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Mark L. Willenbring, MD NIAAA/National Institutes of Health RSA 2008, Washington, DC Implementation: A Practical Approach.

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Presentation on theme: "Mark L. Willenbring, MD NIAAA/National Institutes of Health RSA 2008, Washington, DC Implementation: A Practical Approach."— Presentation transcript:

1 Mark L. Willenbring, MD NIAAA/National Institutes of Health RSA 2008, Washington, DC Implementation: A Practical Approach

2 Case Manager

3 OR…


5 Scientific Inquiry Level I: Consensus of experts Level II: Small clinical trials Level III: Large randomized controlled trials (RCTs) Meta-analysis

6 are developed using systematic reviews use national or regional guideline development groups (including representatives of key disciplines) note explicit links between recommendations and scientific evidence. »Grimshaw J, Eccles M. et al. Developing clinically valid practice guidelines, J Eval Clin Pract 1995;1(1):37-48 Guidelines are more likely to be valid if they:


8 Inclusion Criteria: 1. Has specified disorder 2. Willing to participate 3. Has home, phone, & transportation 4. Fine upstanding citizen 30-50%

9 Exclusion Criteria: 1. Coexisting psychopathology (incl. addictions) 2. Multiple prior treatments 3. Serious medical problems 4. Lack of housing, transportation 5. Unmotivated 6. Too busy surviving to bother 7. Taking other medications 8. History of non-compliance 9. Lives too far away 10. Serious personality disorder 50-70%

10 Dodo bird: Friend or enemy?

11 Looking in the wrong place? Examined change Unexamined change

12 Results remarkably similar Miller et al., J Stud Alc 62: , 2001

13 Project MATCH Main Outcomes Project MATCH Research Group, J Stud Alc 59: , 1998 Increased drinking quantity before entry Immediate substantial improvement

14 Treatment: instigator or result of change? etc. week PDA Does change occur prior to tx?

15 Compared 5 different treatment approaches for cannabis use disorder in adolescents

16 Dennis et al., JSAT 2004 No difference across groups

17 UKATT Trial Compared 4 sessions of MET with 8 sessions of social and behavior therapy

18 UKATT findings No difference across groups

19 Dodo bird strikes again!

20 A broader view of change Therapeutic techniques may have small effects relative to extrinsic factors

21 A broader view of change Common mechanisms may account for change –Therapeutic alliance and Empathic listening –Social support for change –Therapeutic rituals (cf. Jerome Frank) –Help-seeking itself

22 Implications for research There may be multiple pathways (or mechanisms of action) with similar outcomes, OR We may have been looking in the wrong place

23 Theres many a slip between the cup and the lip.

24 Implemented CBT (high and low standardization) in community program Compared to Treatment as Usual

25 Whoops! Morgenstern et al., JCCP 2001

26 Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study Kathleen M. Carroll, Samuel A. Ball, Charla Nich a, Steve Martino a, Tami L. Frankforter a, Christiane Farentinos b, Lynn E. Kunkel c, Susan K. Mikulich-Gilbertson d, Jon Morgenstern e, Jeanne L. Obert f, Doug Polcin g, Ned Snead h, George E. Woody i and for the National Institute on Drug Abuse Clinical Trials Network a b c d e f g h i Drug and Alcohol Dependence Volume 81, Issue 3, 28 February 2006, Pages

27 Effectiveness of MI Standard intake vs. MI Achieved desired differences in technique Improved engagement No difference in 28 day or 84 day substance use outcomes Carroll et al., Drug and Alcohol Dependence, 2006

28 Take Home Message Multiple treatments have been shown to produce acceptable outcomes Caution is required –Interpretation of empirical findings –Implementation Careful attention to implementation and evaluation is necessary Focus on outcomes



31 73% of primary care physicians believe that they immunize a greater percentage of patients than their colleagues Noe CA, Markson LJ, Prev Med 1998;27(6):767-72

32 In a closed panel academic medical center: 65% of the practitioners are more efficient than their peers in the same practice 65% have sicker patients 75% have better outcome J Perlin, 2000

33 ... and all of the children in Lake Wobegone are above average J Perlin, 2000

34 Rates of Coronary Angiography HI LO

35 Rates of Coronary Angiography HI LO

36 Rates of Radical Prostatectomy HI LO

37 Rates of Radical Prostatectomy HI LO

38 Variation in Inpatient Care for COPD by VISN (Region) Image Removed – Awaiting Copyright Permissions

39 Variation in Ambulatory Care for MDD by VISN (Region) Image Removed – Awaiting Copyright Permissions


41 after DA Burnett, © UHC, 1995 Reasonable Expectation Unfortunate Experience

42 after DA Burnett, © UHC, 1995 What you would want for your family What you would not want Should it matter where you receive care?

43 after DA Burnett, © UHC, 1995 How do we capture and systematize these practices? How do we drive these practices to be more like those above?

44 Implementing Guidelines Requires Broad Skills Leadership and teamwork Negotiation and tact Selling ideas to peers Link evidence to practice guideline

45 Educational Strategies Ineffective: –Traditional CME –Printed materials –?Audit and feedback VERDICT Brief, Spring 1998

46 Educational Strategies Effective: Intensive conferencing w/ interaction, discussion, & role playing VERDICT Brief, Spring 1998

47 Reminders and Prompts Pocket cards & wall charts Formatted records Computerized reminders VERDICT Brief, Spring 1998

48 Interactive Strategies VERDICT Brief, Spring 1998 Opinion leaders Academic detailing (outreach)

49 Multiple strategies work best.



52 Organizational strategies None of the strategies produced consistent results. Professional performance was improved by revision of professional roles and computer systems Wenning et al., 2006

53 Organizational strategies Patient outcomes improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings [came from] integrated care services Wenning et al., 2006

54 So what should a program [leader/provider] do? Technique Outcome measurement Quality improvement Implementation strategies

55 Implications for implementation Examine current system/outcomes Determine where you wish to improve Develop model for how your program improvements will translate into process and/or outcome improvements

56 Is treatment as usual ok? Examine general quality of care –Professionalism –Empathy –Training and skill –Supervision Determine whether implementing a new technique will be helpful, why, and how

57 Implementation Buy in by leadership critical Resources must be provided Multiple strategies

58 Implementation Monitoring performance of individuals not just systems Supervision Plan for improving performance

59 Summary Research on mechanisms of change and improvement in outcomes in the community is needed Until then, paying attention to monitoring performance and upgrading the skills of staff are reasonable strategies

60 Summary Community-research partnerships hold promise for gradually learning about how to improve overall community outcomes Make haste slowly. –Caesar Augustus


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