IDENTIFYING TO GUIDELINE AND gHyd: OVERCOMING ... · 2. Priority setting 3. Guideline group...

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IDENTIFYING AND OVERCOMING BARRIERS TO GUIDELINE IMPLEMENTATION Professor EK Yeoh Director, JC School of Public Health and Primary Care Faculty of Medicine, The Chinese University of Hong Kong KDIGO

Transcript of IDENTIFYING TO GUIDELINE AND gHyd: OVERCOMING ... · 2. Priority setting 3. Guideline group...

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IDENTIFYINGANDOVERCOMINGBARRIERSTOGUIDELINEIMPLEMENTATION

ProfessorEKYeoh Director,JCSchoolofPublicHealthandPrimaryCare FacultyofMedicine,TheChineseUniversityofHongKong

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GuidelineAdoptionandUse•  Systematicreviewofstudiesofguidelineusefoundadoptionandadherencewaslowevenwhenawarenessofandagreementswiththeguidelinesamongtargetuserswashigh

•  Contextualfactorswhichinfluenceanddetermineguidelineadoptionanduse:

•  atlevelsof•  Professional •  Patient •  Institutional •  System

2MickanSetal(2011)PostgradMedJ

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DeterminantsofHealthcarePractices:BarriersandFacilitators

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•  Guidelinefactors•  Healthprofessionalfactors•  Patientfactors•  Incentivesandresources•  Capacityfororganizationalchange•  Social,politicalandlegalfactors

FlottorpSAetal(2013)ImplementationScience

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MethodstoIdentifyDeterminantsofHealthcarePractices:BarriersandFacilitators

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•  Brainstorming•  Focusgroup•  Performancedataanalysis•  Observations•  Interviews•  Questionnaires

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IdentifyingDeterminantsofCareforTailoringImplementationinChronicDiseases:anevaluationofdifferentmethods

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Methods:•  Studyin5Europeancountries,recommendationsforadifferentchronicconditionineachcountry.

•  Methodscompareddirectly:brainstormingamongsthealthprofessionals,interviewsofhealthprofessionals,andinterviewsofpatients.

•  Additionalvalueofdiscussionstructuredthroughreferencetoachecklistofdeterminantsinadditiontobrainstorming,anddeterminantsidentifiedbyopenquestionsinaquestionnairesurvey,investigatedseparately

KrauseJetal(2014)ImplementationScience

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IdentifyingDeterminantsofCareforTailoringImplementationinChronicDiseases:anevaluationofdifferentmethods

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Results:•  601determinantsjudgedtobeplausiblyimportantwereidentified.•  609determinantswerejudgedunlikelytoinformanimplementationintervention,andclassifiedasnotplausiblyimportant.

•  Brainstormingidentified194ofplausiblyimportantdeterminants,healthprofessionalinterviews152,patientinterviews63,openquestion48.

•  Groupdiscussionidentified144plausiblyimportantdeterminantsinadditiontothoseidentifiedbybrainstorming

KrauseJetal(2014)ImplementationScience

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IdentifyingDeterminantsofCareforTailoringImplementationinChronicDiseases:anevaluationofdifferentmethods

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Conclusions:•  Systematicmethodscanleadidentificationoflargenumbersofdeterminants.•  Tailoringincludeaprocesstodecidethosetobeaddressedbyimplementationinterventions.

•  Toidentifydeterminants,combinationshouldbeused.•  Brainstormingasasimple,lowcostmethodrelevanttomanytailoredimplementationprojects

KrauseJetal(2014)ImplementationScience

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TailoredInterventionstoOvercomeIdentifiedBarrierstoChange:EffectsonProfessionalPracticeandHealthCareOutcomes

RBakeretal(2014)CochraneDatabaseSystRev 8

Methods RCT Participants 134 staff in child health clinics

Diagnosis and management of childhood asthma

Interventions Barriers analysis: focus groups Barriers: clinical uncertainty, administrative constraints Theory: planned organizational change, learner centred teaching Intervention: 1.  teaching sessions, discussions of patients, tutorial for physicians, monthly educator

visits 2.  guideline tailoring: moderate

Outcomes Professional practice: identification of patients with asthma, continuity of care, use of medication, patient education

Evans1997

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TailoredInterventionstoOvercomeIdentifiedBarrierstoChange:EffectsonProfessionalPracticeandHealthCareOutcomes

RBakeretal(2014)CochraneDatabaseSystRev 9

Methods RCT Participants 142 general practices

Management of urinary tract infection in women and sore throat Interventions Barriers analysis: literature search, discussion with the guideline development group, brainstorming,

focus group interviews with patients and GP assistants, a pilot study, discussion groups, and informal interviews Barriers: patient expectations, financial disincentives, administrative constraints, other Theory: none Interventions: 1.  summary of guideline recommendations, patient educational material, computer based support and

reminders, increased fees for telephone consultations, printed material to facilitate discussions, interactive courses for GPs and practice assistants, CME point for participants

2.  no intervention

Outcomes Professional practice: rates of use of antibiotics, laboratory tests and telephone consultations

Flottorp2002

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TailoredInterventionstoOvercomeIdentifiedBarrierstoChange:EffectsonProfessionalPracticeandHealthCareOutcomes

RBakeretal(2014)CochraneDatabaseSystRev 10

Methods RCT

Participants Hospital staff caring for patients with community acquired pneumonia Antibiotic use in pneumonia

Interventions Barriers analysis: individual and group interviews Barriers: clinical uncertainty, administrative constraints, other Theory: none Interventions: 1.  lecture, feedback, critical care pathway, plus facilitated modules specific to each

intervention site 2.  no intervention Tailoring: high

Outcomes Professional practice: adherence to 15 guideline recommendations Health outcomes: length of stay, mortality, intensive care unit admission

Schouten2007

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1.  Guidelinefactors2.  Individualhealthprofessionalfactors3.  Patientfactors4.  Professionalinteractions5.  Incentivesandresources6.  Capacityfororganizationalchange7.  Social,politicalandlegalfactors

7DomainsofFactorsintheIntegratedChecklistofDeterminantsofPractice(TICDChecklist)

FlottorpSAetal(2013)ImplementationScience 11

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ChecklistforaSuccessfulGuidelineEnterprise1.  Organization,budget,planningandtraining2.  Prioritysetting3.  Guidelinegroupmembership4.  Establishingguidelinegroupprocesses5.  Identifyingtargetaudienceandtopicselection6.  Consumerandstakeholderinvolvement7.  Conflict-of-interestconsideration8.  Questiongeneration9.  Consideringtheimportanceofoutcomesandinterventions,values,preferences

andutilities10.  Decidingwhatevidencetoincludeandsearchingforevidence

HJSchunemannetal(2014)CMAJ 12

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ChecklistforaSuccessfulGuidelineEnterprise(con’t)

11.  Summerizingevidenceandconsideringadditionalinformation12.  Judgingquality,strengthorcertaintyofabodyofevidence13.  Developingrecommendationsanddeterminingtheirstrength14.  Wordingofrecommendationsandofconsiderationsofimplementation,feasibility

andquality15.  Reportingandpeerreview16.  Disseminationandimplementation17.  Evaluationanduse18.  UpdatingHJSchunemannetal(2014)CMAJ 13

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GuidelineImplementability

•  Contentandformatofguidelinesthatfacilitatetheiradoption

•  Cochranesystematicreview*confirmedguidelineimplementationtools(GItools)developedanddisseminatedwithguidelinesinfluencedclinicalbehaviourandpatientoutcomes

•  Systematicreviewsshowimplementationtools:guidelinesummaries,algorithms,point-of-carechecklists,healthstatusremindersenhancedcompliancewithguidelinerecommendations

14*Flodgrenetal(2016)

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FrameworkofTypesofGuidelineImplementation(GI)ToolsCategory Type Description Patient Support

Information Print or electronic information about the condition, management options, or sources of information

Guideline summary Short versions of guidelines for patients and care partners

Self-management support

Resources such as charts, templates, and action plans used by patients to better manage their disease and daily activities

Clinician Support

Guideline summary Short versions of guidelines in print or electronic format including pocket cards, summaries, or applications

Algorithm Flowcharts or clinical pathways

Form or checklist Print or electronic documents completed by clinicians

Implementation Support

Training material Resources to support educational meetings or self-directed learning

Resources Human, infrastructure or funding resources

Evaluation Support

Audit tools Guidelines or manuals to support the evaluation

Measures

Quality indicators or performance measures to assess compliance with guideline recommendations

LiangLetal(2017)ImplementationScience 15

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Guidelinecharacteristics•  Totalof126guidelinespublishedfromFeb2010toMarch2017

NumberandTypeofGuidelineImplementationTools

LLiangetal(2017)ImplementationScience 16

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NumberandTypeofGuidelineImplementationTools

LLiangetal(2017)ImplementationScience 17

GItoolsperguideline

•  MeannumberofGItoolsperguidelinewas5.5(median4.0,range1to28)

GItoolscharacteristics

•  Informingandsupportingdecision-markingamongclinicians(239,51.5%) •  Informingandsupportingself-managementamongpatients(113,24.4%) •  Supportingguidelineimplementation(66,14.3%) •  Supportingevaluationofguideline-concordantcare(46,9.9%)

GuidelineswithGItools

•  85(67.5%)ofthe126guidelinesaccompaniedbyoneormoreGItools

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TailoredInterventionstoOvercomeIdentifiedBarrierstoChange:EffectsonProfessionalPracticeandHealthCareOutcomes

RBakeretal(2014)CochraneDatabaseSystRev 18

Objective:theeffectivenessofinterventionstailoredtoaddressidentifiedbarriersto,changeonprofessionalpracticeorpatientoutcome

Selectioncriteria:randomisedcontrolledtrials(RCTs)ofinterventionstailoredtoaddressprospectivelyidentifiedbarrierstochangethatreportedobjectivelymeasuredprofessionalpractice

Mainresults:26studiescomparinganinterventiontailoredtoaddressidentifiedbarrierstochangetonointerventionorintervention(s)nottailoredtothebarriers

Authors’conclusion:interventionstailoredtoprospectivelyidentifiedbarriersaremorelikelytoimproveprofessionalpracticethannointerventionordisseminationofguidelines

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Patient-mediatedInterventionstoImproveProfessionalPractice:Cochranesystematicreview

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Patient-mediatedinterventions“anyinterventionaimedatchangingtheperformanceof

healthcareprofessionalsthroughinteractionswithpatients,orinformationprovidedbyortopatients”

FønhusMSSAetal(2018)ScienceDirect

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Patient-mediatedInterventionstoImproveProfessionalPractice:Cochranesystematicreview

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Results•  25randomizedstudieswithatotalof12,268patients•  4typesofpatient-mediatedinterventions1)  Patient-reportedhealthinformationinterventions:informationofpatients’own

health,concernsorneeds2)  Patientinformationinterventions:patientsinformedabout,orremindedto

attendrecommendedcare3)  Patienteducationinterventions:increasepatients’knowledgeabouttheir

conditionandoptionsofcare4)   Patientdecisionaidinterventions:providedwithinformationabouttreatment

optionsincludingrisksandbenefits

FønhusMSSAetal(2018)ScienceDirect

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Patient-mediatedInterventionstoImproveProfessionalPractice:Cochranesystematicreview

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1) Patient-reportedhealthinformationinterventions:Probablyimprovehealthcareprofessionals’adherencetorecommendedclinicalpractice,moderatecertaintyevidenceforevery100patientsconsultedortreated,26(95%CI23-30)inaccordancewithrecommendedclinicalpracticecomparedto17per100inthecomparisongroup(nointerventionorusualcare)

2)Patientinformationinterventions:Mayimprovehealthcareprofessionals;adherencetorecommendedclinicalpractice,lowcertaintyevidenceforevery100patientsconsultedortreated,32(95%CI24-42)areinaccordancewithrecommendedclinicalpracticecomparedto20per100inthecomparisongroup

FønhusMSSAetal(2018)ScienceDirect

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Patient-mediatedInterventionstoImproveProfessionalPractice:Cochranesystematicreview(con’t)

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3)Patienteducationinterventions:Probablyimprovehealthcareprofessionals’adherencetrecommendedclinicalpractice,moderatecertaintyevidenceforevery100patientsconsultedortreated,46(95%CI39-54)areinaccordancewithrecommendedclinicalpracticecomparedto35per100inthecomparisongroup

4)Patientdecisionaidinterventions:Littleornoeffectonhealthcareprofessionals’adherencetorecommendedclinicalpractice,low-certaintyevidenceforevery100patientsconsultedortreated,32(95%CI24–43)areinaccordancewithrecommendedclinicalpracticecomparedto37per100inthecomparisongroup

FønhusMSSAetal(2018)ScienceDirect

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TheoreticalDomainsFrameworkofBehaviourChangetoInvestigateImplementationProblems

23AtkinsLetal(2017)ImplementationScience

TheoreticalDomainsFramework(TDF) • Developedforimplementationresearchtoidentifyinfluencesonhealthprofessionalbehaviorrelatedtoimplementationofevidence-basedrecommendations

• Integratedtheoreticalframeworksynthesizedfrom128theoreticalconstructsfrom33theoriesjudgedmostrelevanttoimplementationquestions

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TheoreticalDomainsFramework

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Knowledge An awareness of the existence of something

Skills An ability or proficiency acquired through practice

Social/ professional role and identity

A coherence set of behaviours and displayed personal qualities of an individual in a social or work setting

Beliefs about capabilities Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use

Optimism The confidence that things will happen for the best or that desired goals will be attained

Reinforcement Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus

Intentions A conscious decision to perform a behavior or a resolve to act in a certain way

Goals Mental representations of outcomes or end states that an individual wants to achieve

Memory, attention and decision processes

The ability to retain information, focus selectively on aspects of the environment and choose between 2 or more alternatives

Environmental context and resources

Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behavior

Social influences Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours

Emotion A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event

Behavioural regulation Anything aimed at managing or changing objectively observed or measured actions

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ImprovingOutcomeswithGuidelines

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•  Development•  Implementability•  Implementation•  Adoption,adherenceanduse•  Evaluation•  Sustainability

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SustainabilityofGuidelinesUseandImpact

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� Determinants•  Designandcharacteristics

•  Organisationalcontextandfactors

•  Socio-economicandpoliticalenvironmentandfactors

� Sustainabilityasinstitutionalisationandroutinisationintoorganisationalsystems

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ThankyouKDIGO