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1
TheTranslational Toolbox
Ralph Gonzales, MD, MSPH
Henry Lee, MD, MSJune 2011
Henry Lee• Assistant Professor of
Pediatrics, Division of Neonatology
• Associate Director of Data Analysis, California Perinatal Quality Care Collaborative
Ralph Gonzales• Professor of Medicine,
Epidemiology & Biostatistics
• Director, UCSF Program in Implementation and Dissemination Sciences (IDS)Collaborative
• UCSF CTSI KL2 Scholars Program
(IDS)
• Associate Director, CTSI KL2 Scholars Program
Background Taxonomy
2
Translating “Evidence”…
1. Level of “evidence”; establishing “evidence”
Efficacy, effectiveness, systematic reviews, guidelines/recommendationsg /
;
Translating “Evidence”…
1. Level of “evidence”; establishing “evidence”
Efficacy, effectiveness, systematic reviews, guidelines/recommendations
2. Translating “evidence” into practiceg p
Innovations that improve health/outcomes2a. Processes of Care
• Influence health outcome– Behaviors, tests, treatments, procedures, etc
2b. Health Care Interventions
• Influence processes of care– Translational Tools; Implementation strategies; Policies
• Decision support tools
• Health coaches
• Prenatal vitamins
• Electronic health records
Which are Processes of Care?
• Electronic health records
• Telemedicine
• Antiretroviral therapy
• Cognitive behavioral therapy
3
• Decision support tools
• Health coaches
• Prenatal vitamins
• Electronic health records
Processes of Care vs. Tools
• Electronic health records
• Telemedicine
• Antiretroviral therapy
• Cognitive behavioral therapy
Implementation Strategies
TranslationalTranslational Tools
Evidence
Processes of Care
OUTLINE
• Classifying Tools– 3 Dimensions
• Exemplars– Patients: Decision Support
– Clinicians: Practice Guidelines
– Community: CBPR
4
Translational Tool
• A strategy, program, mechanism, tool used to translate evidence into practice.
– Evidence = processes of care directly linked to health outcomeshealth outcomes
• Although final process always involves patients/persons, behavior change targets of translational tools can vary.
ICE
TH
Tool Dimension #1: Target
NCE Stakeholders
li
• Government
• Payors/Insurers
• Societies
• Hospitals
PRACTI
HEA
LT
EVIDEN
Delivery Systems
Individuals
• Hospitals
• Clinic/Practices
• Health Depts
• Providers
• Patients
• Public
5
ENVIRONMENT
B h i l
Contemplation
Pre‐ Contemplation
PREDISPOSING REINFORCINGENABLING
Behavioral Intention
Action Maintenance
Theory of Planned Behavior
Preparation
Self -Efficacy
Beliefs Attitudes
Social Norms
Motivation and Persuasion
REFS-Prochaska-Azjen-Green
Phase 1Social
assessment
HealthProgram
Phase 4a
Predisposing
Phase 3Educational &
ecologicalassessment
Phase 4b
Phase 2Epidemiological
Assessment
Genetics
PRECEDE-PROCEED
InterventionAlignment
• Predisposing,
• Reinforcing, &
• Enabling
• Constructs in
• Educational/Ecological
• Diagnosis &
• Evaluation
• Policy,
• Regulatory &
• Organizational
• Constructs in
• Educational &
• Environmental
• Development
Phase 7Impact & Outcome evaluation
Quality of Life
Health
Educational strategies
Policyregulation
organization
Phase 5Implementation
Phase 6Process evaluation
Enabling
Reinforcing
Behavior
Environment
Administrative &Policy Assessment
Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.
Tool Dimension #2: PRECEDE
1. Predisposing Factors – Rx=Why you should change
– Examples: Media Campaigns; Education; Guidelines
2 R i f i F t2. Reinforcing Factors– Rx=Align rewards/penalties
– Examples: Incentives; Feedback; Opinion Leaders; Laws/Regulations
3. Enabling Factors (make it easy to do it)
– Rx=Make it easy to do it
– Examples: Skills; Decision Support; Authorization; Registries; Reminders
6
Tool Dimension #3: Platform
Examples…
‐Education• Brochures; Computerized; Video; Mass Media; In‐Person
D i i t‐Decision support• Computerized; HealthCoach; Action Plans; Telephone Advice Nurse
‐Laws and regulations• Federal/state laws; work‐place regulations; school regulations; licensing
The Translational Toolbox‐individual behavior change tools
Community• Health fairs• Mass media• Advice lines• Support
Patient• Education
– Printed– Computer– Internet– Video/multi-media
Clinician• Education
– CME– Detailing
• Guidelines• Prior Auth’npp
groups• Conditional
payments• Taxes
• Decision Aids• Disease
management– Coaches– Action plans
• Copayments• P4P• Motivational
interviewing
• Prior Auth n• Decision
support• Registries• Reminders• Audit &
feedback• P4P• Opinion leader
KeyPredisposingReinforcingEnabling
OUTLINE
• Classifying Tools– 3 Dimensions
• Exemplars– Patients: Decision Support
7
Patient Behavior Change‐van de Meer V et al. Ann Intern Med 2009;151:110‐120
Background• Despite the availability of monitoring tools and effective therapy, asthma
control is suboptimal and long‐term management falls far short of the goals set in the guidelines
• Self‐monitoring, education, and specific medical care are important aspects in improving the lives of patients with asthma
• However, many patients with mild or moderate persistent asthma do not attend checkups regularly or visit their physician with symptoms of the disease.
• Internet technology is increasingly seen as an appealing tool to support self‐management for patients with chronic disease.
Patient Behavior Change‐van der Meer V et al. Ann Intern Med 2009;151:110‐120
Problem and Intervention
What is the evidence? Medical management
What is the quality gap? “under‐utilization”
Is the quality gap linked to the outcome gap? yes
Tool: decision support tool
Target:
PRECEDE:
Platform:
8
Patient Behavior Change‐van der Meer V et al. Ann Intern Med 2009;151:110‐120
Problem and Intervention
What is the evidence? Medical management
What is the quality gap? “under‐utilization”
Is the quality gap linked to the outcome gap? yes
Tool: decision support tool
Target: patients with asthma/internet access
PRECEDE: knowledge; skills; feedback
Platform: internet
9
Patient Decision Aids“Informed Decision Making”g
Patient Decision Aid SpecsO’Connor AM et al. Cochrane Reviews 2003
• What is it?
– An adjunct to counseling that
• explains options
• clarifies personal values for the benefits vs. harms
• guides patients in deliberation and communication
• Outcomes– Improve Decision Quality
• Decisions are informed (knowledge; risk perception)
• Decisions based on personal values (congruence)’
• Most common conditions• Breast, prostate and colon cancer screening & treatment• Menopause options• Cardiovascular disease management• Prenatal testing
10
Patient Decision Aid SpecsO’Connor AM et al. Cochrane Review 2003
• Cost:• Feasibility:• Complexity:• Efficacy/Effectiveness:
Patient Decision Aid SpecsO’Connor AM et al. Cochrane Review 2003
• Cost: development… low‐medium—person‐hours• Feasibility: very feasible• Complexity: potential for high complexity• Efficacy/Effectiveness:
– Most RCTs measured process/intermediate outcomes (knowledge; realistic expectations; decisional conflict)realistic expectations; decisional conflict)
• Main effects are on knowledge and realistic expectations, with OR about 1.4‐1.6.
• Reductions in decisional conflict appear modest• 5/9 studies showed improvement in satisfaction with decision
Patient Behavior Change Tools
Predisposing
• Patient education
Reinforcing
Enabling
• Decision support
• Action plans
Reinforcing
• Reminders
• Coaches
11
OUTLINE
• Classifying Tools– 3 Dimensions
• Exemplars– Patients: Decision Support
– Clinicians: Practice Guidelines
Clinician Behavior Change‐Campbell SM et al. N Engl J Med 2009;361:368‐78
Background
• In 2004, the U.K. government introduced a pay‐for‐performance scheme with 136 indicators for family practices.
• Payments make up approximately 25% of family practitioners’ income, and 99.6% of family practitioners participated in the pay‐for‐performance scheme, which is voluntary.
Clinician Behavior Change‐Campbell SM et al. N Engl J Med 2009;361:368‐78
Problem and Intervention
What is the evidence? Asthma, diabetes, CHD care
What is the quality gap? underperformance
Is the quality gap linked to the outcome gap? Yes
Tool: Financial Incentives/P4P
Target:
PRECEDE:
Platform:
12
Clinician Behavior Change‐Campbell SM et al. N Engl J Med 2009;361:368‐78
Problem and Intervention
What is the evidence? Asthma, diabetes, CHD care
What is the quality gap? underperformance
Is the quality gap linked to the outcome gap? Yes
Tool: Financial Incentives/P4P
Target: Family Practices
PRECEDE: Reinforcing
Platform: Governance
Results
Clinical Practice Guidelines
13
Practice Guideline Specs
• What is it?– Cost: person‐hours
– Feasibility: buy‐in; participation
– Complexity: varies
• S mmar of e idence i ff ti i i l ti• Summary of evidence ineffective in isolation
Practice Guideline Specs
• What is it?– Cost: person‐hours
– Feasibility: buy‐in; participation
– Complexity: varies
• S mmar of e idence i ff ti i i l ti• Summary of evidence ineffective in isolation
• Ideal uses– Target behaviors single, simple actions
– Target barriers knowledge/attitudes
• Conclusion: it’s all about ‘implementation’
Practice Guidelines seem to be most effective…
• for acute care conditions
• when quality of evidence is superior
• when compatible with existing values
• when decision making complexity is low
• when desired performance/behavior is clearly understood
• when new skills or organizational support is not necessary for behavior change
14
The influence of intervention strategy and organisational factors on practice guideline effectiveness.
Adapted from Dijkstra et al, BMC Health Services Research 2006;6:53
PLATFORM
Educational Meeting
Educational Material
Consensus Meeting
Reminders
SETTING
Inpatient
Outpatient
OUTCOMESReminders
Feedback
Patient-Mediated
Outreach
Opinion Leader
Revision of Prof Roles
Financial
Organisational
ORGANISATIONAL EFFECT MODIFIERS
Leadership (Management Support)
Learning Environment (Academic)
Physician Type and Specialty
Local Consensus (Development)
-behavioral
-clinical
SUMMARYCPG Interventions
• Development– identify clinician knowledge and behavior gaps
– identify barriers to change
– evidence‐based “best practice”
– quantify benefit of CPG compliance on system, practice and patient
– local input & endorsement
• Implementation– opinion leader; clinical champion
– point‐of‐service reminders
– feedback/profiling
Clinician Behavior Change Tools
Predisposing
• Guidelines
• CME
Enabling
• Decision support
• Teams
Reinforcing
• Opinion Leaders
• Financial Incentives
• Penalties
15
OUTLINE
• Classifying Tools– 3 Dimensions
• Exemplars– Patients: Decision Support
– Clinicians: Practice Guidelines
– Community: CBPR
Public Behavior Change‐Manandhar DS et al. Lancet 2004;364:970‐79
Background
• In India, neonatal mortality accounts for up to 70% of infant mortality. Most deaths happen at home, and many could be avoided with changes in antenatal, delivery, and newborn care practicespractices.
• Primary and secondary health‐care systems have difficulties in reaching poor rural residents. In Makwanpur district, Nepal, for example, 90% of women give birth at home, and trained attendance at delivery is uncommon .
Translational Tool: CBPR
16
Public Behavior Change‐Manandhar DS et al. Lancet 2004;364:970‐79
Problem and Intervention
What is the evidence being translated? Prenatal/postnatal care
What is the quality gap? see Table 4 control group
Is the quality gap linked to the outcome gap? yes
Tool: CBPR
Target: pregnant women
PRECEDE: knowledge; decision support; social support
Platform: CBPR; “facilitators”
Results
Public Behavior Change Tools
Predisposing
• Health Fairs
• Mass Media
• Outreach
Enabling
• Built Environment
• Self‐Efficacy
• Outreach
• Health Coaches
Reinforcing
• Reminders
• Opinion Leaders
• Conditional Payments
• Co‐Payments
17
SUMMARY
• Guidelines/Knowledge/Awareness is a necessary starting point, but rarely sufficient to create behavior change
• Think about an intervention strategy that uses multiple tools across the spectrum of predisposing, reinforcing and enabling factors depending on the relevant theory
• Tools don’t work by themselves. Implementation is the key
Translational Tool ResourcesAHRQ Innovations Exchange (http://www.innovations.ahrq.gov)
Cochrane Effective Practice and Organisation of Care Group (EPOC) (http://www.epoc.cochrane.org)
National Guidelines Clearinghouse (www.guideline.gov)
References
1. Prochaska JO, DiClemente CC. Stages and processes of self‐change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology 51(3): 390–395, 1983.
2. Azjen I, Driver BL. Prediction of leisure participation from behavioral, normative, and control beliefs: an application of the theory of planned behavior. Leisure Science 13:185–204, 1991.
3. Green LW, Kreuter MW. Health Program Planning: An Educational and Ecological Approach. 4th edition. NY: McGraw‐Hill Higher Education, 2005.
4. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice (4th Edition). San Francisco, Calif.: Jossey‐Bass, 2008.
18
Appendix
CASE STUDY:The IMPAACT Trial
Supported by AHRQ (1 R01 HS013915) and VA HSR&D (AVA‐03‐239)
• Emegency Department Intervention:
1. Provider education (practice guidelines) delivered by local opinion leadersdelivered by local opinion leaders
2. Group audit and feedback
3. Patient education
• Sites provided individualized adaptation of components
IMPAACT Intervention Sites
Northwestern Memorial Hospital Chicago VAMC
Lincoln Medical CenterBronx VAMC
UNM Health Sciences CenterAlbuquerque VAMC
Medical College of GeorgiaAugusta VAMC
19
60
80
100
escr
ipti
on R
ate
EMNet Average year 1 Truman year 1Truman year 2 EBM Target
Group Audit and Feedback
*
0
20
40
URI Bronchitis Pharyngitis AECB
Ant
ibio
tic
Pre
URI, Bronchitis, Pharyngitis: excludes COPD, and antibiotic-responsive secondary diagnosesAECB: as 1st diagnosis, or URI/bronchitis 1st diagnosis in patient with PMHx COPD* < 5 visits
*
Patient Education
• Waiting Room Patient Education– Pamphlets/Cards
– Informational KioskInformational Kiosk
• Examination Room Materials– Bronchitis Posters
Exam Room Poster
20
KIOSK
• Waiting room signs directed patients to kiosk
• Patients were encouraged to use kiosk by ED staff
• Rotating messages on screen suggested content
• All text on screen could be heard through speakers
• Bilingual educational printout at end of program
Kiosk Care Plan(Spanish and English)
21
Adjusted Abx Rx Rates for URI/AB
5
10
15
p = .04
tib
ioti
cs:
Per
iod
s
-15
-10
-5
0
Control Sites Intervention Sites% V
isit
s P
resc
rib
ed A
nt
Inte
rven
tio
n -
Bas
elin
e P
Adjusted Abx Rx Rates for all ARIs
5
10
15
p= .17
d A
nti
bio
tic
s:
lin
e P
eri
od
s
-15
-10
-5
0
Control Sites Intervention Sites
% V
isit
s P
res
cri
be
dIn
terv
en
tio
n -
Ba
se
l
ABx Treatment of URIs/Bronchitis Decreased at Intervention Sites
Metlay et al, Ann Emerg Med, 2007.
22
References & Resources1. Azjen I, Driver BL. Prediction of leisure participation from behavioral, normative, and control beliefs: an
application of the theory of planned behavior. Leisure Science.1991;13:185–204.
2. Campbell SM et al. Effects of pay for performance on the quality of primary care in England. N Engl J Med. 2009;361:368‐78.
3. Dijkstra R et al. The relationship between organisational characteristics and the effects of clinicalguidelines on medical performance in hospitals, a meta‐analysis. Bio Med Central Health Services Research. 2006;6:53. doi:10.1186/1472‐6963‐6‐53.
4. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice 4th
Edition. San Francisco, California: Jossey‐Bass, 2008.h5. Green L, Keuter M. Health Program Planning An Educational and Ecological Approach 4th Edition. NY,
London: McGraw‐Hill, 2005.
6. Manandhar DS et al. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster‐randomised controlled trial. Lancet. 2004;364:970‐79.
7. Metlay et al. Cluster‐randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments. Annals of Emergency Medicine. 2007;50(3):221‐230. doi:10.1016/j.annemergmed.2007.03.022.
8. O’Connor AM et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2003;1. doi: 10.1002/14651858.CD001431.
9. Poses RM, Cebul RD, Wigton RS. You can lead a horse to water – Improving physicians’ knowledge of probabilities may not affect their decisions. Medical Decision Making. 1995;15:65‐75.
10. Prochaska JO, DiClemente CC. Stages and processes of self‐change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology.1983;51(3): 390–395.
References & Resources11. US Department of Health and Human Services, National Institutes of Health. Theory at a glance: a guide
for health promotion practice. National Cancer Institute. Available at http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf. Accessed on January 19, 2012.
12. Van der Meer V et al. Internet‐based self‐management plus education compared with usual care in asthma: a randomized trial. Annals of Internal Medicine. 2009;151(2):110‐20.