Clinical Practice Guidelines We Can Trust (2011) / Chapter Skim
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6 Promoting Adoption of Clinical Practice Guidelines
6 Promoting Adoption of Clinical Practice Guidelines
Pages 145-186
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From page 145... ...
Characteristics of the intended users and context of practice are as important as guideline attributes for promoting adoption of CPG recommendations. The committee's recommendations for individual and organizational interventions for CPG implementation are as fol lows: Effective multifaceted implementation strategies targeting both individuals and healthcare systems should be employed by implementers to promote adherence to trustworthy CPGs.
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of adults living in 12 metropolitan areas of the United States found participants received recommended care 54.9 percent of the time. The proportion of those receiving recommended care varied only slightly among adults in need of preventive care (54.9 percent)
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From page 147... ...
STRATEGIES FOR IMPLEMENTATION OF CPG RECOMMENDATIONS Promoting uptake and use of CPGs at the point of care delivery represents a final translation hurdle to move scientific findings into practice. The field of translation research is a relatively young science, and addressing this final step of bringing research findings into the mainstream of typical practice is an important challenge (Avorn, 2010)
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From page 148... ...
(This topic is discussed further in Chapter 5.) Implementation strategies that address the process of integrating essential content from CPGs to the local practice context and
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From page 149... ...
Ultimately, incorporation of reminders and clinical care algorithms into electronic decision support systems holds great promise to promote use of CPGs and is discussed in further detail in the sec tion on Electronic Interventions for CPG Implementation. Electronic decision support systems can also address adoption of recommendations from multiple CPGs in the care of individuals with multiple comorbidities.
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. Forsetlund summarized 81 trials on continuing medical educa tion didactic lectures and workshops and found consistent but small effects, with a mean 6 percent absolute increase in desired clinical practices from educational meetings used alone or as a component of multifaceted interventions (Forsetlund et al., 2009)
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From page 151... ...
Intended users of a CPG must be clearly delineated to promote use of CPG recommendations at the point of care delivery. CPGs are likely to impact the practice of multiple players and types of clini
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Specific practice indicators selected for PGA are derived from CPG recommendations. Studies have shown improvements in performance when PGA is part of a multifaceted implementation intervention (Horbar et al., 2004; Titler et al., 2009)
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. One study on use of data feedback for improving treatment of acute myocardial infarction found that (1)
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Healthcare Systems Type (e.g., public, private) and complexity of healthcare organizations influence adoption of CPG recommendations.
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. Infrastructure Support Infrastructure support to promote use of CPG recommendations is defined in a variety of ways, but usually includes absorptive capacity, leadership, and technology infrastructure (discussed in the section on Electronic Interventions for CPG Implementation)
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From page 156... ...
implement staff performance expectations that include using CPG recommendations; (3) integrate the work of CPG implementation into the governance structure of the healthcare system; (4)
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Interventions aimed at knowledge management (optimal organization of knowledge within an organization principally via use of technology to support patient care) resulted in improved adherence to CPG recommendations and patient outcomes.
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From page 158... ...
This information is then used in tailoring an intervention for the setting that will promote use of specified CPG recommendations. Based on a recent systematic review of 26 studies, effectiveness of tailored implementation interventions is modest, and shows wide variation across studies (Baker et al., 2010)
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The GAP quality improvement project measured implementation of improvement strategies in 10 acute care hospitals in southeast Michigan. Mehta and colleagues found adherence to key treatments increased in administration of aspirin (81 percent vs.
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In summary, multiple organizational factors influence implementation of CPG recommendations. While allowance for alternatives to CPG recommendations is necessary given patient variation and preferences as well as contrasting guideline implementation processes across clinical topics and actions, implementation strategies at the organizational level are critical.
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From page 161... ...
Computer-aided clinical decision support, often based on translation of CPGs, should facilitate a more personalized and timely form of guideline-based care. Diagnostic decision support, preventive care reminders, disease management or protocols for bundles of reminders, and drug dosing and prescribing protocols are all examples of interactive, point-of-care CDS (Garg et al., 2005)
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From page 162... ...
The web tool offered patient-tailored recommendations based on patient-specific input data supplied by physicians. A randomized controlled trial (RCT)
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From page 163... ...
; and (4) offered choices, or the options available to a decision support user when a rule is invoked (e.g., change a medication order)
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From page 164... ...
CPG use in EHR reminders practice Internet-based Improve physician Generic Physician volition decision support knowledge of (i.e., no EHR-based for tuberculosis guidelines trigger) therapy Clinical Improve quality of care Generic -- reminders for diabetes and heart for diabetes, disease using EHR coronary reminders heart disease Highly Physician opens tailored medical record Asthma-Critic Provide patient- Generic -- specific asthma treatment feedback Highly Automatic when using EHR data tailored record is open and asthma-specific data are entered SOURCE: Jones et al.
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From page 165... ...
165 PROMOTING ADOPTION OF CLINICAL PRACTICE GUIDELINES Input Data Intervention Offered Choices Tailored inbox message Inbox message lists internal in EHR that links to and external guideline patient record resources that provide detailed information on osteoporosis evaluation and management Demographic and diagnostic information from the EHR used to identify patients requiring management None Availability of web- None; guidelines are read based or CD-ROM– only based access to text of guidelines for dementia, Chronic Heart Failure, Urinary Track Infection, and colorectal carcinoma Physician-provided data Web-based Guideline-based on patient characteristics implementation of recommendations for and clinical reaction to hierarchical decision treatment diagnostic test tree for administering preventive therapy -- -- Care recommendation; reminders were actionable, but did not require acknowledgment or link to intervention EHR data (lab, radiology Reminders list in the -- results, problem list, medi- EHR in the context cation list, allergy list) of other patient data -- -- -- Physician-entered data on On-screen, patient- Physician presented with diagnosis and treatment specific comments "critiquing comments" presented to physician, related to treatment tailored to current decisions; can drill down clinical situation to view guidelines to understand reason for comment
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Yet even when EHR systems are in place, input data may be poorly represented (e.g., U.S. Preventive Services Task Force gonorrhea guideline requirement for sexual activity assessment)
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in Boston, Wishard Health System/Regenstrief Institute and Roudebush VA Medical Center in Indianapolis, the Mid-Valley Independent Physicians Association in Salem, Oregon, and the University of Medicine and Dentistry of New Jersey in New Brunswick, New Jersey with both commercially developed and internally developed EHR and CDS systems. From this effort arose guidance for enhancement of CDSdriven CPG implementation founded on locally extant knowledge and systems that were applicable to the universe of clinical practice environments.
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From page 168... ...
Where risk of confusion and of making the "wrong decision" increase (e.g., as decision complexity increases) , decision support tools may become increasingly important for providers involved in care processes at all levels.
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From page 169... ...
Electronic Health Records (EHRs) will result include laboratory test results, patient in guidelines that cannot be incorporated in demographics, and the problem list; CPGs a computable manner within EHRs should specify only coded data types that are currently or soon will be available in certified EHRs 2 Work on increasing clarity CPGs should minimize the ambiguity Logic in CPGs must be able to be and internal consistency of of their recommendations (e.g., include incorporated in a computer-executable form all clinical logic included in threshold values for blood pressure rather guidelines than stating "if the patient's blood pressure is high then.
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From page 170... ...
TABLE 6-2 Continued 170 Number Recommendation Description Rationale 4 Guidelines should facilitate Specify explicitly when particular rules Allow rules to be turned off when they do selective filtering or either apply or don't apply in the rule's not apply to a clinical context (e.g., specific tailoring of rules logic description practices, physicians, specialties, or clinical situations) 5 Guidelines should support Specific definitions of items such as clinical Allow EHRs to link to specific sections of the Health Level (HL7)
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From page 171... ...
DECISION ANALYTIC MODELING AND CPG IMPLEMENTATION A frontier of evidence-based medicine is decision analytic modeling in health care alternatives' assessment. Through discussions with leaders in the field, David Eddy and Wiley Chan, the committee explored potential applications of decision analysis to development and implementation of CPGs.
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From page 172... ...
The following section discusses some of the legal issues related to use or nonuse of guidelines. All physicians are affected by medical malpractice, whether they have been sued by a patient or not, through insurance premiums they pay.
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. The authors compared those data to specialty and state liability environments and found that physicians had high levels of concern about risks of malpractice cases across specialty, fee-for-service, or health maintenance practice settings, and geographic areas.
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. Further, some CPG proponents worry that if courts use guidelines as standards of care in malpractice suits, CPG developers may be more reluctant to write strong clinical recommendations (and instead water down recommendations with weasel words and disclaimers)
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In Committee on Standards for Trustworthy Clinical Practice Guidelines commissioned paper. Baars, J
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2004a. Data feedback efforts in quality improvement: lessons learned from U.S.
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2008. Prompting clinicians about preventive care measures: A systematic review of randomized controlled trials.
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Practice guidelines as affirmative defense: The Cesarean Demonstration Project Report. Fonarow, G
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Cochrane Database of Systematic Reviews (1)
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In Committee on Standards for Trustworthy Clinical Practice Guidelines commissioned paper. Kanter, M., O
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2007. Use of clinical practice guidelines in medical malpractice litiga tion.
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2001. Of swords and shields: The role of clinical practice guidelines in medical practice litigation.
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In Committee on Standards for Developing Trustworthy Clinical Practice Guidelines commissioned paper. Scott, S
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2009b. A set of preliminary standards recommended for achieving a national repository of clinical decision support interven tions.
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2009. Clini cal decision support capabilities of commercially-available clinical information systems.
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