Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

1. Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn Implementing Clinical Prediction Rules in primary care: evidence, challenges and possible solutions Tom Fahey

2. Outline of talk • Background • Evidence concerning implementation of CPRs • Barriers to implementation • Solutions to implementation • Cochrane Register of CPRs in primary care • Computer based clinical decision support systems (CDSSs)

3. (1) Background • Definitions • Stages of development • Implementation

4. Definitions • Clinical Prediction Rule • Clinical tools that quantify the contribution of • Patient History • Physical Examination • Diagnostic Tests • Stratify patients diagnosis • Probability of having target disorder. • Outcome can be in terms of diagnosis, prognosis, referral or treatment

5. Example of a CPR: The Centor Score

6. (2) Evidence concerning implementation of CPRs

7. Stages of development of CPR

8. Impact analysis studies • Some clinical examples • Evidence base • Issues that need to be considered

9. CPR pigmented skin lesions

10. Canadian C-spine Rule

11. CPR for deep venous thrombosis (DVT)

12. Chest pain triage CPR

13. Ottawa ankle rule

14. Primary prevention of Cardiovascular disease

15. Implementation studies- stage 3 (level 1 evidence)

16. Issues that arise from Implementation studies

17. (3) Barriers to implementation • Cognitive process in relation to diagnosis/prognosis • Challenges

18. Diagnostic stages & strategies .

19. Focussed clinical assessment

20. Strategies used for refining diagnosis

21. CPRs in diagnostic process • One of several “refinement” techniques • Not always appropriate to use in terms of clinical context • Not always available

22. Barriers to implementation • Cognitive process in relation to diagnosis/prognosis • Challenges

23. Challenges to Implementation Knowledge Attitudes Behaviour Sources of Behaviour Change • External Barriers • Lack of time • Resources • GP Software companies • Poor integration into workflow • Lack of agreement • Uncertain application • Unclear applicability • Lack of familiarity • Time Investment • Inadequate infrastructure Barriers to Innovation Adapted from Lang et al.2007

24. (4) Solutions to implementation • Cochrane register of CPRs in primary care • Implementation of CPRs with computer-based clinical decision support systems

27. Work package #2 • Develop a web-based register of CPRs for use in primary care

28. Problems with developing and maintaining the register • Problems associated with developing and maintaining the register • Interchangeable terminology for CPRs • No Medical Subject Heading (MeSH) term for CPRs • Over two million articles are published every year

29. Problems with developing and maintaining the register Haynes and the Hedges Team have developed search tools to identify CPRs.

30. 30 journals included on the register

31. Search filter for CPRs in primary care • Manually searched 30 journals relevant to primary care for the year 2008 (‘reference standard’) • 7 individual electronic searches of the 30 journals (each filter treated as ‘diagnostic tests’) • Test accuracy analysis: Sensitivity and specificity • Aim: to maximise sensitivity

33. Results Manual ‘reference standard’ search retrieved 6344 articles, 41 of which were CPRs

34. MEDLINE versus the final search filter applied to 30 primary care journals (1966 – 2008) Number of articles in PubMEd Year of publication

35. Creating the International Register 2008-1980 resulted in 252 CPRs relevant to primary care * Still awaiting inter-library loans

36. Clinical Domains – ICPC2Percentage articles retrieved for each clinical domain % %

37. Clinical Domains – ICPC2Respiratory System

38. Quality assessmentCPRs (derivation), 2008, n=18

39. Quality assessmentCPRs (validation), 2008, n=20

40. Electronic CPR Register International electronic register of CPRs Searchable electronic resource Web based user friendly access Manage and maintain register

41. Registry 1 2 3 4 5 6

42. Ongoing Work Register

43. Register of CPRs- current status • Identified the search filter with the highest level of sensitivity to search the MEDLINE database using the PubMed interface • Significant reduction in the items to be searched • Approximately 252 CPRs across several clinical domains (2008-1980) • Still awaiting inter-library loans • Further resources are being searched as part of ongoing work

44. Solutions to implementation • Cochrane register of CPRs in primary care • Implementation of CPRs with computer-based clinical decision support systems (CDSSs)

45. Implementation of evidence

50. Clinical decision support system Clinical decision support system (CDSS) Systems that are designed to improve clinical decision making Key points Integrated with the electronic patient record Available at the point of care Computerised knowledge base Provide patient-specific content