1 / 42

Medical thinking or clinical action ?

Medical thinking or clinical action ?. Dr Jeremy Wyatt FRCP DM Professor of health informatics, University of Dundee, Scotland j.wyatt@chs.dundee.ac.uk Acknowledgements: Prof Susan Michie, UCL. The problem. The NHS costs £80Bn per annum; there are severe workforce pressures

iniko
Télécharger la présentation

Medical thinking or clinical action ?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Medical thinking or clinical action ? Dr Jeremy Wyatt FRCP DM Professor of health informatics, University of Dundee, Scotland j.wyatt@chs.dundee.ac.uk Acknowledgements: Prof Susan Michie, UCL

  2. The problem • The NHS costs £80Bn per annum; there are severe workforce pressures • For some tests and therapies, we know enough about what helps patients to recommend that their use should be reduced or increased • Despite this evidence, there is much geographical variation in clinical practice and patient outcomes How can we narrow the gap between what clinicians know and what they do ?

  3. What evidence do we have ? Source: 2329 therapies reviewed for Clinical Evidence issue 12, 2005

  4. Why medical thinking ? • In the UK in 2006, more prescribers are non-medical than medical: nurses, pharmacists • Patients & carers responsible for key health related decisions: • Are my symptoms serious ? • Who to go to ? • Do I believe them ? • Shall I take this therapy ? • Is it better now ? • Strong pressures toward multi-skilled clinical practitioners, shared decision making, team based care • Clinical, not medical, is what matters

  5. Why clinical thinking ? • Mismatches between what people know, remember, think, decide, intend, say and do • Limited skills, confidence, self efficacy to put decision into action • Pressures from peers, patients, NHS Trusts, NICE… • Action slips • Limited resources to carry out action: staff, time, equipment… Result: gulf between the good intentions resulting from clinical thinking and actual clinical actions

  6. Constraints • Cost of tests, drugs • Health system reality • Society’s values • Lobbying from patients, industry Expert opinions recommendation 2 recommendation 3 Practice guidelines Evidence Practice guideline recommendation 1

  7. provide access use as basis of disseminate Innovation method Library Newsletter participates in searches receives What can we do with guidelines ? Guideline Clinician

  8. Clinical practice innovation Aim: to narrow the gap between what we know and do Synonyms: implementation of research, behaviour change, getting research into practice, change management At least 63 methodsavailable, including: • Paper / computer reminders • Audit and feedback • Patient information leaflets • Decision support systems • Outreach visits • Opinion leaders...

  9. Impact of outreach visits on care given to 4500 pregnant women 25 Eligible obstetric units Follow-up data collection Baseline data collection control units Randomisation • Outreach visit: • Guideline feedback • Discuss EBM, give video, CCPC, train • Discuss innovation methods, give slides outreach units Follow-up data collection CCPC: Cochrane module on pregnancy & childbirth (Wyatt, BMJ 1998)

  10. Recommendation Recommendation Recommendation Innovation method Innovation method Innovation method Control clinicians Control clinicians Control clinicians Innovation clinicians Innovation clinicians Innovation clinicians Difference in practices Difference in practices Difference in practices Difference in outcomes Difference in outcomes Difference in outcomes Summarising evidence on innovation methods Systematic review of innovation studies Evidence about innovation methods

  11. Example: review of manual paper reminders • Definition: reminder, decision support or audit & feedback ? • Finding studies: 324, spread across 101 journals • Study quality: only 22 RCTs of 82 relevant studies of manual reminders • Other issues: • 17 studies from USA (largely fee-for-service) • 3 “positive” studies had unit of analysis errors & 1 showed 2% change - so 10 clinically positive studies • Poor reporting – able to examine only 5 of 10 effect modifiers of interest • Success rate varied by reminder type and targeted clinical practice; need meta-regression (Wyatt et al 2001)

  12. Cochrane EPOC review group Founded 1994 by JW as “Cochrane Collaboration on Behaviour Change” (!) Now “Effective Practice & Organisation of Care” group Base in Canada: Google “Cochrane epoc” Editors: Jeremy Grimshaw, Andy Oxman, Merrick Zwarenstein, Lisa Bero Output: 26 completed reviews, further 17 in progress

  13. How likely are disseminated guidelines etc. to improve clinical practice ?

  14. How likely are lectures to improve practice ? (Davis, JAMA 1999)

  15. How likely are clinical innovation methods to improve practice ?

  16. Low numbers ! How likely are different methods to improve patient outcomes ?

  17. Which clinical practices are easiest to improve ? Davis D. JAMA 1995; 274:700-5

  18. knowledge access, dissemination Clinician knows recommendation motivation, incentives Clinician wants to improve their practice resources, skills, support Clinician able to improve their practice commitment, good memory The gulf between recommendations and outcomes Guideline recommendation Improved clinical practice Improved patient outcome

  19. Not knowing Outreach visit, TM Audit and feedback Not caring No drugs, equipment Provide drugs, equipment Train with opinion leader, TM No skills, support Target peer group, patients Fear of consequences Reminder, decision support Forgetting, action slips Matching innovation methods to barriers Barrier to change Innovation method Guideline recommendation knowledge access, dissemination Clinician knows recommendation motivation, incentives Clinician wants to improve their practice resources, skills, support Clinician able to improve their practice commitment, good memory Improved clinical practice Improved patient outcome

  20. Should we bother with barriers ? Davis D. JAMA 1995; 274:700-5

  21. How long might innovation take ? 100% laggards late adopters Uptake % early adopters innovators 0 Time Rogers EM. The diffusion of innovations. New York Free Press 1993

  22. What might make change more likely ? The change is compatible with participant needs, norms, beliefs The change is relevant to user’s work, provides an advantage for participants Benefits can be easily observed, limited risk The change is simple, can be broken down into steps, has a core with fuzzy boundaries The change can be re-invented locally The change is easy to try out – no infrastructure needed All necessary knowledge or support available (Rogers ’93, Greenhalgh Millbank Q 2005)

  23. Relevant theories 1. PRECEDE (Green L, 1988): • Predispose the person to change • Enable the change • Reinforce the change 2. Theory of planned behaviour (Ajzen I, 1991)

  24. Theory of planned behaviour Human action is guided by three considerations: • Behavioural beliefs about the likely outcomes of the behaviour and evaluations of these outcomes • Normative beliefs about the expectations of others and motivation to comply with these • Control beliefs about factors that may facilitate or impede performance of the behaviour and perceived behavioural control In combination, these lead to intention to perform the behaviour in question Intention assumed to be the immediate antecedent of behaviour. Given a sufficient degree of actual control over the behaviour, people are expected to carry out intentions when the opportunity arises. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211.

  25. Relevant psychological constructs Consensus study of 62 psychologists etc.: • Knowledge • Skills • Professional role and identity • Beliefs about capabilities • Beliefs about consequences • Motivation and goals • Memory, attention and decision processes • Environmental context and resources • Social influences • Emotion • Action plans • Nature of the behaviour Michie S, Johnston M, et al (2005) Making psychological theory useful for implementing evidence based practice: a consensus approach, Quality and Safety in Health Care, 14, 26-33

  26. Wording of recommendations The challenge is to ensure: • Comprehension – understanding what needs be done • Recall – remembering what to do in the relevant context • Planning of this behaviour • Performance of behaviour Specificity of instructions is associated with attaining goals (Locke and Latham, 1990), so specify: • Who should do • What • How • Where, and • When Use “if-then" plans and active verbs (do) Avoid general exhortations (should), passive descriptions (may) Michie, S. and Johnston, M. Changing clinical behaviour by making guidelines specific. BMJ2004, 328: 343–5

  27. Evidence about specific recommendation wording Grol’s study: 61 GPs & 47 recommendations from 10 national Dutch clinical guidelines GPs followed recommendations: • on 2/3 of occasions when it was concrete and specific • on 1/3 of occasions when it was vague and non-specific NB. Specificity accounted for only 17% of the variance Grol et al. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998, 317:858-61

  28. Some research issues Barriers to change: • Are the methods to elicit them reliable, valid ? • Are some barriers more important than others ? • Are barriers generic, or must we always tailor innovation ? Practice innovation methods: • Is there evidence to match methods to barriers ? • How can psychological theory help in designing methods ? • Are some innovation methods more effective in specific: • combinations ? • clinical practices or settings ? • professional groups ? General: • Can we develop a valid “intention to implement” scale ? • Can an “innovation toolkit” & web site help clinicians change ?

  29. Make the change UCL KMC clinical practice innovation model No Loop A Is innovation needed ? Choose a clinical practice recommendation Audit local practice Identify & engage all participants Yes Analyse barriers to change Loop B Wait for a while Select & apply innovation method(s)

  30. Examples of participants GP prescribing: GPs, patients, pharmacists, nursing home staff… Lab test ordering: junior doctors, senior doctors, medical schools, lab staff, patients, phlebotomists… Cardiovascular risk reduction: patients, friends, relatives, manager of workplace / private gym / pub, local council, regional government, food industry…

  31. Some practical conclusions 1. Guidelines do not themselves change practice 2. An innovation programme is needed: • Choose a clinical practice from the guideline that really does improve (or worsen) patient outcomes • Obtain high-level support for an innovation programme 3. Implement the programme: • Carry out a careful local audit • Identify all participants (including opinion leaders) • Search for barriers to change • Select appropriate innovation method(s) • Monitor progress; consider a rigorous trial • Collaboration with psychologists, management scientists & ethnographers is likely to be useful

  32. Some research questions • How to use psychological theory to design and evaluate innovation methods ? • Do different theories apply to increasing and decreasing actions ? • Are barriers generic and enduring or person and episode specific ? • How to validate theories eg. functional imaging • How much clinical variation depends on individual cognition vs. team dynamics / environment ?

  33. Does diagnosis matter ? • At least 1/3 of encounters associated with long term illness – diagnosis made years ago • Most advances in 20th century associated with quicker, more accurate diagnostic tests • Challenging diagnoses rare in routine clinical practice • Challenges for health services are: • which test in what order • assembling patient data from multiple sources • test interpretation • monitoring of long term illness • improving teamwork (work force) • shifting services closer to home – self testing

  34. One innovation method, or many ? a) Indirect, between-study comparison (Davis, 1995): b) Direct, within-study comparisons (Wensing, 1994): Multi-part interventions led to a larger effect in general practice than a single intervention in 4 / 10 RCTs

  35. How long does the impact last ? • Few RCTs follow-up after audit & feedback stop: • 3 months: both groups improved test usage (Martin A ‘80) • 12 months: generic prescribing declined, but still better than control group (Gehlbach ‘84) • 14 months: improved management of cystitis (Norton P ‘85) • Conclusion:“There is insufficient data to clarify when the effects are most likely to deteriorate after feedback stops” Thomson O’Brien. CL 1999

  36. How much does innovation cost and save ? • Cost of outreach visit: 1400 euro (1995 prices; Wyatt BMJ ‘98) • Cost to deliver paper reminders (Wyatt unpub.): • measured in 4 studies • ranged from 10c to 75 euro per patient • cost one sixth of the cost of pt. invitation letters for cervical screening • Savings from paper reminders: • cut inflation in asthma treatment costs to one third • saved 1100 euro per inpatient (earlier discharge)

  37. What might help guidelines succeed ? Opinionsurvey of 1500 US internists - features they claim would cause them to comply (Hayward JGIM ‘96): • Guidelines as short pamphlet: 86% in favour • Summary of supporting evidence: 85% • Benefits quantified: 77% • Endorsed by respected colleague (72%) or major organisation (69%) Study of actual practice - guidelinefeatures & actual use by 61 Dutch GPs (12 features, 12900 decisions - Grol BMJ ‘98): • Positive correlation: recommendation was specific, uncontroversial, required no change in existing routine • However, these accounted for only 17% of the variance

  38. Systematic reviews of innovation studies Special problems: • Innovation methods poorly defined, indexed, reported • Studies heterogeneous: different clinicians, settings, practices... • Few direct comparisons within the same study • Study designs poor, with bias and confounding (co-interventions, Hawthorne Effect, contamination…) • Multiple measures of clinical practice - often subjective • Consequences: • Hard to identify studies, few studies eligible • Qualitative review (vote counting) usually more appropriate than quantitative (meta-analysis) • Meta regression rarely possible: too many variables, too few studies

  39. From knowledge to outcome Forgetting External knowledge Perception Internalised knowledge Peer pressure Distraction Motivation Perceived self efficacy Clinical decision Framing effects Cognitive biases Action slips Action Patient concordance Opportunity Improved patient outcome Tacit knowledge and skills

More Related