Introduction

1. Nils Chaillet, Ph.D : Département Obstétrique et GynécologieUniversité de Montréal(Alexandre Dumont, MD, PhD ; William Fraser, MD, M.Sc, FRCSC) Knowledge Transfer Experiences in Obstetrics: A Systematic Review of Evidence-based Strategies to effectively change behaviors

2. Introduction • Background • Clinical Practice Guidelines implement best evidence into practice (Evidence based medicine) • The challenge now lies in implementing these guidelines • Strategies for implementing CPGs in Medicine • Ineffective: Mailing and Didactic traditional medical education • Mixed effect: Opinion leader, Audit and Feedback, and Continuous quality improvement • Generally effective: Manual or computerized reminders, Academic detailing, and Multifaceted interventions

3. Introduction • Most common strategies used in obstetric services as a routine activity • Educational activities • Audit activities (Confidential enquiries, Audit and Feedback) • Hypothesis • Key factors of effective strategies in obstetric differs from those of other medical specialties • Objective • To estimate effective strategies for implementing clinical practice guidelines in obstetric care

4. Material and method • Data sources • Cochrane Library, EMBASE, MEDLINE • Reference lists from identified studies and expert suggestions • Identification of studies • MeSH terms: Guideline, Obstetrics, Guideline adherence and Practice guideline • Text words: Relevant strategies for implementing CPGs • Mailing, Education, Audit, Opinion leader, Academic detailing, Quality improvement, Reminder, Multifaceted strategy

5. Material and method • Inclusion criteria • RCT, CCT, CBA, ITS from 1990 to 2005 • Cochrane and EPOC criteria in respect with the design • C-RCT / RCT: Random allocation of units in each group • CCT: Quasi-Random allocation of units in each group • CBA: 2 inclusion criteria • ITS : 4 inclusion criteria • EPOC Quality criteria in respect with the design • C-RCT, RCT, CCT and CBA: 7 quality criteria • ITS: 7 quality criteria • Exclusion criteria • Studies from other than obstetrics specialties • Studies with no clear relation to CPGs implementation • Opinion letters or studies including less than 100 patients • Qualitative studies

6. Material and method • Data extraction • According to Cochrane and EPOC criteria standard Checklist • 2 reviewers independently abstracted specific information from full text studies • Discordances between the 2 reviewers were resolved by consensus • An efficacy qualitative scale was ascribed to each study (Ineffective, Mixed effect and Effective)

7. Study eligibility flow chart

8. Results • Characteristics of included studies (33) • Design • 10 C-RCT, 6 RCT, 1 CBA, 16 ITS (1 081 006 women) • Strategies in obstetric • EDUC: Educational strategies (4) • AF: Audit and feedback (11) • OL: Opinion leader (2) • QUAL: Quality improvement (4) • ACAD: Academic detailing (1) • REM: Reminders (2) • MULTI: Multifaceted strategies (9) • Including combination of the following sub-interventions: EDUC / AF / OL / ACAD / REM

9. Results • Nature of the desired change among the 33 studies • Reduction of cesarean sections (53% of studies) • Management of mild hypertension • Reduction of infections • Promotion of active management of labor • Promotion of VBAC • Reduction of maternal mortality in low-income countries • Reduction of suboptimal cares in low-Apgar babies • Reduction of unnecessary clinical visits • Enhance use of antenatal corticosteroid for fetal maturation • Enhance use of antibiotics • Breastfeeding support • Antenatal corticosteroid use for pulmonary fetal maturation • Reduction of the pregnant smokers’ rates

10. Results • Educational strategies (1 C-RCT, 2 RCT, 1 ITS) • Generally ineffective to directly change physicians or patients behavior (Management of mild hypertension / Verbal patient education to promote VBAC) • Present mixed effects to change nurses behavior (Decrease use of EFM) • Present effective effects to change patients behavior by trained prenatal care providers: nurses, social workers, nutritionists (Reduction of pregnant smoker rate) • Audit and feedback (3 C-RCT, 1 CBA, 7 ITS) • Generally effective In obstetric context to change professional behavior (9 studies) • Key factors • Intensive feedback • Participation of local health professionals in the Audit process

11. Results • Opinion leaders (2 C-RCT) • Ineffective to change patient behaviors (Improvement of breast feeding rates) • Present mixed effects to change physicians behavior (promotion of VBAC to reduce cesarean section, 1991 context) • Key factors • Opinion leader act as a facilitator to improve acceptation of a local intervention • The leadership of the local opinion leader must be assessed • Quality improvement (3 RCT, 1 ITS) • Continuity of midwifery care: generally effective to reduce cesarean section rate • Key factors • Consistent relationship developed between mother and their midwives and obstetrician • Availability of midwives to provide advice and information to women • Active management of labor: seems ineffective to reduce cesarean section rate • Can be effective if the implementation is improved by local initiatives and when the program is locally standardized according to each provider (1 ITS only)

12. Results • Academic detailing in obstetrics (1 C-RCT) • Present mixed effects to change physician’s behaviors (Enhance use of Antibiotics in Cesarean Section, and Steroids in preterm deliveries) • Key factors • An optimal determination of the duration and frequency of visits • Clear description of leadership and roles of senior obstetric staff • Reminders in obstetrics (1 C-RCT, 1 ITS) • Generally effective to change Health professionals and patients behaviors (Reduction of cesarean rates, and reduction of clinic visits in middle income countries context) • Key factors • Reminders developed from CPGs and from prospective studies of the barriers to change • Local staff agreement • Intensive feedback due to the local diffusion of the evidences • Inclusion of local physicians in the study to locally adapt the reminders

13. Results • Multifaceted strategies (2 C-RCT, 1 RCT, 6 ITS) • Generally effective to change Health professionals and patients behaviors (100% of studies are effective) • Identified effective sub-interventions • Educational activities (generally used to improve provider’s knowledge of CPGs and intervention) • Audit and feedback (used to target clinical practices and involving health professionals in the audit process) • Opinion leader (used as facilitator of the program’s implementation) • Academic detailing (used in association with education and opinion leader to promote breast feeding among women) • Reminders (used in association with audit and feedback and developed from the recommendations of the audit process) • Key factors • Prospective study to determine the most adapted sub-interventions • Intensive feedback (ensured by OL or AF by the involvement of local professionals) • Barriers of each strategy are balanced by other strategies involved in the program

14. Conclusion • Efficacy of each strategy in obstetric cares

15. Conclusion • CPGs as evidence based medicine • Sensitize Health professionals • Not sufficient to effectively change behavior • In obstetrics, multifaceted strategy based on a training component, an audit and feedback, and facilitated by an opinion leader seem effective to change health professionals behaviors. • Key factors • Ensure intensive feedback (EDUC + OL) • Involve Health professionals in the audit process • Provide local evidences for reinforcing the effect of CPGs and effectively change behaviors • Use of reminders is also advised to reinforce the audit committee recommendations and feedback