1. 1 Knowledge Transfer Experiences in Obstetrics: A Systematic Review of Evidence-based Strategies to effectively change behaviors Nils Chaillet, Ph.D : Département Obstétrique et Gynécologie Université de Montréal (Alexandre Dumont, MD, PhD ; William Fraser, MD, M.Sc, FRCSC)

2. 2 Introduction Introduction Background Clinical Practice Guidelines implement best evidence into practice (Evidence based medicine) The challenge now lies in implementing these guidelines Strategies for implementing CPGs in Medicine Ineffective: Mailing and Didactic traditional medical education Mixed effect: Opinion leader, Audit and Feedback, and Continuous quality improvement Generally effective: Manual or computerized reminders, Academic detailing, and Multifaceted interventions

3. 3 Introduction Introduction Most common strategies used in obstetric services as a routine activity Educational activities Audit activities (Confidential enquiries, Audit and Feedback) Hypothesis Key factors of effective strategies in obstetric differs from those of other medical specialties Objective To estimate effective strategies for implementing clinical practice guidelines in obstetric care

4. 4 Material and method Material and method Data sources Cochrane Library, EMBASE, MEDLINE Reference lists from identified studies and expert suggestions Identification of studies MeSH terms: Guideline, Obstetrics, Guideline adherence and Practice guideline Text words: Relevant strategies for implementing CPGs Mailing, Education, Audit, Opinion leader, Academic detailing, Quality improvement, Reminder, Multifaceted strategy

5. 5 Material and method Material and method Inclusion criteria RCT, CCT, CBA, ITS from 1990 to 2005 Cochrane and EPOC criteria in respect with the design C-RCT / RCT: Random allocation of units in each group CCT: Quasi-Random allocation of units in each group CBA: 2 inclusion criteria ITS : 4 inclusion criteria EPOC Quality criteria in respect with the design C-RCT, RCT, CCT and CBA: 7 quality criteria ITS: 7 quality criteria Exclusion criteria Studies from other than obstetrics specialties Studies with no clear relation to CPGs implementation Opinion letters or studies including less than 100 patients Qualitative studies

6. 6 Material and method Material and method Data extraction According to Cochrane and EPOC criteria standard Checklist 2 reviewers independently abstracted specific information from full text studies Discordances between the 2 reviewers were resolved by consensus An efficacy qualitative scale was ascribed to each study (Ineffective, Mixed effect and Effective)

7. 7 Study eligibility flow chart Study eligibility flow chart

8. 8 Results Results Characteristics of included studies (33) Design 10 C-RCT, 6 RCT, 1 CBA, 16 ITS (1 081 006 women) Strategies in obstetric EDUC: Educational strategies (4) AF: Audit and feedback (11) OL: Opinion leader (2) QUAL: Quality improvement (4) ACAD: Academic detailing (1) REM: Reminders (2) MULTI: Multifaceted strategies (9) –Including combination of the following sub-interventions: EDUC / AF / OL / ACAD / REM

9. 9 Results Results Nature of the desired change among the 33 studies Reduction of cesarean sections (53% of studies) Management of mild hypertension Reduction of infections Promotion of active management of labor Promotion of VBAC Reduction of maternal mortality in low-income countries Reduction of suboptimal cares in low-Apgar babies Reduction of unnecessary clinical visits Enhance use of antenatal corticosteroid for fetal maturation Enhance use of antibiotics Breastfeeding support Antenatal corticosteroid use for pulmonary fetal maturation Reduction of the pregnant smokers’ rates

10. 10 Results Results Educational strategies (1 C-RCT, 2 RCT, 1 ITS) Generally ineffective to directly change physicians or patients behavior (Management of mild hypertension / Verbal patient education to promote VBAC) Present mixed effects to change nurses behavior (Decrease use of EFM) Present effective effects to change patients behavior by trained prenatal care providers: nurses, social workers, nutritionists (Reduction of pregnant smoker rate) Audit and feedback (3 C-RCT, 1 CBA, 7 ITS) Generally effective In obstetric context to change professional behavior (9 studies) Key factors Intensive feedback Participation of local health professionals in the Audit process

11. 11 Results Results Opinion leaders (2 C-RCT) Ineffective to change patient behaviors (Improvement of breast feeding rates) Present mixed effects to change physicians behavior (promotion of VBAC to reduce cesarean section, 1991 context) Key factors Opinion leader act as a facilitator to improve acceptation of a local intervention The leadership of the local opinion leader must be assessed Quality improvement (3 RCT, 1 ITS) Continuity of midwifery care: generally effective to reduce cesarean section rate Key factors Consistent relationship developed between mother and their midwives and obstetrician Availability of midwives to provide advice and information to women Active management of labor: seems ineffective to reduce cesarean section rate Can be effective if the implementation is improved by local initiatives and when the program is locally standardized according to each provider (1 ITS only)

12. 12 Results Results Academic detailing in obstetrics (1 C-RCT) Present mixed effects to change physician’s behaviors (Enhance use of Antibiotics in Cesarean Section, and Steroids in preterm deliveries) Key factors An optimal determination of the duration and frequency of visits Clear description of leadership and roles of senior obstetric staff Reminders in obstetrics (1 C-RCT, 1 ITS) Generally effective to change Health professionals and patients behaviors (Reduction of cesarean rates, and reduction of clinic visits in middle income countries context) Key factors Reminders developed from CPGs and from prospective studies of the barriers to change Local staff agreement Intensive feedback due to the local diffusion of the evidences Inclusion of local physicians in the study to locally adapt the reminders

13. 13 Results Results Multifaceted strategies (2 C-RCT, 1 RCT, 6 ITS) Generally effective to change Health professionals and patients behaviors (100% of studies are effective) Identified effective sub-interventions Educational activities (generally used to improve provider’s knowledge of CPGs and intervention) Audit and feedback (used to target clinical practices and involving health professionals in the audit process) Opinion leader (used as facilitator of the program’s implementation) Academic detailing (used in association with education and opinion leader to promote breast feeding among women) Reminders (used in association with audit and feedback and developed from the recommendations of the audit process) Key factors Prospective study to determine the most adapted sub-interventions Intensive feedback (ensured by OL or AF by the involvement of local professionals) Barriers of each strategy are balanced by other strategies involved in the program

14. 14 Conclusion Conclusion Efficacy of each strategy in obstetric cares Efficacy In Obstetrics In general medicine (literature) Ineffective- Education (physicians)- Education Mixed effect - Education (non physicians) - Opinion leader - Quality improvement - Academic detailing - Audit and feedback - Opinion leader - Quality improvement Effective - Audit and feedback - Reminders - Multifaceted strategies - Academic detailing - Reminders - Multifaceted strategies

15. 15 Conclusion Conclusion CPGs as evidence based medicine Sensitize Health professionals Not sufficient to effectively change behavior In obstetrics, multifaceted strategy based on a training component, an audit and feedback, and facilitated by an opinion leader seem effective to change health professionals behaviors. Key factors Ensure intensive feedback (EDUC + OL) Involve Health professionals in the audit process Provide local evidences for reinforcing the effect of CPGs and effectively change behaviors Use of reminders is also advised to reinforce the audit committee recommendations and feedback