Sifting Through the Translational Toolbox

1. Sifting Through theTranslational Toolbox Ralph Gonzales, MD, MSPH Professor of Medicine; Epidemiology & Biostatistics 1 October 2009

2. OUTLINE • Classifying Tools • 3 Dimensions • Exemplars • Community Engagement:Public Health • Internet Decision Support:Patients • Financial Incentives:Clinicians • Case Study • Pot Pourri • Readings • Homeworks • Office Hours

4. ENVIRONMENT PREDISPOSING REINFORCING ENABLING Pre- Contemplation Contemplation Behavioral Intention Preparation Action Maintenance Beliefs Attitudes Social Norms Self -Efficacy Theory of Planned Behavior Motivation and Persuasion

5. Predisposing, • Reinforcing, & • Enabling • Constructs in • Educational/Ecological • Diagnosis & • Evaluation • Policy, • Regulatory & • Organizational • Constructs in • Educational & • Environmental • Development Phase 3 Educational & ecological assessment Predisposing Phase 1 Social assessment Reinforcing Quality of life Health Enabling PRECEDE-PROCEED Phase 2 Epidemiological Assessment Phase 4a Intervention Alignment Health Program Genetics Phase 4b Educational strategies Administrative & policy assessment Behavior Policy regulation organization Environment Phase 7 Impact & Outcome evaluation Phase 5 Implementation Phase 6 Process evaluation Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.

6. Tool Dimension #1 TYPE • Predisposing Factors (what and why you should do it) • Awareness; Education; Guidelines • Reinforcing Factors (make you want to do) • Feedback; Incentives; Penalties; Reminders; Opinion Leaders; Social Marketing • Enabling Factors (make it easy to do) • Decision support; Skills-building; CPOE; Prior Authorization; Laws & Regulations; Registries

8. Tool Dimension #2 IMPLEMENTATION; MODE OF DELIVERY -Example: Education • Brochures; Computerized; Video; Mass Media; In-Person -Example: Decision support • Computerized; HealthCoach; Action Plans; Telephone Advice Nurse -Example: Laws and regulations • Federal/state laws; work-place regulations; school regulations; licensing

9. Tool Dimension #3: Behavior Change Target STAKEHOLDERS * Government Payors Prof. Societies Academia * COMMUNITY Health Care Delivery Systems EVIDENCE * Providers Patients Public * PRACTICE HEALTH

10. Community Health fairs Mass media Conditional payments Taxes Advice lines Support groups The Translational Toolbox-individual behavior change tools • Patient • Education • Printed • Computer • Internet • Video/multi-media • Copayments • P4P • Motivational interviewing • Decision Aids • Disease management • Coaches • Action plans • Physician • Education • CME • Detailing • Guidelines • Audit & feedback • P4P • Prior Auth’n • Decision support • Registries Key Predisposing Reinforcing Enablement

11. Public Behavior Change-Manandhar DS et al. Lancet 2004;364:970-79 Background • In India, neonatal mortality now accounts for up to 70% of infant mortality. Most perinatal and neonatal deaths happen at home, and many could be avoided with changes in antenatal, delivery, and newborn care practices. • However, primary and secondary health-care systems have difficulties in reaching poor rural residents, and a potentially effective perinatal health strategy must recognise this reality. In Makwanpur district, Nepal, for example, 90% of women give birth at home, and trained attendance at delivery is uncommon . • Previous Research: Warmi Project and SEARCH Project

12. Public Behavior Change-Manandhar DS et al. Lancet 2004;364:970-79 Problem and Intervention What is the evidence being translated? What is the quality gap? Is the quality gap linked to the outcome gap? Tool Type: Tool Implementation: Behavior Change Target:

13. Results

14. Public Behavior Change Tools Predisposing • Health Fairs • Mass Media • Outreach • Health Coaches Reinforcing • Reminders • Opinion Leaders • Conditional Payments • Co-Payments Enabling • Built Environment

15. Patient Behavior Change-van de Meer V et al. Ann Intern Med 2009;151:110-120 Background • With appropriate medical care, well-informed and empowered patients can control their asthma and live full, active lives. However, despite the availability of monitoring tools and effective therapy, asthma control is suboptimal in many patients worldwide, and long-term management falls far short of the goals set in the guidelines • Self-monitoring, education, and specific medical care are important aspects in improving the lives of patients with asthma . However, many patients with mild or moderate persistent asthma do not attend checkups regularly or visit their physician with symptoms of the disease . In addition, in practice, both patients and their health care providers are reluctant to use written self-management plans. • Internet technology is increasingly seen as an appealing tool to support self-management for patients with chronic disease in remote and underserved populations

16. Patient Behavior Change -van de Meer V et al. Ann Intern Med 2009;151:110-120 Problem and Intervention What is the evidence? What is the quality gap? Is the quality gap linked to the outcome gap? Tool Type: Tool Implementation: Behavior Change Target:

21. Patient Decision Aids“Informed Decision Making”

22. Patient Decision Aid SpecsO’Connor AM et al. Cochrane Reviews 2003 • What is it? • An adjunct to counseling that • explains options • clarifies personal values for the benefits vs. harms • guides patients in deliberation and communication • Decision Quality • Decisions are informed (knowledge; risk perception) • Decisions based on personal values (congruence)’ • Most common conditions… most are web-based: • Breast, prostate and colon cancer screening & treatment • Menopause options • Cardiovascular disease management • Prenatal testing

23. Patient Decision Aid SpecsO’Connor AM et al. Cochrane Review 2003 • Cost: development… low-medium—person-hours • Feasibility: very feasible • Complexity: potential for high complexity • Summary of evidence: • Most RCTs measured process/intermediate outcomes (knowledge; realistic expectations; decisional conflict) • Main effects are on knowledge and realistic expectations, with OR about 1.4-1.6. • Reductions in decisional conflict appear modest • 5/9 studies showed improvement in satisfaction with decision • Ideal uses • Target behaviors: health care decisions that depend on patient preferences for harms/benefits of different options • Target barriers: poor patient knowledge;doctors too busy; low priority problem • Conclusion: useful in selected circumstances

24. Patient Behavior Change Tools Predisposing • Patient education Reinforcing • Reminders • Coaches Enabling • Decision support • Action plans

25. Clinician Behavior Change-Campbell SM et al. N Engl J Med 2009;361:368-78 Background • In 2004, the U.K. government introduced a pay-for-performance scheme with 136 indicators for family practices. • Payments make up approximately 25% of family practitioners’ income, and 99.6% of family practitioners participated in the pay-for-performance scheme, which is voluntary.

26. Clinician Behavior Change-Campbell SM et al. N Engl J Med 2009;361:368-78 Problem and Intervention What is the evidence? What is the quality gap? Is the quality gap linked to the outcome gap? Tool Type: Tool Implementation: Behavior Change Target:

27. Results

28. Clinician Behavior Change Tools Predisposing • Guidelines • CME Reinforcing • Opinion Leaders • Financial Incentives • Penalties Enabling • Decision support • Teams

29. Practice Guidelines • The Beginning: AHCPR Guidelines • Currently: Produced by professional societies, governmental agencies, expert panels • Evidence-based frameworks • Recommended behaviors implicit or explicit • Conclusion: necessary, but not sufficient • Relate back to transtheoretical model, or cognitive theory (knowledge/awareness must be present before action)

30. Practice Guideline Specs • What is it? • Cost: person-hours • Feasibility: buy-in; participation • Complexity: varies • Summary of evidence ineffective in isolation • Ideal uses • Target behaviors single, simple actions • Target barriers knowledge/attitudes • Conclusion: it’s all about ‘implementation’

31. Practice Guidelines seem to be most effective… • for acute care conditions • when quality of evidence is superior • when compatible with existing values • when decision making complexity is low • when desired performance/behavior is clearly understood • when new skills or organizational support is not necessary for behavior change

32. The influence of intervention strategy and organisational factors on practice guideline effectiveness. Adapted from BMC Health Services Research 2006;6:53 SETTING Inpatient Outpatient INTERVENTION Educational Meeting Educational Material Consensus Meeting Reminders Feedback Patient-Mediated Outreach Opinion Leader Revision of Prof Roles Financial Organisational OUTCOMES -behavioral -clinical ORGANISATIONAL EFFECT MODIFIERS Leadership (Management Support) Learning Environment (Academic) Physician Type and Specialty Local Consensus (Development)

33. Effectiveness of Specific Intervention Components BMC Health Services Research 2006;6:53

34. SUMMARYCPG Interventions • Development • identify clinician knowledge and behavior gaps • identify barriers to change • evidence-based “best practice” • quantify benefit of CPG compliance on system, practice and patient • local input & endorsement • Implementation • opinion leader; clinical champion • point-of-service reminders • feedback/profiling

35. CASE STUDY:IMPAACT Trial • Emegency Department Intervention: • Provider education (practice guidelines) delivered by local opinion leaders • Group audit and feedback • Patient education • Sites provided individualized adaptation of components

36. IMPAACT Intervention Sites Lincoln Medical Center Bronx VAMC Northwestern Memorial Hospital Chicago VAMC UNM Health Sciences Center Albuquerque VAMC Medical College of Georgia Augusta VAMC

37. Truman Medical Center * * URI, Bronchitis, Pharyngitis: excludes COPD, and antibiotic-responsive secondary diagnoses AECB: as 1st diagnosis, or URI/bronchitis 1st diagnosis in patient with PMHx COPD * < 5 visits

38. Patient Education • Waiting Room Patient Education • Pamphlets/Cards • Informational Kiosk • Examination Room Materials • Bronchitis Posters

39. Exam Room Poster

40. KIOSK • Waiting room signs directed patients to kiosk • Patients were encouraged to use kiosk by ED staff • Rotating messages on screen suggested content • All text on screen could be heard through speakers • Bilingual educational printout at end of program

42. Kiosk Care Plan printout (Spanish and English)

43. Adjusted Abx Rx Rates for URI/AB % Visits Prescribed Antibiotics: Intervention - Baseline Periods

44. Adjusted Abx Rx Rates for all ARIs

45. ABx Treatment of URIs/Bronchitis Decreased at Intervention Sites Metlay et al, Ann Emerg Med, 2007.

46. SUMMARY • Guidelines/Knowledge/Awareness is a necessary starting point, but rarely sufficient • Develop an approach that is based on a theoretical framework and understanding of the target behavior(s) • Think about an intervention strategy that uses multiple tools across the spectrum of predisposing, reinforcing and enabling factors depending on the relevant theory

47. http://www.innovations.ahrq.gov

48. EPI 245 HOMEWORK #2: The Translational Tool Box…Please turn-in by Monday, October 5th, 2009. Describe one tool that you will employ in your intervention strategy…. What type of tool is it, how will it be implemented, and who will the tool be targeting? • Describe some of the ideal circumstances or situations in which your tool and implementation strategy are most effective, and how this relates to your Target Population. Try to support with references from a PubMed Search.