patients
still receive care that is highly variable, frequently
inappropriate, and too often, unsafe” Braithwaite, 2013
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Knowledge Translation (KT) Terms - 1
• Applied health research• Capacity building• Complex interventions• Complexity science• Complexity studies• Co-optation• Diffusion of innovations• Diffusion(s)• Dissemination• Evidence based practice• Getting knowledge into practice• Implementation• Implementation research• Implementation science
• Information dissemination and utilization
• Innovation adaptation• Innovation adoption• Innovation diffusion• Knowledge communication• Knowledge cycle• Knowledge dissemination• Knowledge exchange• Knowledge management• Knowledge mobilization (mobilisation)• Knowledge transfer• Knowledge translation• Knowledge transformation• Knowledge uptake
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - WikispacesACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Knowledge Translation (KT) Terms - 2
• Knowledge utiliz(s)ation• Linkage and exchange• Organizational change• Outcomes effectiveness research• Policy research• Popularization (popularisation) of
research• Research into action• Research into practice• Research mediation• Research transfer• Research transformation • Research translation• Research utiliz(s)ation
• Sociology of knowledge• Technology transfer• Third mission• Translation(al) research• Translating Research into Practice (TRIP)• Translation(al) science• Transmission• Utilization (utilisation)• Knowledge to action• Knowledge development and application• Knowledge diffusion• Applied dissemination• Effective dissemination• Research implementation
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - WikispacesACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
DisseminationConscious efforts to spread new knowledge, ideas, policies and
practices to specific target audiences or to a public at large
Green et al 2009
Acknowledgements: NHMRC/NICS - Rosie Forster
ImplementationTranslation & application of innovations, recommended
practices or policies. A process of interaction between the setting
of goals & actions geared to achieving them Stickability!
T1 T2
Institute of Medicine, Clinical Research Roundtable Sung, JAMA 2003
T1 T2 T4T3
Discovery to health
application
Health application to
evidence-based practice
guidelines
Practice guidelines to
health practice
Practice to population
health impact
Phase I and II clinical trials
Observational studies
Phase III clinical trials
Observational Studies
Evidence synthesis and guidelines development
Dissemination research
Implementation research
Diffusion research Phase IV clinical trials
Outcomes research (includes many
disciplines)
Population monitoring of morbidity and mortality,
benefits and risks
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Knowledge Discovery and Application Processes
Discovery and Production• Ideas• Lab/bench science• Animal testing• Early human Phase I
• Middle human Phase II
• RCTs Phase III
• Post marketing
Application and Implementation
• Aware• Accepted• Applicable• Able• Acted upon• Agreed to• Adhered to
T1
T2
T3
T3
T4
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - WikispacesACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Knowledge Discovery and Application Processes
Discovery and Production• Ideas 100,000
• RCTs 100
Application and Implementation
• Aware 100%
• Adhered to 20%
Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - WikispacesACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Introducing service/care changes
Acknowledgements: Centre for Clinical Effectiveness, Southern Health - Claire Harris
UK Medical Research Council
framework (2000)
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
•..the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence,
to improve the quality and effectiveness of health services. It includes the study of influences on health care professionals and organisational behaviour
•Eccles Implementation Science 2006
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
The evidence-practice
gap
Perceived quality problem or emergence of new evidence
The evidence-practice
gap
Perceived quality problem or emergence of new evidence
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Implementation improvements
New knowledge, guideline
Perceived problem in healthcare
Is this knowledge applied
in practice?
Is there “evidence” on best practice?
Yes
No
Yes
No
Prevent relapse,
monitor use
Implementation interventions,
evaluation
Experimentation, evaluation
Richard Grol, 2013ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
TEAM
APPROACH
including Endocrinologists
Obstetricians
Midwives
Diabetes Educators
Dietitians
Better GDM control through improved diet therapy and
BGLs
Less medication use Fewer injections Improved QoL Patient satisfaction Better pregnancy outcomes Decreased weight retention Lower chronic disease incidence through improved follow up
American Dietetic Association Guidelines
MMH 2009
MMH2010
MMH2011
1 new visit 70.8% 94.7% 92.5%
3 review visits (min) 1 <1% 5.6% 5.3%
2 0 0 0
3 0 0 0
1 postnatal visit 0 0 0
Better GDM control through improved diet therapy and
BGLs
Less medication use Fewer injections Improved QoL Patient satisfaction Better pregnancy outcomes Decreased weight retention Lower chronic disease incidence through improved follow up
1
Diet controlled GDM (2009-2011)
MMH: 20-30%
RCTs: 70-80%
50% ‘unnecessarily’ on medication
evidence-practice
gap
evidence-practice
gap
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
The evidence practice gap
Perceived quality problem or
emergence of new evidence
Assessment of influencing factors
Design of implementation strategies
Evidence-basedInformed by theory
Optimal care/Behaviour
change
Explicitly evaluating your intervention
using a theory-driven approach
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Assessment of influencing factorsDesign of implementation strategies
Evidence-basedInformed by theory
Assessment of influencing factorsDesign of implementation strategies
Evidence-basedInformed by theory
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
I always plan to, but other things take up my time
I don’t have the right equipment
I’d prefer to exercise with others, but people are often doing other things at the time I
want to go
I’d like to do a new sport like rock climbing or kayaking but I don’t know how to get started
priorities
Gyms are expensive
Sustained improvement of patient care…
..is usually influenced by a complex mix of factors related to:
•Proposal for change•Patient•Individual professional•Social context•Team and collaboration•Organisational context•Wider political and economical context
Grol et al, Milbank Q 2006
barrierstheory
intervention
barrierstheory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Braithwaite, 2011
Above the waterline lie the observable
workplace behaviours, practices and discourse: this is the way we do things
around here
Below the waterline lie the
underlying beliefs, attitudes, values, philosophies and taken-for-granted
aspects of workplace life: “how we think”
and “why we do the things we do
around here” The ‘iceberg model’ of culture
Change strategies: a great variety on the market• Evidence-based medicine and clinical
guidelines• Total quality management• Accreditation and certification• Continuous professional development• Portfolio and problem based learning• Patient empowerment and partnership• Organisational development• Performance indicators, accountability,
transparency• Public reporting and physician profiling• Business process redesign• Breakthrough collaboratives• Leadership development
• Disease management, case management, managed care
• Balanced score cards• Risk management• Shared decision making• Complex adaptive systems thinking• Etc……..
barrierstheory
intervention
barrierstheory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
If the only tool you have is a hammer, it’s tempting to treat every problem you
have like a nail
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Assessment of influencing factorsConsider:1.Who needs to do what, differently?
2.Using a theoretical framework, which barriers and enablers need to be addressed?
3.Which intervention components (behaviour change techniques) and modes of delivery could overcome the modifiable barriers and enhance the enablers?
4.How can behaviour change be measured and understood? (French et al, Implementation Science, 2012, 7:38)
Tools/Readings• Improving Patient Care • NHMRC/NICS Barriers and Enablers tool• Frameworks…including..
• PARIHS framework• TDF (Theoretical Domains Framework)
barrierstheory
intervention
barrierstheory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Assessment of influencing factors :The TDF
The Theoretical Domains Framework (Cane et al, Implementation Science, 2012, 7:37)
barrierstheory
intervention
barrierstheory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Design of implementation strategies
• Requires a multi-level (theory-based) approach to change• 3 essential conditions are required (Michie et al, Implementation Science, 2011)
barrierstheory
intervention
barrierstheory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Design of implementation strategiesSOURCES OF BEHAVIOUR – the green hub
barrierstheory
intervention
barrierstheory
intervention
… from the TDF
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Design of implementation strategiesINTERVENTION FUNCTIONS – the red circle
barrierstheory
intervention
barrierstheory
intervention
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
Design of implementation strategiesINTERVENTION FUNCTIONS – the red circle
barrierstheory
intervention
barrierstheory
intervention
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
Design of implementation strategiesPOLICY FUNCTIONS – the grey circle
barrierstheory
intervention
barrierstheory
intervention
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
Design of implementation strategiesPOLICY FUNCTIONS – the grey circle
barrierstheory
intervention
barrierstheory
intervention
DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD
Improving practice: the international evidence
• No evidence that one of many, many (new) approaches to improving clinical practice is superior for ALL problems
• Change, even after well prepared interventions is usually moderate (5-10%), but potentially relevant for patients
• Most new, interesting strategies and approaches have not been evaluated well (and are based on beliefs or good experiences rather than evidence)
Grol & Grimshaw, Lancet 2003; Grimshaw et al 2004
barrierstheory
intervention
barrierstheory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Slow change: the rule of Benedictus
There is only one speed in the improvement of things: “conversio morum” … piecemeal quality management and
improvement or gradual, day-to-day change in small, feasible and achievable steps, instead of “breakthrough
changes”
“steadily pushing in the right direction”
EPOC interventions (Effective Practice and Organisation of Care Group – Cochrane)
• Clinical pathways; standardized protocols• Audit and feedback• Local opinion leaders• Local consensus processes• Small group interactive continuous education• Electronic patient management systems
barrierstheory
intervention
barrierstheory
intervention
N trialsN trials Median changeMedian change
Printed education material 23 +4%
Educational materials 56 +6%
Educational outreach visits 34 +5%
Audit and feedback 118 +5%
http://epoc.cochrane.org/epoc-reviews
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
GDM TRIP
Clinicians (dietitians, O&G, Obs Med physicians, midwives, diabetes
educator); Women
Knowledge; Beliefs about consequences, Social/professional role
and identity, Social influences, Intentions, Memory, attention, decision processes, Environmental context and
resources
Training re NPG (w/ outcomes), Audit & feedback , Clinical
Champions, Local opinion leaders, Care pathways Women’s
engagement, $$, and rooms
Clinical practice measures and patient outcome measures
Step 1: Who needs to do what differently?
Step 2: Using a theoreticalframework, which barriers and
enablers need to be addressed?
Step 3: Which intervention componentscould overcome the modifiable barriers
and enhance the enablers?
Step 4: How will we measurebehaviour change?
barrierstheory
intervention
barrierstheory
interventionAim: To translate GDM model of care appointments in the MMH
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
barrierstheory
intervention
barrierstheory
intervention
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
The evidence practice gap
Perceived quality problem or
emergence of new evidence
Assessment of influencing factors
Design of implementation strategies
Evidence-basedInformed by theory
Optimal care/Behaviour
change
Explicitly evaluating your intervention
using a theory-driven approach
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Optimal care/Behaviour change
Explicitly evaluating your intervention using a theory-driven
approach
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Evaluating the intervention
• Research is different from the real (TRIP) world
• Research = defined boundaries/structures vs real world = messy/complex
• Can’t control everything, but you can monitor and describe
• Outcomes should link with your intervention strategies
• Try to use routinely collected data, where possible– Process measures, including fidelity (adherence and moderators)– Good to have clinical measures as well, but you’re not re-validating or re-
proving your guidelines!– Economic measures
outcomes(process,clinical)
outcomes(process,clinical)
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Process outcomes:Primary: uptake of the new dietetic schedule, as measured by adherence to the NPG appointment scheduleSecondary: clinician (i) awareness,
(ii) knowledge and (iii) acceptance
Clinical outcomes:Primary: effect of the NPG schedule on requirement for pharmacotherapy (insulin/metformin) Secondary: (i) rate of maternal weight gain,
(ii) diet quality, physical activity and pt satisfaction (iii) birth weight.
+ cost-benefit analysis and other clinical outcomes
outcomes(process,clinical)
outcomes(process,clinical)
GDM TRIPStudy design: 9 months pre/post implementation study
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
• Increased proportion of women receiving best practice care, but no change in medication use• Await clinical outcomes, diet, activity and satisfaction measures
• Data shortcomings influence findings• Reality of health service research – messy, complex, real world• Potentially didn’t influence prescribing behaviour
• Model of care ‘integration’ required four, rather than one month…• slower than expected process could have been overcome by wider
(higher) clinician and management engagement• Who else needs to be involved? Who else needs to know?
• Prepare for, but don’t guess your barriers• Visit clinic/ward at least once a week for entire project
GDM TRIP: IMPLICATIONS & RELFECTIONS
Where to next?
• Dissemination
• Scaling up and rolling out
• Sustainability
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Queensland Health - Health Research Fellowship (2014-2016)
Study 3 Aim: to improve the nutritional management of women with GDM in Qld•build on implementation findings from the MMH GDM NHMRC TRIP project
Acknowledgements• NHMRC/NICS
– Fellowship funding, Masterclass training, Slides/images
- Project team @ Mater Health Services/Mater Mothers: - David McIntyre, Director Obstetric Medicine - Sally McCray, Director Nutrition & Dietetics- Mike Beckmann, Director Obstetrics & Gynaecology- Annette Parry, Diabetes Educator/Midwife- Sam Drew, Midwifery Unit Manager, ANC
- Mentors: - David McIntyre (Project); - Adele Green (TRIP)(Deputy Director, QIMR)
- My eyes and ears on the ground:- Debbie Tolcher, Elin Donaldson & Ellen Heads, MMH dietitians [email protected]
ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD
Transformation isn’t a matter of intent, it’s a matter of alignment
Peter Fuda