Evidence based implementation for quality and health promotion in hospitals Professor Jos Kleijnen Director Centre for Reviews and Dissemination University of York United Kingdom

State of affairs in the UK at the end of the 20 th Century Variable uptake of new health technologies or management programmes, without adequate evidence of clinical and/or cost-effectiveness Variable persistence of outdated technologies and programmes Slow introduction of new methods, even if they were proven effective and value for money Different local decisions about available healthcare in the context of budgetary constraints Inequalities in health and health care: ‘postcode prescribing’

Problems related to evidence based health care Availability of evidence Accessibility of evidence Assessment of evidence (systematic reviews and health technology assessments) Appraisal of evidence leading to guidance Applicability of evidence and guidance

Availability of evidence Good: A lot of guidelines are available A lot of (systematic) reviews are available Not so good: Quality of primary research evidence is generally poor Many more good studies are needed Often guidelines and reviews do not cover specific, practical problems or settings

Searching the TRIP database for “prevention” and “falls” (25 May 2004) Evidence based 79 Guidelines 63 Query-answering services 8 E-textbooks 420 Medical images 2 Patient information leaflets 51 Peer reviewed journals Therapy articles 201 Diagnosis articles 32 Etiology articles 300 Prognosis articles 104

Evans D, et al. Fall prevention: a systematic review. Clinical Effectiveness in Nursing 1999; 3: Authors' conclusions Despite the importance of patients falls in hospitals, and the large amount of published information, there is currently little evidence on which to base clinical practice.

Accessibility of evidence National electronic Library for Health Turning Research into Practice Centre for Reviews and Dissemination (CRD) Cochrane Library (free for 116 HINARY countries, only abstracts free for others) Most Health Technology Assessment agencies (via HTA database at CRD) Health Development Agency (public health and health promotion)

Accessibility of evidence Good: A lot of information is accessible free Not so good: Difficult to know who/what you can trust You need easy access to the internet Printed copies usually attract a charge

Assessment Good: Processes for assessment in place in many Western countries International collaboration is increasing: WHO Health Evidence Network, Cochrane Collaboration, Guidelines International Network, INAHTA etc. Many resources with assessed information Not so good: Not easy for busy decision makers and practitioners Ideally by independent academic groups with appropriate methodological and clinical expertise Takes a lot of time to do, whereas you need it by tomorrow Is expensive: one systematic review at £70,000, one technology assessment report £80,000 – 160,000

Appraisal Assessment is scientific work by independent academics, appraisal is decision making by appropriate bodies such as the National Institute for Clinical Excellence and the Health Development Agency Appraisal takes more factors into account such as needs, resources, priorities, innovation and others Assessed evidence should inform appraisal just as evidence should be integrated with clinical experience in individual patient care

Appraisal Good: If it takes best available evidence into account If it takes views of all relevant stakeholders into account If it takes affordability and practical barriers into account (sorry we can’t do this because we would need to train 300,000 nurses….) Not so good: If the process is not transparent If information is used that is not in the public domain When evidence is lacking and strong different opinions are prevalent

Applicability JM Grimshaw et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment 2004;8:6.(84 pages – download free from “There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances” “Decision makers need to use considerable judgement about how best to use the limited resources they have for improving the quality of care and related activities to maximise population benefits”

Applicability Good: There is evidence that some dissemination and implementation strategies work in some circumstances Simple single interventions may be as effective as complex multifaceted interventions Dissemination of educational materials may lead to modest but potentially important effects Not so good: Decision makers need to exercise considerable judgement about what may be effective in their circumstances There rarely is a budget for implementation Guidance may not be applicable to individual patients There are too many guidelines and there is too little time to implement the recommendations

Further information