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
IDENTIFYINGANDOVERCOMINGBARRIERSTOGUIDELINEIMPLEMENTATION
ProfessorEKYeoh Director,JCSchoolofPublicHealthandPrimaryCare FacultyofMedicine,TheChineseUniversityofHongKong
KDIGO
GuidelineAdoptionandUse• Systematicreviewofstudiesofguidelineusefoundadoptionandadherencewaslowevenwhenawarenessofandagreementswiththeguidelinesamongtargetuserswashigh
• Contextualfactorswhichinfluenceanddetermineguidelineadoptionanduse:
• atlevelsof• Professional • Patient • Institutional • System
2MickanSetal(2011)PostgradMedJ
KDIGO
DeterminantsofHealthcarePractices:BarriersandFacilitators
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• Guidelinefactors• Healthprofessionalfactors• Patientfactors• Incentivesandresources• Capacityfororganizationalchange• Social,politicalandlegalfactors
FlottorpSAetal(2013)ImplementationScience
KDIGO
MethodstoIdentifyDeterminantsofHealthcarePractices:BarriersandFacilitators
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• Brainstorming• Focusgroup• Performancedataanalysis• Observations• Interviews• Questionnaires
KDIGO
IdentifyingDeterminantsofCareforTailoringImplementationinChronicDiseases:anevaluationofdifferentmethods
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Methods:• Studyin5Europeancountries,recommendationsforadifferentchronicconditionineachcountry.
• Methodscompareddirectly:brainstormingamongsthealthprofessionals,interviewsofhealthprofessionals,andinterviewsofpatients.
• Additionalvalueofdiscussionstructuredthroughreferencetoachecklistofdeterminantsinadditiontobrainstorming,anddeterminantsidentifiedbyopenquestionsinaquestionnairesurvey,investigatedseparately
KrauseJetal(2014)ImplementationScience
KDIGO
IdentifyingDeterminantsofCareforTailoringImplementationinChronicDiseases:anevaluationofdifferentmethods
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Results:• 601determinantsjudgedtobeplausiblyimportantwereidentified.• 609determinantswerejudgedunlikelytoinformanimplementationintervention,andclassifiedasnotplausiblyimportant.
• Brainstormingidentified194ofplausiblyimportantdeterminants,healthprofessionalinterviews152,patientinterviews63,openquestion48.
• Groupdiscussionidentified144plausiblyimportantdeterminantsinadditiontothoseidentifiedbybrainstorming
KrauseJetal(2014)ImplementationScience
KDIGO
IdentifyingDeterminantsofCareforTailoringImplementationinChronicDiseases:anevaluationofdifferentmethods
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Conclusions:• Systematicmethodscanleadidentificationoflargenumbersofdeterminants.• Tailoringincludeaprocesstodecidethosetobeaddressedbyimplementationinterventions.
• Toidentifydeterminants,combinationshouldbeused.• Brainstormingasasimple,lowcostmethodrelevanttomanytailoredimplementationprojects
KrauseJetal(2014)ImplementationScience
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
1. Guidelinefactors2. Individualhealthprofessionalfactors3. Patientfactors4. Professionalinteractions5. Incentivesandresources6. Capacityfororganizationalchange7. Social,politicalandlegalfactors
7DomainsofFactorsintheIntegratedChecklistofDeterminantsofPractice(TICDChecklist)
FlottorpSAetal(2013)ImplementationScience 11
KDIGO
ChecklistforaSuccessfulGuidelineEnterprise1. Organization,budget,planningandtraining2. Prioritysetting3. Guidelinegroupmembership4. Establishingguidelinegroupprocesses5. Identifyingtargetaudienceandtopicselection6. Consumerandstakeholderinvolvement7. Conflict-of-interestconsideration8. Questiongeneration9. Consideringtheimportanceofoutcomesandinterventions,values,preferences
andutilities10. Decidingwhatevidencetoincludeandsearchingforevidence
HJSchunemannetal(2014)CMAJ 12
KDIGO
ChecklistforaSuccessfulGuidelineEnterprise(con’t)
11. Summerizingevidenceandconsideringadditionalinformation12. Judgingquality,strengthorcertaintyofabodyofevidence13. Developingrecommendationsanddeterminingtheirstrength14. Wordingofrecommendationsandofconsiderationsofimplementation,feasibility
andquality15. Reportingandpeerreview16. Disseminationandimplementation17. Evaluationanduse18. UpdatingHJSchunemannetal(2014)CMAJ 13
KDIGO
GuidelineImplementability
• Contentandformatofguidelinesthatfacilitatetheiradoption
• Cochranesystematicreview*confirmedguidelineimplementationtools(GItools)developedanddisseminatedwithguidelinesinfluencedclinicalbehaviourandpatientoutcomes
• Systematicreviewsshowimplementationtools:guidelinesummaries,algorithms,point-of-carechecklists,healthstatusremindersenhancedcompliancewithguidelinerecommendations
14*Flodgrenetal(2016)
KDIGO
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
KDIGO
Guidelinecharacteristics• Totalof126guidelinespublishedfromFeb2010toMarch2017
NumberandTypeofGuidelineImplementationTools
LLiangetal(2017)ImplementationScience 16
KDIGO
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
KDIGO
TailoredInterventionstoOvercomeIdentifiedBarrierstoChange:EffectsonProfessionalPracticeandHealthCareOutcomes
RBakeretal(2014)CochraneDatabaseSystRev 18
Objective:theeffectivenessofinterventionstailoredtoaddressidentifiedbarriersto,changeonprofessionalpracticeorpatientoutcome
Selectioncriteria:randomisedcontrolledtrials(RCTs)ofinterventionstailoredtoaddressprospectivelyidentifiedbarrierstochangethatreportedobjectivelymeasuredprofessionalpractice
Mainresults:26studiescomparinganinterventiontailoredtoaddressidentifiedbarrierstochangetonointerventionorintervention(s)nottailoredtothebarriers
Authors’conclusion:interventionstailoredtoprospectivelyidentifiedbarriersaremorelikelytoimproveprofessionalpracticethannointerventionordisseminationofguidelines
KDIGO
Patient-mediatedInterventionstoImproveProfessionalPractice:Cochranesystematicreview
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Patient-mediatedinterventions“anyinterventionaimedatchangingtheperformanceof
healthcareprofessionalsthroughinteractionswithpatients,orinformationprovidedbyortopatients”
FønhusMSSAetal(2018)ScienceDirect
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
TheoreticalDomainsFrameworkofBehaviourChangetoInvestigateImplementationProblems
23AtkinsLetal(2017)ImplementationScience
TheoreticalDomainsFramework(TDF) • Developedforimplementationresearchtoidentifyinfluencesonhealthprofessionalbehaviorrelatedtoimplementationofevidence-basedrecommendations
• Integratedtheoreticalframeworksynthesizedfrom128theoreticalconstructsfrom33theoriesjudgedmostrelevanttoimplementationquestions
KDIGO
TheoreticalDomainsFramework
24AtkinsLetal(2017)ImplementationScience
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
KDIGO
ImprovingOutcomeswithGuidelines
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• Development• Implementability• Implementation• Adoption,adherenceanduse• Evaluation• Sustainability
KDIGO
SustainabilityofGuidelinesUseandImpact
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� Determinants• Designandcharacteristics
• Organisationalcontextandfactors
• Socio-economicandpoliticalenvironmentandfactors
� Sustainabilityasinstitutionalisationandroutinisationintoorganisationalsystems
KDIGO
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ThankyouKDIGO