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  • Making information useful for decision makers Jeremy Grimshaw MD, PhD Director of the Canadian Cochrane Centre and Network Clinical Epidemiology Program, Ottawa Health Research Institute Department of Medicine, University of Ottawa

  • Outline

    • Background • Effectiveness of strategies targeting different

    decision makers • Current knowledge translation concepts • Health technology applications

  • Background

    • Health technology assessments aim to inform decision making at all levels of health care systems.

    • Considerable development over last two decades in health technology methods.

    • Health technologies are struggling to optimise the dissemination and implementation of health technology assessments to maximise their impact.

  • Background

    Potential target audiences for HTA • Policy makers

    – Macro (national/provincial) – Meso (organisational)

    • Managerial • Provider • Consumer

  • Background

    • Most of the approaches to dissemination and implementation are more often based on beliefs than on scientific evidence

    • ‘Evidence based medicine should be complemented by evidence based implementation’

    Grol (1997). British Medical Journal.

  • Effectiveness of strategies targeting different decision makers

    Cochrane Effective Practice and Organisation of Care (EPOC) Group aims to undertake systematic reviews of interventions to improve healthcare delivery and healthcare systems including:

    • Professional interventions (e.g. continuing medical education, audit and feedback)

    • Financial interventions (e.g. professional incentives) • Organisational interventions (e.g. the expanded role of

    pharmacists) • Regulatory interventions

    Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Zwarenstein (2005). Cochrane Library.

  • EPOC progress to date - register and reviews • Register of 3500+ primary studies • 33 reviews, 26 protocols • Collaborating with over 180 researchers from 12

    countries

    Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Zwarenstein (2005). Cochrane Library.

    Effectiveness of strategies targeting different decision makers

  • Effectiveness of strategies targeting policy makers and managers

    • Health policy-makers perceptions of their use of evidence: a systematic review

    • 24 studies involving 2014 interviews with health policy makers

    • Most studies focused on hypothetical scenarios or retrospective perception of the use of evidence in relation to specific cases.

    Innvaer, Vist, Trummald, Oxman (2002). Journal of Health Services Research and Policy

  • Effectiveness of strategies targeting different decision makers

    • Facilitators – Personal contact (13/24) – Timely relevance (13/24) – Inclusion of summaries with policy recommendations

    (11/24) • Barriers

    – Absence of personal contact (11/24) – Lack of timeliness or relevance of research (9/24) – Mutual mistrust (8/24) – Power and budget struggles (7/24)

    Innvaer, Vist, Trummald, Oxman (2002). Journal of Health Services Research and Policy

  • Effectiveness of strategies targeting health care professionals

    Effective Health Care Bulletin (1999). Getting evidence into practice. Effective Health Care Bulletin, 5(1). London, Royal Society of Medicine Press.

    Also available from: http://www.york.ac.uk/inst/crd/ehc51.pdf

  • Effectiveness of strategies targeting health care professionals

    Multifaceted interventions

    Educational outreachLocal opinion leadersDidactic educational session

    RemindersAudit and feedbackDissemination of printed educational materials

    Generally effectiveMixed effectsGenerally ineffective

    Bero et al (1998). BMJ Grimshaw et al (2002). Medical Care

  • Effectiveness of strategies targeting health care professionals

    Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C, Vale L et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004.

    (Available from: http://www.hta.nhsweb.nhs.uk/)

  • Effectiveness of strategies targeting health care professionals

    Results • Included 285 reports of 235 studies, yielding

    309 separate comparisons • 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

  • Effectiveness of strategies targeting health care professionals

    –1.0%, +34.0%

    +1.3%, +16.0%

    +3.6%, +17.0%

    Range

    +14.1%14Reminders

    +7.0%5Audit and feedback

    +8.1%5Educational materials

    Median effect size

    Number of CRCTs

    Intervention

    Single interventions

  • Effectiveness of strategies targeting health care professionals

    16 28 46 63 56 N =

    Absolute effect size

    Number of interventions in treatment group

    >4 4 3 2 1

    80%

    60%

    40%

    20%

    0%

    -20%

    -40%

    -60%

    -80%

    Multifaceted interventions

  • Effectiveness of strategies targeting health care professionals

    Multifaceted interventions including educational outreach •13 CRCT

    Range –4% to +17.4% (median +6.0%)

  • Effectiveness of strategies targeting health care professionals

    • 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

  • Effectiveness of strategies targeting patients

    • Cochrane Consumers and Communication Review Group aims to undertake systematic reviews of interventions to improve communication with consumers

    • Register of 4538 primary studies • 12 systematic reviews and 20 protocols

    – Decision aids for people facing health treatment or screening decisions

    – Interventions for helping patients to follow prescriptions for medications

    – Recordings or summaries of consultations for people with cancer

  • Effectiveness of strategies targeting patients

    • Decision aids for people facing health treatment or screening decisions

    • Included 35 RCTs • Decision aids improved:

    – knowledge – more realistic expectations – lower decisional conflict related to feeling informed – increased proportion of people active in decision making – reduced proportion of people who remained undecided post

    intervention • Decision aids had a variable effect on which healthcare options

    were selected. O'Connor AM, et al (2003). Cochrane

  • Effectiveness of strategies targeting different decision makers

    Summary • Relatively sparse evidence base especially for

    policy makers and managers • Health technology agencies need to use

    considerable judgment about how to disseminate HTAs to different target audiences

  • Current knowledge translation concepts

    • Knowledge translation is about ensuring that: – stakeholders are aware of and use research evidence

    to inform their decision making – research is informed by current available evidence

    and the experiences and information needs of stakeholders

  • Knowledge translation models

    • Push • Pull • Linkage and exchange • Knowledge brokers

  • Push models (1)

    • Improving dissemination by researchers • Five key questions

    – What should be transferred? – To whom should research knowledge be transferred? – By whom should research knowledge be transferred? – How should research knowledge be transferred? – With what effect should research knowledge be

    transferred?

    Lavis JN, Robertson D, Woodside JN, Mcleod CB, Abelson J (2003) Milbank Quarterly

  • Push models (2)

    • Multiple approaches targeting different stakeholder groups – Actionable messages – Policy briefings (1, 3, 25) – Policy seminar and workshops – Toolkits – Peer reviewed papers – Other – patient decision aids, guidelines

  • Pull models

    • Increase demand from decision makers • Enhancing receptor capacity

    – Critical appraisal skills – EXTRA training program – Policy maker secondments

  • Linkage and exchange

    • Creating new relationships between HTA agencies and policy makers to enhance mutual understanding and develop partnerships for framing and conducting HTA.

  • Knowledge brokers

    • Using knowledge brokers to build and nurture relationships between those involved in joint knowledge production (researchers and policy makers)

  • Making information useful for decision makers

    • Health technology agencies

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