HIEBP Implementation Science Lecture Notes Jan 2024 PDF

Implementation Science: Getting evidence into practice MBBS Stage 1 Health Informatics and Evidence- Based Practice Professor Patrick White School of Life Course and Population Sciences Learning objectives for this lecture Understand what Implementation Science is* Understand the Su...

Implementation Science: Getting evidence into practice MBBS Stage 1 Health Informatics and Evidence- Based Practice Professor Patrick White School of Life Course and Population Sciences Learning objectives for this lecture Understand what Implementation Science is* Understand the Surgical Safety Checklist and how to interpret its effectiveness* Processes in implementation of evidence* Gaps in our understanding Interventions we might use* The research gaps * objectives that could be examined Improvement science – quality improvement by any other name Knowledge mobilization Knowledge utilization Quality improvement Knowledge transfer Knowledge translation What happens when evidence is implemented Change in behaviour Replace a behaviour, reject a behaviour, or adopt a new behaviour – at an individual level, group level or system level Implementation Science An example WHO Surgical Safety Checklist Health Informatics and Evidence Based Medicine Haynes et al 2009, NEJM, doi: 10.1056/NEJMsa0810119 What is evidence-based medicine? What is evidence-based medicine? What is evidence-based medicine? NHS: WHO Surgical Safety Checklist Where does the evidence come from? The WHO Surgical Safety Checklist Canadian Trial – NEJM 2014 Pre-checklist (n=109,341) Post-checklist (n=106,370) 30 day mortality 0.71% 30-day mortality 0.65% Complication risk 3.86% 30-dy mortality 3.82% Why were the results not replicated? Different materials and protocols? Different location and contexts? Statistical regression to the mean? Why were the results not replicated? “The likely reason for the failure…………………… ……….Is that it was not actually used” Dr Lucian Leape, Professor of Health Policy, Harvard, NEJM 2014 To put it another way…. The behaviour in the operating theatre didn’t change Can a checklist actively do anything? A checklist on a wall has no intrinsic power If the surgical team decides to incorporate it into their practice that will lead to behaviour change Behaviour change can be a powerful force for good ……. or ill  Why were the results not replicated? A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the “Surgical Checklist Implementation Project” Russ et al Ann Surg 2015 DOI: 10.1097/SLA.0000000000000793 10 hospitals in England Implementation varied in hospitals Some preplanned/phased approaches to the checklist “appearing” in operating rooms staff feeling it had been imposed Problematic integration into pre-existing processes. The most common barrier was resistance from senior clinicians.  Fig. 2 Estimated use of the Surgical Safety Checklist in facilities in low, medium, high and very high Human Development Index Countries Br J Surg, Volume 107, Issue 2, January 2020, Pages e151–e160, https://doi.org/10.1002/bjs.11321 The content of this slide may be subject to copyright: please see the slide notes for details. Determinants of behaviour Behaviour is influenced by a range of internal and external factors: Knowledge Skills Social/professional role and identity Beliefs about capabilities Beliefs about consequences Motivation and goals Memory, attention and decision processes Environmental context and resources Social influences Emotion Behavioural regulation Nature of the behaviours, and other factors Behaviour Change Techniques – BCTs – Susan Michie Taxonomy of behaviour change techniques – 93 at latest count Reference point for deciding the BCTs chosen to achieve a particularly behaviour outcome Requires understanding the behaviour change that is required Requires understanding the behaviour you want to change Michie S, et al A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy. Psychol Health. 2011 Nov;26(11):1479-98. doi: How do we change behaviour in health care? Lots of different approaches Public health campaigns - media, health service, schools, Legislation – seat belts, smoking, clean air, childhood immunisations Screening programmes – cancer screening, early childhood screening Local commissioning of services – smoking, breast feeding, Education of healthcare staff – prevention programmes Financial incentives - Quality and outcomes framework, Commission for Quality and Innovation Policing of services – Care Quality Commission What is the best approach for the behaviour change we are seeking? Statins are drugs to lower cholesterol in our blood Lowering cholesterol significantly reduces the risk of a recurrence of arterial blockage in those who have demonstrable arterial narrowing. They should be prescribed in high doses of the cheapest form of the drug. What are the obstacles to the behaviour? Eg changing the approach to the prescription of ‘statins’  Provide an educational programme for all prescribers on the use of statins Run a national media programme to inform patients what to expect Prevent the dispensing by chemists of the more expensive statins without justification Install a pop-up in the computer Block the prescribing of the expensive versions of the drug within the NHS Do an experiment to see which is the most cost-effective approach – fund it by the drug savings made? What does NICE say? NICE is committed to implementation of their guidance They offer >1100 pieces of guidance / advice on implementation of guidelines in local settings There is a common-sense approach – dominated by dissemination, audit, local service encouragement, and incentives There is very little evidence for what works best in each circumstance Do not do recommendations Nottinghamshire Healthcare collaboration with NICE Cessation of treatment Cessation of combined inhalers in chronic obstructive lung disease – COPD 2003 –a combination inhaler for Chronic Obstructive Pulmonary Disease In three years these combinations were the most costly drugs in the NHS. Most with COPD took them - only indicated for a minority Evidence published in 2013 – took six years for prescribing to fall White P et al 2013 PLOS One. doi:10.1371/journal.pone.0075221 Obstacles to implementation Lack of experience in the executors of Lack of necessary resources the implementation plan Lack of leadership Inadequate planning Lack of commitment Disorganised work culture Lack of prioritisation Poor readiness to change Poor team structure Key issues in implementation science 1. Implementation of evidence-based practice is about behaviour change 2. To achieve change the behaviour should be understood 3. Understanding the behaviour leads to the best change techniques 4. Evidence of benefit does not ensure implementation in practice 5. Interventions to implement change in health care should be tested The implementation of evidence-based practice Huge financial investment to show intervention efficacy/effectiveness The implemention of the intervention in clinical practice is rarely tested!