The complexity and difficulties of implementing effective health care and how to do it

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The complexity and difficulties of implementing
effective health care- and how to do it

• Michel Wensing, Ph.D., senior lecturer
• Centre for Quality of Care Research (WOK)
• Radboud University Nijmegen Medical Centre
  Netherlands

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Overview of the presentation

• My background
• Implementation problem
• Implementation model
• Evidence on implementation
• New interventions
• Conclusions

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Centre for Quality of Care Research (WOK)

• Societal mission support policy and practice
  regarding quality improvement in patient care
• Scientific mission develop implementation
  science
• Active in primary care, hospital care, nursing
  and allied health professions
• 3 professors 2 associate professors
• 40 Ph.D students finished 70 ongoing

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• WWW.WOKRESEARCH.NL

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The implementation problem (1)

• Evidence-based recommendations on best patient
  care are available for many conditions
• Large variations in quality of care across
  patients and providers (quality, performance,
  safety, and outcomes)
• Current health care can be improved

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The implementation problem (2)

• There is much knowledge on what is good health
  care for patients and/or society
• Initial training of health professionals is too
  slow to adapt to this continuously changing
  knowledge
• It is the responsibility of health professions
  and society to use the available knowledge better

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Example aspirin after stroke (Woolf 2005)

• Aspirine reduces risk for recurring stroke (by
  25), but only 60 of eligible patients receive
  it.
• Invest in development of better drug or in better
  use of aspirin ?
• Break even point at population level new drug
  that reduces risk by 40 100 of patients use
  aspirin

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Has arthritis care special implementation
problems?

• Large patient populations, mostly treated by
  generalistic health providers (GPs and others)
• High relevance of multiprofessional
  collaboration, both in teams and across care
  providers (referrals)
• Not only doctors, but also allied health
  professionals and others with various levels of
  professional development
• Emphasis on life style change (physical exercise,
  weight control, etc.)

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Example multidisciplinary guidelines on low back
pain (Engers 2005)

• Guidelines launched in 2002
• Written survey in 17 health professions
• N950 (38) response
• Results mostly positive on content of
  guidelines, no group expected resistance from
  direct colleagues
• But physicians expected resistance in allied
  health professionals, while manual therapists
  expected resistance in physicians
• All expected resistance in patients

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• HOW?

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Interventions for improving quality of care

• -feedback -continuing education
• -integrated care -accreditation
• -visitation -Breakthrough
• -reminder systems -opinion leaders
• -decision support -quality management
• -professional development -complaint procedures
• -process control -leadership
• -process redesign -disease management
• -transparancy -patient empowerment

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New research evidence and best practices
A. Large-scale implementationevaluation B.
Update of guidelines, performance indicators
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Development of guidelines performance indicators
Small-scale implementa-tion evaluation (trial)
Analysis of determinants of effective change
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Research evidence and best practices
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Choice of implementation objectives
Project planning, pilot tests
Tailoring implementation-interventions
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Evidence on professional-orientated
implementation

• Overview of systematic reviews
• Effective Health Care Bulletin (1998). Getting
  evidence into practice. Effective Health Care
  Bulletin, 5(1). London, Royal Society of
  Medicine Press
• Also available from
• http//www.york.ac.uk/inst/crd/ehc51.pdf

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Some other findings

• Large majority was in fact multifaceted
  interventions a large variation of combinations
  was found
• Multifaceted interventions were not consistently
  more effective than single interventions
• Large variation of effect sizes median effect on
  professional performance was 10 absolute
  improvement
• Rigorous evaluations (mainly trials) mostly
  concerned professional orientated interventions

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Organisational interventions (Wensing 2006)

• Review of 36 reviews, published in 1995-2003
• Improved professional performance revision of
  professional roles, increased computer use
• Improved patient outcomes multidisciplinary
  teams, integrated care services, increased
  computer use
• Cost savings integrated care services
• Uncertain benefits quality management

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• BMC Implementation Science
• www.biomedcentral.com

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New interventions

• Revision of professional roles
• Multidisciplinary/-professional collaboration
• Integrated care service/ disease management
• Knowledge management (increased computers use)
• Quality management
• Accreditation/certification
• Performance-based payment
• Patient self-management programmes

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About these interventions

• They change the context in which people work
• They may have impact on a range of issues, not
  just one specific change in patient care
• They may have various aims, such as evidence
  based practice, patient empowerment, saving
  costs, provide more health care, increase
  accessibility to health care, provide career
  perspectives for health professionals, etc.

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Example Structured diabetes care (Ward 2004)

• Retrospective study showed higher quality of
  care in VA medical centres with the following
  characteristics
• Educational programmes to implement guidelines
• Frequent feedback on diabetes quality of care
• Active regional leadership
• Designation of guideline champion
• Timely implementation of changes in patient care
• More effective nurse-doctor communication
• Patient participation in quality improvement

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Environment
Prof 1
Prof 2
Prof 3
Implementation interventions
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Environment
Implementation interventions
Prof 1
Prof 2
Prof 3
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Example ostearthritis

• Individual large scale implementation of
  individual counselling on physical exercise,
  analgesics, and optimal surgeryrevalidation
• Environment better multiprofessional
  collaboration, different financial incentives,
  prompts for patients to use stairs instead of
  elevators, physical exercise programmes for the
  elderly

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Perspectives on implementation in healthcare

• Individual
• Focused on individuals and their social
  interactions
• Targetted at specific behaviours
• Mostly focused on motivation, information and
  education
• Relatively strong body of fundamental research
• No clear perspective on further innovations ?

• Context
• Upstream changes in the environment
• Targetted at conditions for range of behaviours
• Focused on structural, organisational and
  societal factors
• Weak fundamental research (except economics?)
• Promising but yet insufficiently specific

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Conclusions

• Implementation of best evidence in patient care
  is a developing field of practice, policy and
  research
• Professional orientated interventions (education,
  feedback) are needed
• Current focus is on organisational, structural
  and patient-targetted interventions to improve
  health care
• Evaluation is always recommended and requires
  flexible methods and should include local factors
  what works for whom under what circumstances?

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• Many thanks!