We have the evidence to improve venous leg ulcer outcomes: How do we get this evidence into practice? Rajna Ogrin BSc, BPod(Hons), PhD Senior Research Fellow Appropriateness of Healthcare delivery in the community American adults received recommended care only 55% of the time in the years 1999 2000 (McGlynn et al, 2003) Similar study in Australia: Adult Australians received appropriate care at 57% (95% CI, 54% 60%)of 35 573 eligible health care encounters (Runcimanet al, 2012)
Current information on care of VLU in Australia KPMG 2013 study commissioned by AWMA VLU treatment currently involves Variety of treatment provider arrangements Across jurisdictions Variable Compression therapy use: By community nurses range from 17-100% By GP s range from 0-50% Limited data available on healing times Had to draw on the published literature Coyer et al 2005 shows more detailed info re: variation from best practice And yet we have many clinical practice guidelines and systematic reviews highlighting what is best practice... NHMRC 61 new guidelines and standards issued between 2009 2012 We have a number of clear, evidence based, clinical practice guidelines in VLU for: Assessment Diagnosis Management Prevention of recurrence Eg. AWMA, SIGN
VLU We know that implementing evidence based care is significantly related to improved healing outcomes (p < 0.001) (Edwards et al, 2013) So why isn t evidence implemented in practice? Need to ask... How do clinicians translate new knowledge into specific clinical actions that they adopt into practice?
Current thinking Evidence Something magic happens Change in practice Reality Requires active processes of translation Start with clinicians awareness that there s an issue End with patient adherence to the recommended care New science developed on this topic: Implementation Science Much research being done in this area Indicate that a raft of processes required Complex
GreenhalghT, Robert G, Macfarlane F, Bate P, KyriakidouO. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly2004;82(4):581-629. To simplify 5 key questions From Grimshaw et al. 2012
What should be transferred? Up-to-date systematic reviews or other syntheses of the global evidence BUT must be in a form that is appropriate for those using them To whom should research knowledge be transferred? Varies by the type of research being translated Eg clinical research demonstrating harm of treatment National policy makers (including regulatory bodies) and industry. clinical research demonstrating benefits from treatment Patients, healthcare practitioners, local administrators, national policy makers, and industry
By whom should research knowledge be transferred? Depends on the target audience and research knowledge being transferred Need to spend effort to identify most appropriate May be an individual healthcare provider, researcher, or consumer, group, organization, or healthcare system. Must have... Credibility with the target audience, Possess the skills and experience needed to transfer the research knowledge at hand, and Have time and resources to do so
How should research knowledge be transferred? Process must be planned Systematic sequence including over a dozen steps Most need to be addressed BEFORE implementation begins. Best achieved through combination of multiple activities assessment, negotiation and collaboration, organized planning and structuring, personal reflection and critical analysis. (Meyer, Durlak and Wandersman, 2012) Identify barriers and which are modifiable and non-modifiable Organizational culture lack of leadership commitment lack of middle management engagement lack of ownership lack of equitable resourcing for people, process and technology
Operational barriers poor Knowledge Management processes lack of appropriate technology and skills issues with the scope of the content too large, inadequately representative No culture of continually learning and incorporating the needed and accessible knowledge into practice the physical layout of the work environment does not match the collaborative intent of the strategy. Individual barriers Eg. Resistance to the sharing of knowledge at the individual level It s not convenient. They don t know what they know. They don t know the value of what they know. They believe knowledge hoarding is job security. They don t get credit for it. They don t have the time. (Taylor Gates, 2006)
Barriers to EBP in wounds: Lack of: information and skills (Coyer et al, 2005; Harrison et al, 2005) difficulties with access to evidence based guidelines (Fife et al, 2010) reimbursement associated with specialist wound care and treatments such as compression bandaging high cost of care (Fife et al, 2010; Weller, & Evans, 2012) limited access to specialist multidisciplinary teams (Ndip& Jude, 2009) poor communication (Coyer, et al, 2005) Taken from Edwards et al, 2013 Next step... Choose appropriate interventions to address overcoming barriers and supporting enablers: identify potential adopters and practice environments; and prioritise which barriers to target based upon consideration of mission critical barriers.
Strategies Professional behaviour change strategies Printed educational materials Educational meetings Interactive and participatory Educational outreach Local opinion leaders Reminders Audit and feedback any summary of clinical performance of healthcare over a specified period of time to change health professional behaviour Tailored interventions Multifaceted interventions Strategies focusing on consumers Interventions to: facilitate communication and/or decision-making support behaviour change inform and educate Strategies focusing on policy makers and senior health service managers Increase interactions between researchers and policy makers; and Research to match beliefs, values, interests, or political goals & strategies of elected officials, social interest groups, &others.
With what effect should research knowledge be transferred? Varies across different stakeholder groups Health care professionals Practice that is more evidence-based Observable changes in professional behaviours and quality indicators. Policy Makers ensure that consideration of research evidence is a key component of their decision making, but recognize that there are other legitimate factors Eg. the policy context for policy makers, values and preferences of individual patients so likely evidence-informed Continuous Improvement Should be based on ongoing monitoring of the appropriateness of care (Runciman et al, 2012). A Clinical registry is one effective approach... It provides a summary of clinical performance of healthcare over a specified period of time Can be used to change health professional behaviour
References Coyer, Fiona M., Edwards, Helen E., & Finlayson, Kathleen J. (2005) National Institute for Clinical Studies Report for Phase 1, Evidence Uptake Network : Best Practice Community Care for Clients with Chronic Venous Leg Ulcers. Queensland University of Technology, Brisbane, QLD. http://eprints.qut.edu.au/. Edwards H, Finlayson K, Courtney M, Graves N, Gibb M and Parker C. Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care. BMC Health Services Research 2013, 13:86. http://www.biomedcentral.com/1472-6963/13/86 Fife C, Carter MJ, Walker D: Why is it so hard to do the right thing in wound care? Wound Repair Regen2010, 18:154 158 GrimshawJM, Eccles MP, LavisJN, Hill SJ, Squires JE. Knowledge translation of research findings. Implementation Science 2012;7(50). Harrison MB, Graham ID, LorimerK, Friedberg E, PierscianowskiT, BrandysT: Leg-ulcer care in the community, before and after implementation of an evidence-based service. Can Med Assoc J 2005, 172:1447 1452. McGlynnEA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N EnglJ Med 2003; 348: 2635-2645. Meyers DC, DurlakJA, WandersmanA. The Quality Implementation Framework: A Synthesis of Critical Steps in the Implementation Process. American Journal of Community Psychology 2012. NdipA, Jude E: Emerging evidence for neuroischemicdiabetic foot ulcers: Model of care and how to adapt practice. Int J Lower Extrem Wounds 2009, 8:82 94 NHMRC NHMRC Strategic Plan 2013 2015. NHMRC, Canberra, 2012. RuncimanWB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012; 197: 100-105. Taylor Gates, O. (2006). The knowledge management toolkit. Ovitz Taylor Gates Pty Ltd. Available for purchase at http://www.w3j.com/2/index.html Weller C, Evans S: Venous leg ulcer management in general practice. Aust Fam Physician 2012, 41:331 337. Thank you rogrin@rdns.com.au