When Evidence Is Not Implemented in Practice Lecture 2024 - PDF

When Evidence is not Implemented in Practice MBBS Stage 1 Health Informatics and Evidence-Based Practice Block Patrick White Professor of Primary Care Respiratory Medicine School of Life Course and Population Sciences Learning objectives of this lecture The efficacy - effectiveness gap T...

When Evidence is not Implemented in Practice MBBS Stage 1 Health Informatics and Evidence-Based Practice Block Patrick White Professor of Primary Care Respiratory Medicine School of Life Course and Population Sciences Learning objectives of this lecture The efficacy - effectiveness gap The limits of randomised controlled trials Achieving implementation of evidence Analysing failed implementation Getting our ducks lined up Being prepared Communicating effectively Ensuring the required resources are available Enlisting the help needed for the task Using these resources efficiently Link with a vertical theme in the curriculum The vertical theme to which we are linked is Quality Improvement and Evidence-Based Practice. Year 2 Introduction to Clinical Research Year 3 Scholarly Projects Year 4 Quality Improvement Projects Year 5 Clinical Project – Transition to Practice Efficacy and effectiveness Efficacy the power or ability to produce an effect best tested in medicine with a randomized controlled trial Effectiveness the degree to which something is successful in producing a desired result best tested in medicine with a ‘real’ world trial Efficacy - effectiveness gap The efficacy-effectiveness gap describes the differences in outcomes between patients treated in RCTs and those treated in the ‘real world’ In an RCT everything is arranged to represent the ideal In real world trials the experiment is messy because the restrictions on participants, staff and patients, is much less. Randomised Controlled Trials – their limits Randomised Controlled Trials – their strengths experiment to reduce bias when testing treatment efficacy random allocation of subjects to two or more groups treat them differently, compare the response the experimental group—receives the intervention, eg a drug the control group—receives an alternative perhaps a placebo the groups are monitored to determine the efficacy of the experiment Randomised Controlled Trials – their strengths Accurate unbiased measurement of treatment effect High degree of internal validity Strict eligibility criteria - homogenous study population Accurate measurement of treatment effect Reduced inter-patient variability Randomised Controlled Trials – their limits Randomised Controlled Trials – their Limits Suboptimal representation of patients treated in the real world setting Most marked among patients with advanced age or greater comorbidities Alternative – Real World Trials Less restrictive recruitment criteria Ensure that people with previous ineligible characteristics are matched on both sides of the trial Implementation Science The study of methods of integration of research and evidence-based interventions into routine clinical practice Increasingly, research trials have an implementation çomponent Research funders want to see successful treatments implemented without delay Antibiotics Prescribing of antibiotics Questionable effectiveness in respiratory infections Associated with increasing resistance in bacteria Associated with 50,000 preventable deaths in people admitted to hospital Can be costly Associated with side effects Prescribing of antibiotics for respiratory infections Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial Little et al. Southampton Lancet 2013 DOI: 10.1016/S1473-3099(12)70300-6 Prescribing of antibiotics for respiratory infections Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial Lancet 2013 DOI: 10.1016/S1473-3099(12)70300-6 Conclusion: When pneumonia is not suspected clinically, amoxicillin provides little benefit for acute lower-respiratory-tract infection in primary care both overall and in patients aged 60 years or more, and causes slight harms. Implementation challenge Antibiotic Prescribing Areas of implementation Individual clinician Local groups Professional groups Organisation Region Society Individual clinician Investigation Prescribing Non-drug interventions Local groups Hospital teams General practices Community teams Professional groups Paediatricians Infectious disease clinians Public health clinicians Facilitators of implementation Experienced leadership Detailed planning Team engagement Prioritisation Provision of required resources Obstacles to implementation Lack of commitment by management Disorganised work culture Poor readiness to change Poor team structure Implementation challenges The implementation of research evidence to improve the health outcomes of disease The implementation of research evidence to prevent harm from the persistence of discredited treatments.