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A public lecture on the Science Art of
Implementing Evidence
Getting a Grip on Guidelines

• Dave Davis, MD, CCFP, FCFP, FRCPC (hon)
• University of Toronto Faculty of Medicine
• Associate Dean, Continuing Education
• Principal Investigator, Knowledge Translation
  Program
• Ontario Guidelines Advisory Committee, Chair

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If you dont like that title

• Translating Guidelines into Practice
• Putting Guidelines in Place
• Using Evidence-based educational principles to
  help clinicians put evidence into practice
• Knowledge Translation
• old concept new tools better effect?

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Vanessa Young, 1985-2000

• Mild eating disorder (early satiety) diagnosed in
  1998, in Oakville, Ontario
• Seen by child psychiatrist and family doc.,
  prescribed cisapride, with excellent results
• 1990 massive drug launch, all the bells
  whistles
• 1992-98 subsequent, sporadic findings of cardiac
  arrhythmias released by drug company bulletins,
  federal warnings (via print materials)
• 2000 Vanessa dies suddenly
• 2001 coroners inquest family doctor especially
  expresses inability to keep up with the
  information overload, like an avalanche

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An outline knowing when to nap

• Definitions
• The Care Gap
• evidence for the gap in care its extent
  nature
• Causes of the gap
• problems with the learner, the message, the
  system
• A Possible Solution
• The creation and best use of guidelines
• the question of translating knowledge into
  practice

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Definitions

• Knowledge translation is the effective and
  timely incorporation of evidence-based
  information into the practices of health
  professionals in such a way as to effect optimal
  health care outcomes and maximize the potential
  of the health system
• Adapted from the Canadian Institutes for Health
  Research definition, 2001

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• Diffusion distribution of information and the
  practitioners natural unaided adoption of
  policies and practices
• Dissemination communication of information to
  clinicians to improve their skills
• Implementation putting a guideline in place,
  involves effective communication, overcomes
  barriers by administrative and educational
  techniques
• (after Lomas)...

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What do CME CPD mean?any all ways by which
physicians learn change AMA 1972
courses
reminders
patient ed
mailed materials, guidelines
outreach visits
peers, consultants
www search
AV aids
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Continuing professional development

• broader than CME, continuing professional
  development permits a consideration of many
  non-clinical topic areas, allows for a broader
  range of methods and settings. Further, it is
  more adult-learner centered.
• Davis, Barnes, Fox, eds., The Continuing
  Professional Development of Physicians, AMA
  Press, 2003

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Information overload
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DEFINITIONS

• Clinical practice guidelines are consensus and/or
  evidence-based statements of care intended to
  provide direction and assist decision-making in
  clinical care for both patients and clinicians..
• Adapted from the Institute of Medicine, 1990

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The clinical care gap
Ideal, evidence-based practice
clinical care gap
Current practice
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WARNING!! this is the interactive part

1. Think about a gap in your practice, setting or
   experience
2. Define it
3. Figure out the why question what are the
   barriers to full implementation of the guideline,
   evidence, whatever
4. (Figure out the how to fix it question)

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Exercise 1

• Identify a clinical gap in practice/health care
  with which youre familiar

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overuse

• Others
• (Ministry of Health, Ontario data, 2001-04)
• Hysterectomies
• Repeat C-Sections
• Modified radical mastectomy in breast CA
• Routine, pre-op chest X-rays, EKGs
• Lumbosacral X-rays for acute low back pain
• Routine q6-12month echocardiograms in stable CHF
  
• ? Sleep studies

• Acute pharyngitis
• Fahey 1998
• Acute Otitis Media
• Delmar 1997
• Acute bronchitis
• 65-80 vs 20
• Gonzales 1997
• ?PSA screening
• ?Mammography for low risk women age 40-50
• Gotzsche, 2000

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Underuse

• Pap Smears Pirkis, 1998
• CHF ACE inhibitors Hickling 2001
• and beta blockers in the elderly McAlister 1999
• Post MI patients
• Lipid lowering Kong, 1998 Aronow, 1998
• ASA
• Beta blockers
• Atrial Fib anticoagulation
• Mendelson, 1999
• Diagnosis of mental disorders
• Craig and Boardman, 1997
• ?Screening for colorectal cancer gt50

• and misuse
• Beta blockers in diabetics, asthmatics
• Tricyclic antidepressants in the presence of
  cardiac arrhythmias
• Cisapride (knowing what we know today)

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Exercise 2

• Describe the causes of the gap

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What causes the gap? The evidence-to-practice
puzzle
The evidence/guideline
The clinician
The educational delivery system

• Health Care
• System issues
• Patient
• Team members

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problems with the learner-clinician

• age, experience, time
• (dis)incentives
• training
• emphasis on knowledge, not knowledge management
• inability to detect needs, evaluate performance
• self-directed learning
• critical appraisal

• type of practice
• competence
• motivation
• too narrow a definition of learner
• learning cycle awareness, agreement, adoption,
  adherence

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No time
No, Thursdays out. How about never-is never good
for you?
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Daves top 10 reasons for not buying into CPGs

• 10) They change all the time
• 9) Guidelines, what guidelines?
• 8) I am too busy to adopt this new stuff
• 7) Patient problems dont fit neatly into those
  little boxes
• 6) They were made in Washington (Ottawa,
  Saskatchewan), wouldnt apply here

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Daves top 10, contd

• 5) I dont trust all this EBM stuff
• 4) There were no family docs (left-handed
  psychiatrists, etc) on the panel
• 3) MY patients expect ME to make decisions!
• 2) I already DO abide by the guidelines, yup,
  yessirree, 100, all the time thats me - Mr.
  Guidelines.....and
• 1) MY patients are different!!

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.problems with the guideline, evidence itself

• compatibility
• complexity
• cost
• relative advantage
• accessibility
• format
• patency of evidence, process of development
• opportunity trial-ability
• Note the AGREE instrument

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Producing disseminating guidelines

• 1) selection of clinical question
• 2) literature searching
• 3) distillation/synopsis of literature
• 4) agreement by consensus, review
• 5) development of statement
• 6) endorsement of statement
• 7) distribution/dissemination

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Information management is like having your mouth
to a firehose David Naylor, Dean, Faculty of
Medicine, University of Toronto 2002 Its pretty
simple, really just review the world literature
every two weeks Sharon Straus, KT program,
University of Toronto Last week
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problems with the Delivery System for CME
CPD does it work?

• Does CME work, Dave?
• All these short courses - do they change how
  physicians practice? Fraser Mustard
• (not the guy in CLUE)
• Dean, Faculty of Health Sciences, McMaster
  University
• July 1977

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Three Reviews of educational interventions

• INCLUSION CRITERIA
• Randomized Controlled Trials
• Replicable, educational interventions meetings,
  feedback, audiotapes, reminders, lectures, etc
• gt50 practicing physicians/professionals
• Objective outcomes of physician performance or
  patient/health care status

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Strategies

• Educational materials
• Formal educational meetings
• Outreach visits
• Local opinion leaders
• Patient mediated strategies
• Audit/feedback

• Reminders
• Mass media
• Combination strategies

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Other overall findings

• Needs Assessment (social marketing) appears to
  be important the more the better (subjective
  needs, objective, gaps and barrier analysis)
• No evidence much about long-term effects
• Enabling materials helpful?

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Others findings (1999 2004)Cochrane Reviews-
Thompson-OBrien, Grimshaw, others

• Most effects pretty much small to moderate at
  best, INCLUDING
• Multiple methods
• Mailed materials
• Reminders still mostly moderate-large effects,
  but few/no long-term studies
• Methodology better understood, but studies often
  very messy, lack details, poorly designed
• And
• Quantitative methodology necessary but not
  sufficient to understand change
• NO common theoretical base mostly kitchen sink
  research

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Reason for the gap 4769 the CME ProcessA
Database of Physician Education
Changewww.cme.utoronto.ca/rdrb

• The Research and Development Resource Base in CME
• educational, clinical health services
  literature
• supported by the
• AMA, ACME, SACME, Royal College of Physicians
  and Surgeons of Canada, the University of Toronto

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Some comments on these reviews.

• COMMENTS
• size/scope/
• nature of field
• What we do doesnt work
• What we dont do does

• CAUTIONS
• publication bias
• screening bias
• reporting gaps
• very narrow, quantitative, EBM-ish RCT bias
• focus of this review - change, not learning
• but.........

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..Exercise 3
Implications

• What are the implications of this gap, and its
  causes, for us as practitioners?

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What guidelines cant do
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A CRITICAL LOOK AT GUIDELINE DEVELOPMENT

• The AGREE instrument
• The Not-all-guidelines-are-equal Guideline

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APPLICABILITY
CLARITY and PRESENTATION
RIGOR OF DEVELOPMENT
EDITORIAL INDEPENDENCE
SCOPE and PURPOSE
www.agreecollaboration.org
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• Scope and purpose
• concerned with the overall aim of the guideline,
  the specific clinical questions and the target
  patient population.
• Item 1. The overall objective(s) of the
  guideline is (are) specifically described
• Item 2. The clinical question(s) covered by the
  guideline is(are) specifically described
• Item 3. The patients to whom the guideline is
  meant to apply are specifically described

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2. Stakeholder involvement focuses on the extent
to which the guideline represents the views of
its intended users. Item 4. The guideline
development group includes individuals from all
relevant professional groups Item 5. The
patients views and preferences have been sought
Item 6. The target users of the guideline are
clearly defined. Item 7. The guideline has been
piloted among target users.
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3. Rigor of development relates to the process
used to gather and synthesize the evidence, the
methods to formulate the recommendations and to
update them.  Item 8. Systematic methods were
used to search for evidence Item 9. The criteria
for selecting the evidence are clearly
described Item 10. The methods used for
formulating the recommendations are clearly
described
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3. Rigor of development (continued)  Item 11.
The health benefits, side effects, and risks
have been considered in formulating the
recommendations Item 12. There is an explicit
link between the recommendations and the
supporting evidence Item 13. The guideline has
been externally reviewed by experts prior to its
publication Item 14. A procedure for updating the
guideline is provided
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4. Clarity and presentation deals with the
language and format of the guideline.  Item 15.
The recommendations are specific and
unambiguous Item 16. The different options for
management of the condition are clearly
presented Item 17. The key recommendations are
easily identifiable Item 18. The guideline is
supported with tools for application
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5. Applicability pertains to the likely
organizational, behavioral and cost implications
of applying the guideline. Item 19. The potential
organisational barriers in applying the
recommendations have been discussed. Item 20. The
possible cost implications of applying the
recommendations have been considered Item 21.
The guideline presents key review criteria for
monitoring and/or audit purposes
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6. Editorial independence concerned with the
independence of the recommendations and
acknowledgement of possible conflict of interest
from the guideline development group. Item 22.
The guideline is editorially independent from
the funding body Item 23. Conflicts of interest
of guideline development members have been
recorded
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Seems simpleSo whats all the fuss?
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The clinical care gap possible
theory-to-practice solutions, probable research
questions
Ideal, evidence-based practice
The information
Interventions
The learner-target
knowledge translation strategies
Current practice
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1) Solving the information problem one
example

• The Guidelines Advisory Committee, Ontario
• Joint body of the Ontario Medical Association and
  the Ministry of Health and Long term Care,
  Ontario
• Chooses a topic area reviews all guidelines in
  that area scores them by the Cluzeau/AGREE
  instrument
• Mounts them on a website
• Quick, 30 second synopsis
• Parallel patient synopsis
• Other links to QA tools, algorithms
• Simultaneous distribution/dissemination/implementa
  tion through medical schools, licensing body,
  professional associations, hospitals, etc
• Other Efforts Skolar, Cochrane, Ovid, Bandolier

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  2) Solving the CME/Intervention Problem a
possible model BMJ 2003
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Solving the learner problem 3 Consumers can
drive change, too why not educate them?
NHS Consumer Health Information Web Site December
2001 5.2 million hits 171,900 visitors (Powell
Clarke, 2002)
Fifty-eight per cent of GPs have been approached
by patients with Internet healthcare information.
Sixty-five per cent of the information presented
by patients was new to GPs. (Wilson, 1999) NOTE
communication skills
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A few final words

• Large body of educational/change literature
  largely unused in guideline implementation
• NO single effective change agent (except maybe
  reminders) multiple methods may work best if
  they include the awareness-to-agreement
  continuum methods work at different levels of
  change - predisposing, enabling reinforcing
• Need to re-conceptualize CME, in order to
  incorporate models of knowledge translation, or
  guideline implementation need to re-think
  targets
• Hope for the future better models, more
  practical tools, information systems,Commonwealth
  initiatives in health, NICS, others, and
• Remember Vanessa

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For more information.
www.ktp.utoronto.ca
www.cme.utoronto.ca
www.gacguidelines.ca