Knowledge translation for professionals Jeremy Grimshaw MD PhD Director, Clinical Epidemiology Program, OHRI Director, Canadian Cochrane Centre

Potential barriers to KT Information management is necessary but not sufficient to ensure knowledge translation The new tower of Babel? Hibble, Kanka, Pencheon, Pooles. BMJ (1998)

Structural (e.g. financial disincentives) Organisational (e.g. inappropriate skill mix, lack of facilities or equipment) Peer group (e.g. local standards of care not in line with desired practice) Professional (e.g. knowledge, attitudes, skills) Professional - patient interaction (e.g. problems with information processing) Patient (e.g. knowledge, attitudes, skills) Potential barriers to KT

Assess + Monitor + Evaluate barriers & supports strategy application outcomes & degree of use Practice Environment structural social patients economic Potential Adopters attitudes knowledge skill Evidence - Based Recommendations development process innovation attributes Strategies barrier management transfer uptake Adoption intention use Outcomes patient practitioner system Ottawa Model of Research Use Logan & Graham, 2002 Planning change

Choosing interventions Need to identify potential barriers relating to behavior, potential adopters and practice environment. Need to distinguish between modifiable and non modifiable Need to prioritize which are key barriers based on consideration of: Identification of mission critical barriers Potential for addressing barriers through interventions

Towards evidence based implementation Most approaches to changing clinical practice are more often based on beliefs than on scientific evidence ‘Evidence based medicine should be complemented by evidence based implementation’ Grol (1997). British Medical Journal.

Cochrane Effective Practice and Organisation of Care (EPOC) Group EPOC aims to undertake systematic reviews of interventions to improve practice including: Professional interventions (e.g. continuing medical education, audit and feedback) Financial interventions (e.g. professional incentives) Organisational interventions (e.g. the expanded role of pharmacists) Regulatory interventions Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Zwarenstein (2006). Cochrane Library.

Progress to date - register and reviews Register of primary studies 39 reviews, 34 protocols Collaborating with over 300 researchers globally Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Shepperd, Tavender, Zwarenstein (2007). Cochrane Library. Cochrane Effective Practice and Organisation of Care (EPOC) Group

Overview of reviews of professional behaviour change strategies Identified over 150 systematic reviews of professional behaviour change interventions For COMPUS, we summarised approx 50 systematic reviews judged to be likely highest quality and most up- to-date

Overview of reviews Educational materials (1) Educational meetings (1) Educational outreach (1) Audit and feedback (2) Opinion leaders (1) Mass media (1) Reminders – general (4) Reminders – Computer assisted drug dosage (3) Reminders – CPOE (1) Tailored interventions (1) Multifaceted interventions (1) Prescribing – general (10) Prescribing - safety (2) Changing roles – nursing (1) Changing roles – pharmacy (7) Financial (4) Regulatory (1) General (10)

Educational materials Distribution of published or printed recommendations for clinical care, including clinical practice guidelines, audio- visual materials and electronic publications. The materials may have been delivered personally or through mass mailings. Target knowledge, skills barriers at individual health care professional/peer group level Relatively low cost, feasible

Educational materials Farmer (2007) Cochrane Library (in preparation) High quality review 21 studies (RCTs, CCTs, CBAs, ITS) 9 studies included prescribing data Distribution of education materials may be effective for appropriate care including prescribing. (Median effect across 6 RCTs +4.9% absolute improvement)

Educational meetings Health care providers who have participated in conferences, lectures, workshops or traineeships Didactic meetings – largely target knowledge barriers at individual health care professional/peer group level Interactive educational meetings – can also target skills (if simulation/rehearsal involved) and attitudes at individual health care professional/peer group level

Educational meetings Thomson O’Brien (2001) Cochrane Library High quality review 32 studies (RCT, CCT) 5 studies included prescribing data Interactive workshops and mixed interactive-dogmatic activities were generally ineffective for improving appropriate care. Mixed effects were observed for didactic sessions. Insufficient evidence on prescribing.

Educational outreach Use of a trained person who met with providers in their practice settings to give information with the intent of changing the provider’s practice. The information given may have included feedback on the performance of the provider(s).

Educational outreach Derives from social marketing approach Use social persuasion methods to target individual’s knowledge and attitudes Typically aim to get maximum of 3 messages across in minutes using approach tailored to individual health care provider Typically use additional strategies to reinforce approach Typically focus on relatively simple behaviours in control of individual physician eg choice of drugs to prescribe

Educational outreach Relatively expensive although may still be efficient May be less effective for complex behaviours requiring team or system change

Educational outreach Thomson O’Brien (1997) Cochrane Library Medium quality review 18 studies (RCT, CCT) 12 studies included prescribing data Multifaceted educational outreach visits were generally effective for improving appropriate care including prescribing (Grimshaw 2004 – median effect across 13 RCTs of multifacted educational outreahc interventions +6.0%)

Local opinion leaders Use of providers nominated by their colleagues as ‘educationally influential’. The investigators must have explicitly stated that their colleagues identified the opinion leaders. Target peer group knowledge, attitudes Resources required include survey of target group, resources to recruit and support opinion leaders.

Local opinion leaders Doumit (2007) Cochrane Library Medium quality review 12 studies (RCT, CCT) 7 studies included prescribing data Generally effective for improving appropriate care. Insufficient evidence on prescribing. Median effect across studies +10% absolute improvement

Local opinion leaders Appear to be condition specific Likely coverage of target group difficult to assess Grimshaw et al (2006). Implementation Science Stability over time uncertain – Doumit re-surveyed surgeons 2 years after initial survey to identify opinion leaders. Only 4/16 original opinion leaders re-identified Doumit (2006) Masters thesis

Audit and feedback Any summary of clinical performance of health care over a specified period of time. The summary may also have included recommendations for clinical action. The information may have been obtained from medical records, computerised databases, or observations from patients. Adams et al demonstrated that self reported behaviour likely to overestimate actual performance by 27% Adams et al (1999) Int Journal for Quality in Health Care Target health care provider/peer groups’ perceptions of current performance levels Aim to develop cognitive dissonance to motivate physicians to change

Audit and feedback Resources required include data abstraction and analysis costs, dissemination costs (postal or personal) Feasibility may depend on availability of meaningful routine administrative data for feedback

Audit and feedback Jamvedt (2005) Cochrane Library High quality review 118 studies (RCT, CCT) 55 studies included prescribing data Audit and feedback alone, audit and feedback with educational meetings, audit and feedback as part of multifaceted intervention generally effective. Median effect across studies +10% absolute improvement Larger effects were seen if baseline compliance was low.

Reminders Patient or encounter specific information, provided verbally, on paper or on a computer screen, which is designed or intended to prompt a health professional to recall information. This would usually be encountered through their general education; in the medical records or through interactions with peers, and so remind them to perform or avoid some action to aid individual patient care. Computer aided decision support and drugs dosage are included. Focus on professional – patient interaction, prompting professional to remember to do important items

Reminders Resources vary across deliver mechanism Increasing interest in computerised decision support but evidence tends to come from a few highly computerised US academic health science centres Insufficient knowledge about how to prioritise and optimise reminders

Reminders Garg (2005) JAMA Medium quality review 100 studies (RCT, CCT) 49 studies included prescribing data Mixed effects were observed for computerised clinical decision support systems (CDSS) for appropriate care including prescribing

Multi faceted interventions Any intervention including two or more components Multi-faceted interventions are more likely to target different barriers in the system Likely more costly than single interventions Need to carefully consider how components likely to interact to maximise benefits

Effectiveness of strategies targeting health care professionals Grimshaw et al (2004). Health Technology Assessment Multifaceted interventions

Conclusions Imperfect evidence base to support choice of interventions to improve prescribing Choice of intervention should be based upon consideration of: likely barriers evidence of effectiveness of intervention mechanism of action of intervention resources available other feasibility issues

Contact details Jeremy Grimshaw - EPOC –