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Milbank Memorial Quarterly Grol (1997) BMJ Sung et al (2003). JAMA Grol R (2001). Med Care <UPPP<nP1nPnUzO!             JO\  k  - BackgroundLocal health care organisations have relatively few resources for implementation activities and decision makers need to consider how best to use these to maximise benefits Dissemination and implementation strategies are not without costs. In some circumstances, the costs of development and introduction are likely to outweigh their potential benefits. In other circumstances, it may be more efficient to adopt less costly but less effective dissemination and implementation strategies. Zd . Background $  If decision makers are to make decisions about implementation strategies informed by research evidence, they need information on: likely effectiveness of interventions (direction of effect, predicted effect size of intervention and relative effectiveness of different interventions); effect modifiers (practice environment, potential adopter, characteristics of behaviour); and, resources need to deliver interventions. : $   /  Background $  {Rigorous evaluations (mainly randomised controlled trials) provide the best evidence of effectiveness of different interventions because: Effects of interventions are modest Limited understanding of likely confounders Substantial opportunity costs if ineffective or inefficient dissemination and implementation strategies used Eccles (2003) Quality and Safety in Health Care z0 <"  | 0  Background (  Systematic reviews of rigorous evaluations of implementation interventions should inform decisions because they: identify and summarise evidence on the effectiveness of interventions allow the generalisability and consistency of research findings to be assessed allow exploration of data inconsistencies to be explored. Mulrow (1994) British Medical Journal Grimshaw (2003) Quality and Safety in Health Care qY q#    >q Q  q \ 1 'Overview of previous systematic reviews7 )Problems with previous systematic reviews**$) Use of vote counting techniques: Problems handling studies where statistical significance of comparison is uncertain (eg studies with unit of analysis errors) Don t provide any estimate of effect size Inadequate consideration of quality of primary studies Conflation of multifaceted interventions into single intervention category eg educational outreach<!!@v& 8JSystematic review of guideline dissemination and implementation strategiesKJJ Objective Systematic review of the effectiveness and efficiency of guideline dissemination and implementation strategies to promote improved professional practice.(   9JSystematic review of guideline dissemination and implementation strategiesKKJ Inclusion criteria Study designs  RCTs, CCTs, CBAs, ITS Participants  medically qualified health care professionals Interventions  guideline dissemination and implementation strategies Outcomes  objective measures of provider behaviour and/or patient outcome Search strategy Cochrane Effective Practice and Organisation of Care group s search strategy bZZ0Z2NZNn# H ! :4Results  included studies$ Search strategy identified approx 150,000 hits 5,000 hits identified as potentially relevant Full text 863 reports retrieved Included 285 reports of 235 studies, yielding 309 separate comparisons ;@Results  methodological quality!!$  Overall methodological quality poor (eg unit of analysis errors common) Poor description of interventions Only 27% of studies used theories and/or psychological constructs 29.4% comparisons reported any economic data F%CB -  <JSystematic review of guideline dissemination and implementation strategiesKKJ =JSystematic review of guideline dissemination and implementation strategiesKKJ >JSystematic review of guideline dissemination and implementation strategiesKKJ Multifaceted interventions including educational outreach 13 RCT Median effect +6.0% (range  4% to +17.4%) <:+:+ A*  ?JSystematic review of guideline dissemination and implementation strategiesKKJ 0Conclusions Imperfect evidence base for decision makers Many current rigorous evaluations have methodological weaknesses (eg unit of analysis errors) Poor reporting of study settings, barriers to change, content and rationale of intervention Generalisability of study findings is frequently uncertain , Z%Z %L7 Bx, @JSystematic review of guideline dissemination and implementation strategiesKKJ Conclusions Improvements in direction of effect in 86% of comparisons Reminders most consistently observed to be effective Educational outreach only led to modest effects Dissemination of educational materials may lead to modest but potentially important effects (similar effects to more intensive interventions) Multifaceted interventions not necessarily more effective than single interventions*   A5UK MRC Framework for Evaluating Complex Interventions66$5 B E  I#Towards evidence based practice  {Ferlie and Shortell suggested four levels at which interventions to improve the quality of health care might operate: the individual health professional; health care groups or teams; organisations providing health care (e.g., NHS trusts); the larger health care system or environment in which individual organizations are embedded. Ferlie, Shortell (2001). Milbank QuarterlyLw+w@ K  $  J$Towards evidence based practice  kLevels of engagement Policy Macro (national/provincial) Meso (organisational) Managerial Provider Consumer b2228  /  K%Towards evidence based practice  Most clinical care occurs within the context of a provider  patient dyad. Interventions at other levels are mediated through the provider  patient dyad. Provider behaviour is most proximal determinants of evidence based practice. Changing provider behaviour is (one of) the right objective(s) to promote evidence based behaviour. MZM&   ( F Implications for KU research$ Further research is required to develop a better theoretical understanding of professional behavior change by exploring determinants of provider and organisational behaviour to better identify modifiable and non modifiable factors Incremental predictive or action orientated models Emphasis should be on developing standard methods for operationalising theories and then testing their utility &:( F  * L&Implications for KU research$IFurther research is required to estimate the effectiveness and efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers. Rigorous designs (pragmatic RCTs) Maximise informativeness by exploring causal mechanisms (based on theoretical constructs) and economic evaluations&J [O)Implications for KU research$Further research is required to develop practical methods of identifying barriers and facilitators to change outside an academic context. j i G!Implications for KU research$Barriers to progress Lack of consensus around overarching frameworks and candidate theories Measurement issues Lack of interdisciplinary approach Lack of programmatic funding and approaches Lack of cohesion in KU research community (H"SummaryKU research is about saving lives, improving health outcomes and enhancing the quality of health services. The good news  changing physician behavior is possible though current efforts only achieve modest effects. I am currently more optimistic than ever that with concerted research effort within increasingly cohesive research community, it should be possible to improve incrementally KU. 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B2 O'Director, Clinical Epidemiology Program.-@Arial-. 72 V- Ottawa Health Research Institute.-՜.+,D՜.+,l(    On-screen Show ?  (ArialTimes New Roman WingdingsTahoma Book AntiquaNetworkMicrosoft Word PictureMicrosoft Graph Chart7Changing physician behavior: an exercise in futility?Personal perspectiveSlide 3 Background Background Background Background Background Background(Overview of previous systematic reviews*Problems with previous systematic reviewsKSystematic review of guideline dissemination and implementation strategiesKSystematic review of guideline dissemination and implementation strategiesResults included studies!Results methodological qualityKSystematic review of guideline dissemination and implementation strategiesKSystematic review of guideline dissemination and implementation strategiesKSystematic review of guideline dissemination and implementation strategiesKSystematic review of guideline dissemination and implementation strategiesKSystematic review of guideline dissemination and implementation strategies6UK MRC Framework for Evaluating Complex Interventions Slide 22 Slide 23 Towards evidence based practice Towards evidence based practice Towards evidence based practiceImplications for KU researchImplications for KU researchImplications for KU researchImplications for KU researchSummary/Implications for KU trainees (and researchers)  Fonts UsedDesign TemplateEmbedded OLE Servers Slide Titles D 4<Version _70cmmillercmmiller  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdeghijklmnopqrstuvwxyz{|}~     $Root EntrydO)PicturescCurrent UserSummaryInformation(xPowerPoint Document(f7DocumentSummaryInformation8