Research into Practice – An evidence-based approach to implementing evidence. ACT Health Allied Health Symposium, 2014 Bridging the Gap: Translating Evidence

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 AdvAPDQueensland Health- Health Research Fellow, Maternal Health

Mater Health Services/Mater Research

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

“After decades of improving the health care system, patients

still receive care that is highly variable, frequently

inappropriate, and too often, unsafe” Braithwaite, 2013


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

Acknowledgements:N. Wilcynski & A. McKibbon, Knowledge Translation MLA.ppt - WikispacesACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD

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


DisseminationConscious 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

ImplementationTranslation & application of innovations, recommended

practices or policies. A process of interaction between the setting

of goals & actions geared to achieving them Stickability!

T1 T2

Institute of Medicine, Clinical Research Roundtable Sung, JAMA 2003

T1 T2 T4T3

Discovery to health

application

Health application to

evidence-based practice

guidelines

Practice guidelines to

health practice

Practice to population

health impact

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


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

T2

T3

T3

T4


Knowledge Discovery and Application Processes

Discovery and Production• Ideas 100,000

• RCTs 100

Application and Implementation

• Aware 100%

• Adhered to 20%


Introducing service/care changes

Acknowledgements: Centre for Clinical Effectiveness, Southern Health - Claire Harris

UK Medical Research Council

framework (2000)


•..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


The evidence-practice

gap

Perceived quality problem or emergence of new evidence

The evidence-practice

gap

Perceived quality problem or emergence of new evidence


Implementation improvements

New knowledge, guideline

Perceived problem in healthcare

Is this knowledge applied

in practice?

Is there “evidence” on best practice?

Yes

No

Yes

No

Prevent relapse,

monitor use

Implementation interventions,

evaluation

Experimentation, evaluation

Richard Grol, 2013ACT Health AH Symposium 2014 Dr Shelley Wilkinson AdvAPD

TEAM

APPROACH

including Endocrinologists

Obstetricians

Midwives

Diabetes Educators

Dietitians

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

American Dietetic Association Guidelines

MMH 2009

MMH2010

MMH2011

1 new visit 70.8% 94.7% 92.5%

3 review visits (min) 1 <1% 5.6% 5.3%

2 0 0 0

3 0 0 0

1 postnatal visit 0 0 0

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

1

Diet controlled GDM (2009-2011)

MMH: 20-30%

RCTs: 70-80%

50% ‘unnecessarily’ on medication

evidence-practice

gap

evidence-practice

gap


The evidence practice gap

Perceived quality problem or

emergence of new evidence

Assessment of influencing factors

Design of implementation strategies

Evidence-basedInformed by theory

Optimal care/Behaviour

change

Explicitly evaluating your intervention

using a theory-driven approach


Assessment of influencing factorsDesign of implementation strategies


Assessment of influencing factorsDesign of implementation strategies



I always plan to, but other things take up my time

I don’t have the right equipment

I’d prefer to exercise with others, but people are often doing other things at the time I

want to go

I’d like to do a new sport like rock climbing or kayaking but I don’t know how to get started

priorities

Gyms are expensive

Sustained improvement of patient care…

..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

barrierstheory

intervention

barrierstheory

intervention


Braithwaite, 2011

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

Change strategies: a great variety on the market• 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……..

barrierstheory

intervention

barrierstheory

intervention


If the only tool you have is a hammer, it’s tempting to treat every problem you

have like a nail


Assessment of influencing factorsConsider:1.Who needs to do what, differently?

2.Using a theoretical framework, which barriers and enablers need to be addressed?

3.Which intervention components (behaviour change techniques) and modes of delivery could overcome the modifiable barriers and enhance the enablers?

4.How can behaviour change be measured and understood? (French et al, Implementation Science, 2012, 7:38)

Tools/Readings• Improving Patient Care • NHMRC/NICS Barriers and Enablers tool• Frameworks…including..

• PARIHS framework• TDF (Theoretical Domains Framework)

barrierstheory

intervention

barrierstheory

intervention


Assessment of influencing factors :The TDF

The Theoretical Domains Framework (Cane et al, Implementation Science, 2012, 7:37)

barrierstheory

intervention

barrierstheory

intervention



• Requires a multi-level (theory-based) approach to change• 3 essential conditions are required (Michie et al, Implementation Science, 2011)

barrierstheory

intervention

barrierstheory

intervention



Design of implementation strategiesSOURCES OF BEHAVIOUR – the green hub

barrierstheory

intervention

barrierstheory

intervention

… from the TDF


Design of implementation strategiesINTERVENTION FUNCTIONS – the red circle

barrierstheory

intervention

barrierstheory

intervention

DAA GDM Roadshow 2013 Dr Shelley Wilkinson AdvAPD

Design of implementation strategiesINTERVENTION FUNCTIONS – the red circle

barrierstheory

intervention

barrierstheory

intervention


Design of implementation strategiesPOLICY FUNCTIONS – the grey circle

barrierstheory

intervention

barrierstheory

intervention


Design of implementation strategiesPOLICY FUNCTIONS – the grey circle

barrierstheory

intervention

barrierstheory

intervention


Improving practice: the international evidence

• 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

barrierstheory

intervention

barrierstheory

intervention


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”

EPOC interventions (Effective Practice and Organisation of Care Group – Cochrane)

• Clinical pathways; standardized protocols• Audit and feedback• Local opinion leaders• Local consensus processes• Small group interactive continuous education• Electronic patient management systems

barrierstheory

intervention

barrierstheory

intervention

N trialsN trials Median changeMedian change

Printed education material 23 +4%

Educational materials 56 +6%

Educational outreach visits 34 +5%

Audit and feedback 118 +5%

http://epoc.cochrane.org/epoc-reviews


http://epoc.cochrane.org/epoc-reviews

GDM TRIP

Clinicians (dietitians, O&G, 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 Women’s

engagement, $$, and rooms

Clinical practice measures and patient outcome measures

Step 1: Who needs to do what differently?

Step 2: Using a theoreticalframework, which barriers and

enablers need to be addressed?

Step 3: Which intervention componentscould overcome the modifiable barriers

and enhance the enablers?

Step 4: How will we measurebehaviour change?

barrierstheory

intervention

barrierstheory

interventionAim: To translate GDM model of care appointments in the MMH


barrierstheory

intervention

barrierstheory

intervention



The evidence practice gap

Perceived quality problem or

emergence of new evidence

Assessment of influencing factors



Optimal care/Behaviour

change

Explicitly evaluating your intervention

using a theory-driven approach


Optimal care/Behaviour change

Explicitly evaluating your intervention using a theory-driven

approach


Evaluating the intervention

• Research is different from the real (TRIP) world

• Research = defined boundaries/structures vs real world = messy/complex

• Can’t 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 you’re not re-validating or re-

proving your guidelines!– Economic measures

outcomes(process,clinical)



Process outcomes:Primary: uptake of the new dietetic schedule, as measured by adherence to the NPG appointment scheduleSecondary: 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



GDM TRIPStudy design: 9 months pre/post implementation study


• 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 didn’t 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 don’t guess your barriers• Visit clinic/ward at least once a week for entire project

GDM TRIP: IMPLICATIONS & RELFECTIONS

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

Acknowledgements• NHMRC/NICS

– Fellowship funding, Masterclass training, Slides/images

- Project team @ 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 [email protected]


mailto:[email protected]

Transformation isn’t a matter of intent, it’s a matter of alignment

Peter Fuda

Documents

Research into Practice – An evidence-based approach to implementing evidence. ACT Health Allied Health Symposium, 2014 Bridging the Gap: Translating Evidence