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Title: Research into Practice


1
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 AdvAPD
  • Queensland Health- Health Research Fellow,
    Maternal Health
  • Mater Health Services/Mater Research

2
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
3
  • 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
4
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

AcknowledgementsN. Wilcynski A. McKibbon,
Knowledge Translation MLA.ppt - Wikispaces
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
5
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

AcknowledgementsN. Wilcynski A. McKibbon,
Knowledge Translation MLA.ppt - Wikispaces
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
6
  • Implementation
  • Translation application of innovations,
    recommended practices or policies. A process of
    interaction between the setting of goals
    actions geared to achieving them

Stickability!
  • Dissemination
  • Conscious 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
7
T1
T2
T4
T1
T2
T3
Health application to evidence-based practice
guidelines
Discovery to health application
Practice to population health impact
Practice guidelines to health practice
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
  • Institute of Medicine, Clinical Research
    Roundtable Sung, JAMA 2003

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
8
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
T3
T4
T2
T3
AcknowledgementsN. Wilcynski A. McKibbon,
Knowledge Translation MLA.ppt - Wikispaces
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
9
Knowledge Discovery and Application Processes
  • Discovery and Production
  • Ideas 100,000
  • RCTs 100
  • Application and Implementation
  • Aware 100
  • Adhered to 20

AcknowledgementsN. Wilcynski A. McKibbon,
Knowledge Translation MLA.ppt - Wikispaces
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
10
Introducing service/care changes
UK Medical Research Council framework (2000)
Acknowledgements Centre for Clinical
Effectiveness, Southern Health - Claire Harris
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
11
  • ..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
12
The evidence- practice gap Perceived quality
problem or emergence of new evidence
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
13
Implementation improvements
Prevent relapse, monitor use
Yes
New knowledge, guideline
Is this knowledge applied in practice?
No
Implementation interventions, evaluation
Yes
Perceived problem in healthcare
Is there evidence on best practice?
Experimentation, evaluation
No
Richard Grol, 2013
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
14
evidence- practice gap
  • 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
  • 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

TEAM APPROACH including Endocrinologists Obst
etricians Midwives Diabetes Educators
Dietitians
1
Personal costs/savings Clinical costs
costs/savings Health system costs/savings Public
health costs/savings
American Dietetic Association Guidelines MMH 2009 MMH 2010 MMH 2011
1 new visit 70.8 94.7 92.5
3 review visits (min) 1 lt1 5.6 5.3
2 0 0 0
3 0 0 0
1 postnatal visit 0 0 0
Diet controlled GDM (2009-2011) MMH 20-30 RCTs
70-80 50 unnecessarily on medication
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
15
Assessment of influencing factors Design of
implementation strategies Evidence-based Informe
d by theory
Optimal care/ Behaviour change Explicitly
evaluating your intervention using a
theory-driven approach
The evidence practice gap Perceived quality
problem or emergence of new evidence
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
16
Assessment of influencing factors Design of
implementation strategies Evidence-based Informe
d by theory
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
17
I always plan to, but other things take up my
time
I dont have the right equipment
Id like to do a new sport like rock climbing or
kayaking but I dont know how to get started
priorities
Gyms are expensive
Id prefer to exercise with others, but people
are often doing other things at the time I want
to go
18
Sustained improvement of patient care
barriers theory intervention
  • ..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
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
19
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
Braithwaite, 2011
20
Change strategies a great variety on the market
barriers theory intervention
  • 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..

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
21
If the only tool you have is a hammer, its
tempting to treat every problem you have like a
nail
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
22
Assessment of influencing factors
barriers theory intervention
  • Consider
  • Who needs to do what, differently?
  • Using a theoretical framework, which barriers and
    enablers need to be addressed?
  • Which intervention components (behaviour change
    techniques) and modes of delivery could overcome
    the modifiable barriers and enhance the enablers?
  • How can behaviour change be measured and
    understood?
  • (French et al, Implementation Science, 2012,
    738)
  • Tools/Readings
  • Improving Patient Care
  • NHMRC/NICS Barriers and Enablers tool
  • Frameworksincluding..
  • PARIHS framework
  • TDF (Theoretical Domains Framework)

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
23
Assessment of influencing factors The TDF
barriers theory intervention
  • The Theoretical Domains Framework
    (Cane et al, Implementation Science, 2012,
    737)

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
24
Design of implementation strategies
barriers theory intervention
  • Requires a multi-level (theory-based) approach to
    change
  • 3 essential conditions are required (Michie et
    al, Implementation Science, 2011)

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
25
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
26
Design of implementation strategies
barriers theory intervention
  • SOURCES OF BEHAVIOUR the green hub

from the TDF
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
27
Design of implementation strategies
barriers theory intervention
  • INTERVENTION FUNCTIONS the red circle

DAA GDM Roadshow 2013 Dr Shelley Wilkinson
AdvAPD
28
Design of implementation strategies
barriers theory intervention
  • INTERVENTION FUNCTIONS the red circle

DAA GDM Roadshow 2013 Dr Shelley Wilkinson
AdvAPD
29
Design of implementation strategies
barriers theory intervention
  • POLICY FUNCTIONS the grey circle

DAA GDM Roadshow 2013 Dr Shelley Wilkinson
AdvAPD
30
Design of implementation strategies
barriers theory intervention
  • POLICY FUNCTIONS the grey circle

DAA GDM Roadshow 2013 Dr Shelley Wilkinson
AdvAPD
31
Improving practice the international evidence
barriers theory intervention
  • 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

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
32
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

33
EPOC interventions (Effective Practice and
Organisation of Care Group Cochrane)
barriers theory intervention
  • Clinical pathways standardized protocols
  • Audit and feedback
  • Local opinion leaders
  • Local consensus processes
  • Small group interactive continuous education
  • Electronic patient management systems

http//epoc.cochrane.org/epoc-reviews
N trials Median change
Printed education material 23 4
Educational materials 56 6
Educational outreach visits 34 5
Audit and feedback 118 5
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
34
GDM TRIP
barriers theory intervention
Aim To translate GDM model of care appointments
in the MMH
Clinicians (dietitians, OG, 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 Womens engagement, , and rooms
Clinical practice measures and patient outcome
measures
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
35
barriers theory intervention
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
36
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
37
Assessment of influencing factors Design of
implementation strategies Evidence-based Informe
d by theory
Optimal care/ Behaviour change Explicitly
evaluating your intervention using a
theory-driven approach
The evidence practice gap Perceived quality
problem or emergence of new evidence
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
38
Optimal care/ Behaviour change Explicitly
evaluating your intervention using a
theory-driven approach
ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
39
Evaluating the intervention
outcomes (process, clinical)
  • Research is different from the real (TRIP) world
  • Research defined boundaries/structures vs real
    world messy/complex
  • Cant 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
    youre not re-validating or re-proving your
    guidelines!
  • Economic measures

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
40
GDM TRIP
outcomes (process, clinical)
Study design 9 months pre/post implementation
study
  • Process outcomes
  • Primary uptake of the new dietetic schedule, as
    measured by adherence to the NPG appointment
    schedule
  • Secondary 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

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
41
GDM TRIP IMPLICATIONS RELFECTIONS
  • 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 didnt 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 dont guess your barriers
  • Visit clinic/ward at least once a week for entire
    project

42
Where to next?
  • Dissemination
  • Scaling up and rolling out
  • Sustainability
  • 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

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
43
(No Transcript)
44
Acknowledgements
  • NHMRC/NICS
  • Fellowship funding, Masterclass training,
    Slides/images
  • Project team _at_ 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
  • shelley.wilkinson_at_mater.org
    .au

ACT Health AH Symposium 2014 Dr Shelley
Wilkinson AdvAPD
45
  • Transformation isnt a matter of intent, its a
    matter of alignment
  • Peter Fuda
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