# Presentation: 733936

## TRANSLATING EVIDENCE INTO CLINICAL PRACTICE:  WHAT WORKS?

**David A. Katz, MD, MSc**
**University of Iowa **
**March 28, 2006**

**Notes:**
In the prior 2 seminars, we heard about different conceptual models and organizational characteristics associated with implementation of evidence into practice.  
In this seminar, I’ve been asked to discuss “what works in practice.”

## Outline

**Barriers to guideline implementation**
**Attributes of effective interventions**
**Chronic Care Model (CCM) **
**Questions for future research**

**Notes:**
To do this, I will review some of the common barriers to implementation of guidelines in practice, and then will review the attributes of effective interventions that have been identified in qualitative reviews and meta-analysis.  
I will review the chronic care model, which serves as a useful framework for thinking about guideline implementation.
I will also present some examples to highlight selected components of the CCM.
Finally, I will wrap up by presenting some qs for future research.

## Barriers to implementation

**Patient-related factors**
**Low health literacy**
**Low self-efficacy**
**Lack of social support**
**Competing demands (work, family, etc.)**
**Multiple chronic conditions**

**Notes:**
Before we discuss the CCM, it’s worth reviewing some of the barriers to guideline implementation.
This slides shows several barriers related to the patient:
Low health literacy
Low self-efficacy
Lack of social support
Competing demands (work, family)
Multiple chronic conditions 

## Barriers to implementation (cont’d)

**Clinician-related factors**
**Knowledge**
**Lack of awareness**
**Lack of familiarity**
**Attitudes **
**Low self-efficacy**
**Lack of outcome expectancy**
**Clinical inertia**
**Other barriers (lack of time, reimbursement)**

**[Cabana, 1999]  **

**Notes:**
Clinician-related factors can be grouped into 3 categories:
Knowledge
Lack of awareness
Lack of familiarity
Attitudes 
Low self-efficacy
Lack of outcome expectancy (pessimism regarding the ability to change patient behavior)
Clinical inertia
Other barriers (lack of time, reimbursement)

## Barriers to implementation (cont’d)

**Practice-related factors**
**Inadequate resources**
**Lack of leadership (e.g., champion)**
**Lack of organizational commitment to support quality improvement**
**Lack of effective teamwork**
**[Shortell, 2004]**

**Notes:**
Some practice-related barriers to implementation are:
Inadequate resources
Lack of leadership (e.g., champion)
Lack of organizational commitment to support quality improvement
Lack of effective teamwork

## Qualitative review: Attributes of effective interventions for implementing guidelines

**Create a process of continuous improvement at the individual and organizational level**
**Provide face-to-face instruction, feedback **
**Provide practical support (facilitators, resources)**
**Use a combination of methods directed to specific barriers to change**
**[Grol, 1992]**

**Notes:**
In his qualitative review, Grol suggests that effective interventions:
Create a process of continuous improvement at the individual and organizational level (fostering a culture of improvement, setting practice objectives, developing reliable mechanisms for collecting data)
Provide face-to-face instruction, feedback (preferably by well-respected peers)
Provide practical support (facilitators, resources)
Use a combination of methods directed to specific barriers to change for specific target groups

## Meta-analysis:  Interventions used in disease management programs

**Definition of DM: “An intervention designed to manage or prevent a chronic condition using a systematic approach to care and potentially employing multiple treatment modalities.”**
**Published articles from 1987-2001**
**Experimental or quasi- experimental study design**
**Sufficient data to estimate effect size**
**[Weingarten, 2002]**

**Notes:**
The literature on disease management also provides insight on “what works” in clinical practice.
In this meta-analysis, DM was defined as: “An intervention designed to manage or prevent a chronic condition using a systematic approach to care and potentially employing multiple treatment modalities.”
Published articles from 1987-2001
Experimental or quasi- experimental study design
Sufficient data to estimate effect size

## Meta-analysis (cont’d)

**102 articles describing 118 intervention programs**
**59% of DM programs used 2 or more interventions**
**The most commonly used interventions were**
**patient education (92 studies)**
**provider education (47 studies)**
**provider feedback (32 studies)**
**patient reminders (28 studies)**
**[Weingarten, 2002]**

**Notes:**
102 articles describing 118 intervention programs were eligible for analysis.
59% of DM programs used 2 or more interventions.
The most commonly used interventions were
patient education (92 studies)
provider education (47 studies)
provider feedback (32 studies)
patient reminders (28 studies)

## Meta-analysis:  Effects of interventions on provider adherence to guidelines

**[Weingarten, 2002]**

**Notes:**
This table summarizes the effectiveness of interventions in increasing providers’ adherence to guidelines. 
Approximately half of these interventions were effective, with a moderate effect size (0.44 for provider education, 0.61 for provider feedback, and 0.52 for provider reminders).  

## Meta-analysis:  Effects of provider-targeted interventions on disease control

**[Weingarten, 2002]**

**Notes:**
Approximately 40% of these interventions had a significant effect on measures of disease control, with a small-moderate effect size (ranging from 0.17 for provider feedback to 0.35 for provider education).  

## Meta-analysis:  Effects of patient-targeted interventions on disease control

**[Weingarten, 2002]**

**Notes:**
This table summarizes the effectiveness of patient-targeted interventions in improving disease control. 
These interventions were variably effective, with a small-moderate effect size (ranging from 0.24 for patient education to 0.40 for patient financial incentives).

## Meta-analysis: Limitations/caveats

**Great variation in patients, providers, and types of interventions used**
**Few studies directly compared the effectiveness of different interventions**
**Relatively few studies examined cost **
**Reduced cost: 1/7 (14%)**
**Reduced hospitalizations 3/28 (11%)**
**[Ofman, 2004]**

**Notes:**
A couple of limitations about this study:
There was great variation in patients, providers, and types of interventions used
Few studies directly compared the effectiveness of different interventions; thus, it is difficult to evaluate each intervention’s relative effectiveness.
Relatively few studies examined cost of disease management.  
Of those studies that included utilization and cost outcomes, about 10-15% showed significantly decreased resource use.

## Chronic Care Model

**Practice **
**redesign**

**Self-management**
**support**

**Decision **
**support**

**Clinical information**
**system**

**[Wagner, 1996]**

**Chronic Care Model**

**Organizational**
**change**

**Community **
**resources**

**Notes:**
The chronic care model was based upon a survey of best practices, expert opinion, and literature review.  It includes several components that should be considered in implementing guidelines. 
The first component is practice redesign (e.g., use of a nurse case manager).  
The second component is self-management support (e.g., use of telephone follow-up to help pts take a more active role in their self-care).
The third component is a decision support system (e.g., ready access to evidence-based guidelines and support from specialists).  
The fourth component is a clinical information system
-capturing information from all sites of care into a single longitudinal episode 
-providing feedback on patterns of care
The fifth component is community resources to support chronic care management in coordination with the primary care team
The last component is organizational change (e.g., leadership, alignment of financial incentives)

## Example 1: Depression

**Barriers to implementation of depression guidelines**
**Patient ambivalence**
**Confidence and skill of PCP**
**Access to psychiatric care **
**Poor communication between primary care and mental health specialists**
**Potential solution:  3-component model for depression care**

**[Dietrich, 2003]**

**Notes:**
To demonstrate how components of the chronic care model have been applied in clinical practice, I’d like to start with an example from the depression literature.
Barriers to implementation of depression guidelines
Patient ambivalence
Confidence and skill of PCP
Access to psychiatric care 
Poor communication between primary care and mental health specialists
To address these barriers, Dietrich and colleagues developed a 3-component model for depression care that includes several elements of the CCM.

## Example 1: Depression

**Design:  Cluster RCT in 60 primary care practices**
**Patients: Major depression or dysthymia **
**Intervention: **
**Office systems approach to assessment & monitoring of depression (practice redesign)**
**Telephone f/u at 1, 4, and 8 wks from care manager (self management support)**
**Use of psychiatrist to supervise care managers and assist PCP as needed (decision support)**

**[Dietrich, 2004]**

**Notes:**
To evaluate the effectiveness of this model, they randomized 60 primary care practices to guideline-based depression care vs. usual care.
The study included 405 patients with major depression or dysthymia 
The Intervention included the following: 
Office systems approach to assessment & monitoring of depression by primary care clinician (practice redesign)
Telephone f/u from care manager (self management support - focus on adherence)
Oversight of care managers by psychiatrist (decision support)

## Example 1:  Process measures

**Notes:**
Analysis of process measures showed that:
The proportion of pts who were taking antidepressants and who received counseling was similar in both groups
A greater proportion of intervention pts had received at least 1 follow-up visit and at least 1 telephone call for depression at 6 months follow-up.

## Example 1:  Outcome

**Notes:**
Results showed that pts in the intervention group were significantly more likely to have had a treatment response compared to usual care.  At 6 months, approximately 60% of pts in the intervention group showed a treatment response vs. 47% in the usual care group.
The intervention also improved satisfaction with depression care (90 of intervention pts vs. 75% of control pts rated their care as good-excellent)

## Example 2: Smoking cessation

**Barriers:  **
**Organization of care around the patient-initiated 15 minute visit **
**Solution: Use of non-physician personnel to handle routine preventive tasks and pt education**
**Problem:  Limited staffing by nurses**

**Notes:**
Barriers to implementation of smoking cessation guidelines are the organization of care around the patient-initiated 15 minute visit [Wagner, 1997], competing demands, clinical inertia.
-One solution is the creation of health care teams, which use non-physician personnel to handle routine preventive tasks and pt education
The feasibility of this approach has been challenged by the cost-cutting measures of some health care organizations to limit staffing by nurses and to replace them with less-well trained health care workers.  

## Example 2: Smoking cessation

**Design: RCT in 8 primary care practices**
**Patients: Cigarette smokers**
**Intervention:  **
**Training of nursing staff in identification and brief counseling of smokers (practice redesign)**
**Free NRT and proactive telephone counseling by cessation nurse (self-management support)**
**Interim feedback to clinic staff**
**[Katz, 2004]**

**Notes:**
To determine whether a strategy of using non-physician personnel could improve delivery of guideline-recommended care, we randomized 8 primary care clinics to intervention vs. usual care.
The intervention included the following components:  
Training of nurses and MAs in identification and brief counseling of smokers (practice redesign)
Free NRT and proactive telephone counseling by a smoking cessation nurse (self-management support)
Interim feedback to clinic staff (information)

## Results: Adherence to guidelines 

**Recommended activity**

**Control**

**(n=499)**

**Intervention**

**(n=642)**

**Ask about smoking, %**

**67**

** ****87***

**Assess willingness to quit, %**

**30**

** ****73***

**Advice to quit, %**

**38**

**   ****47****

**Set quit date, %**

**1**

** ****27***

**Discuss **

** ****pharmacotherapy, %**

**14**

** ****39***

*****

**p**

**<**

**0.001, **p=0.06**

**Notes:**
Across the board, significantly more pts at intervention sites received recommended cessation counseling versus control pts.  

## Results: Cessation outcomes

**Control**

**(n=499)**

**Intervention**

**(n=642)**

**Adj OR**

**(95% CI)**

**Any quit attempt, %**

**50**

**57**

**1.4 (1.0-1.9)***

**2-mo quit rate,%**

**5.8**

**16.4**

**3.5 (2.0-6.0)***

**6-mo quit rate,%**

**9.8**

**15.4**

**1.8 (1.2-2.7)***

**Plan to quit w/in 6-mo, %****

**35**

**43**

**1.3 (0.9-1.8)**

*****

**p**

**<**

**0.05**

****Applies only to **

**  ****pts who were still smoking at 6-mo follow-up contact**

**Notes:**
During the intervention period, pts at test sites were more likely to make a quit attempt during 6-mo follow-up, 57 vs. 50%, with an adjusted OR of 1.4.
At 2-month follow-up, 16.4 and 5.8% of pts reported abstinence from cigarettes, with and adjusted OR of 3.3. 
At 6-months, 15.4 vs. 9.8% of pts were abstinent from cigarettes.  These differences were statistically significant in our regression model.

## Example 3: Diabetes

**Barriers:  **
**Lack of patient-specific data to inform decision making**
**Data needed to plan care is scattered across several different parts of the medical record**** **
**Solutions:**
**Registry for identification of patients with chronic illness**
**Real-time reminders and feedback that are specific for individual patients**

**Notes:**
Another barrier to effective implementation of evidence is the lack of patient-specific data to inform decision making. This problem is particularly salient for conditions such as diabetes.
In most medical practices, the data needed to plan care and to counsel diabetic patients is scattered across several different parts of the medical record and is hard to find.  
Two solutions to this problem are 
-the development of registries for the identification of patients with chronic illness, and 
-the use of real-time reminders and feedback that are specific for individual patients.  

## Example 3: Diabetes

**Design:  RCT of 58 family physicians**
**Intervention**** **
**Based on ADA care guidelines**
**Local consensus with minor revisions**
**Computer-generated recommendations on which studies were due **
**Recommendations appeared on chart**
**[Lobach, 1997]**

**Notes:**
In one study, Lobach and colleagues performed an RCT of 58 family physicians to determine whether an information systems approach using computer generated reminders would improve adherence to diabetes guidelines.
-The intervention was based on American Diabetes Association guidelines, which were endorsed with minor revisions by the study physicians
-It provided computer-generated recommendations on which studies and procedures were due, based on a series of logic rules that utilized data in the patient’s computer-based medical record.
-The recommendations appeared on the patient’s chart

**Notes:**
The outcome of the intervention was an approximately 50% increase in clinician adherence to guideline recommendations.

## Example 4: Asthma

**Design:  RCT of 42 primary care pediatrics practices (MCO-affiliated)**
**Patients: children with mild-mod persistent asthma**
**Planned care intervention:**
**Peer leader: MD trained to champion the asthma guideline (organizational change)**
**Nurse case manager to provide planned asthma visits (self-management support)**
**Feedback to PCPs using registry based reports (information systems)**
**Compared to: 1) peer leader alone, 2) usual care**

**Notes:**
The next example was designed to determine the effectiveness of an organizational change strategy with or without support from a nurse case manager.  
Design:  RCT of 42 primary care pediatrics practices (MCO-affiliated)
Patients: children with mild-mod persistent asthma
Planned care intervention:
Peer leader: 1 MD in each practice trained to champion the asthma guideline (organizational change)
Nurse case manager to provide planned asthma visits (self-management support)
Feedback to PCPs using registry based reports (information systems)
The full intervention was compared to: 1) peer leader alone, and 2) usual care.

## Example 4: Implementation

- [Lozano, 2004]

**Notes:**
Peer leaders in both intervention arms conducted a mean of 9.5 group sessions over the 2 year study period.
In the planned care arm, nurse managers conducted 3 asthma visits and made 4.7 f/u telephone calls, on average.
The proportion of pts using controller medications during follow-up was significantly greater in the planned care arm.

## Example 4: Outcomes

- [Lozano, 2004]

**Notes:**
The planned care strategy resulted in a significant reduction in annualized asthma symptom days, relative to usual care; a lesser reduction was observed in the peer leader strategy.
Both strategies resulted in similar reductions in the need for oral steroid bursts and clinically important improvements in functional status, based on asthma-specific measures.
Utilization of emergency department care or unplanned doctor visits was not reported.

## Teamwork

**Fundamental assumption of the CCM is the presence of effective teams**
**Few studies have examined the relationship between clinical teams and delivery of guideline-recommended care**

**Notes:**
Fundamental assumption of the CCM is the presence of an effective team.  
Few studies have examined the relationship between clinical teams and delivery of guideline-recommended care
Focus has been on social influence strategies (e.g., opinion leaders, champions)

## Characteristics of effective teams

**Define clear goals with measurable outcomes**
**Build clinical and administrative systems that facilitate getting the work done**
**Divide labor by assigning tasks and roles**
**Train individuals to perform these roles**
**Develop clear structures and processes for communication**

**[Grumbach, 2004]**

**Notes:**
Grumbach identifies 5 characteristics of effective teams:
Define clear goals with measurable outcomes
Build clinical and administrative systems that facilitate getting the work done
Divide labor by assigning tasks and roles
Train individuals to perform these roles
Develop clear structures and processes for communication

## Summary

**Implementation of evidence in practice is more likely to occur when**
**Clinicians receive education, feedback, and/or reminders**
**Workload is shared with ancillary staff**
**Communication between primary care and specialty physicians is enhanced**
**Multiple practice-change strategies are combined**
**Guideline implementation and DM strategies can significantly improve disease control and HRQOL, but effects tend to be modest**

**Notes:**
Implementation of evidence in practice is more likely to occur when
Clinicians receive education, feedback, and/or reminders.  This depends on the presence of supportive information systems.
Workload is shared with ancillary staff
Collaboration between primary care and specialty physicians is enhanced
Multiple practice-change strategies are combined
Guideline implementation and DM strategies can significantly improve disease control and HRQOL, but effects tend to be modest.  The effects can, however, be quite substantial at the population-level.

## Summary (cont’d)

**Chronic care model is a coherent framework for implementing evidence-based care**
**Need to know more about the effectiveness of certain components of chronic care model (organizational change, community resources)**
**Need to figure out how to best integrate single disease strategies for implementing guidelines into the overall care of the patient**

**Notes:**
In summary, the chronic care model is a coherent framework for improving quality of care
Need to know more about the effectiveness of certain components of chronic care model, especially strategies involving organization change and linkages to community resources.
Need to figure out how to best integrate single disease strategies for implementing guidelines into the overall care of the patient

## Questions for future research

**What strategies improve the cohesiveness and overall effectiveness of practice teams?**
**Do financial incentives for clinicians improve the delivery of guideline-recommended counseling and educational activities in support of patient self-management?**
**Does improving access to and collaboration with medical specialists improve the delivery of evidence-based care?**
**What is the incremental cost-effectiveness of strategies for guideline implementation relative to usual care?**

**Notes:**
What strategies improve the cohesiveness and overall effectiveness of practice teams?
Do financial incentives for clinicians improve the delivery of guideline-recommended counseling and educational activities in support of patient self-management?
Does improving access to and collaboration with medical specialists improve the delivery of evidence-based care?
What is the incremental cost-effectiveness of guideline implementation strategies relative to usual care?