Do Guidelines Change Practice?

Discussing why Clinical Guidelines rarely change clinical practice, particularly in relation to inflammatory bowel disease (IBD). Discussion of the Pathman model, and 4 As - Awareness, Agreement, Adoption, and Adherence. How to make guidelines better, and how to make implementation an important part of guideline development. Ways front line clinicians can approach implementation successfully - don't try harder, but structure for success.

Transcript

1. Do Guidelines Change Practice? Peter D.R. Higgins University of Michigan @ibddoctor
2. Clinical Practice Guidelines • Clinical Impact of Guidelines • Barriers: the 4 As of the Pathman Model • Awareness • Agreement • Adoption • Adherence • How to Improve? Pathman, et al., Medical Care 1996; 34: 873-879
3. Do Guidelines Change Practice? •Usually not.
5. What are the Steps to Adherence? The 4 A’s • Awareness • Agreement • Adoption • Adherence Pathman, et al., Medical Care 1996; 34: 873-879
6. Leakage in Implementation The 4 A’s • Some practitioners lack Awareness ~ 10% • Some do not Agree ~ 30% • Some decide not to Adopt ~ 30% • Many do not Adhere ~ 65% Leakage across 29 recommendations in 11 clinical guidelines Micklan, S., et al. Postgrad Med J 2011;87:670-679
7. 1. Barriers to Awareness • Limited time to read journals / to go to meetings • Information overload • AGA has 27 current guidelines • ~10 recommendations in each ~ 270+ • Not available at point of care • Not integrated into care model / EMR • The RVU Hamster wheel Micklan, S., et al. Postgrad Med J 2011;87:670-679
8. Success in Increasing Awareness • Highly Credible Recommendations • Clear and Simple to Communicate • Available in Multiple Forms • Shared Publicly / Easily Accessible • Repeated Exposure • Reach Practitioners at Point of Care • Available in EMR? • Patients flagged with Best Practice Advisories (BPAs)? Mr. Jones is on immunosuppressive therapy for IBD, and has no documented pneumonia vaccinations in the past 5 years Order Pneumovax-23 Order Prevnar-13
9. 2. Barriers to Agreement • Lack of Awareness • Controversial recommendations • Vague recommendations • No evidence of outcome benefit • No evidence of cost-effectiveness • Complicated recommendations • One problematic recommendation makes the rest of the guideline less likely to be accepted. I DON’T THINK SO BMJ 1998; 317: 858-861.
10. Success in Increasing Agreement • Simple, Clear Recommendations • Fewer Recommendations • Consider Bundles • Avoid • Low-grade evidence • Controversial • Without proven outcomes • Expensive • Not cost-effective Micklan, S., et al. Postgrad Med J 2011;87:670-679
11. Problematic Presentation • Three recommendations: High quality No evidence Low quality Gastro 2019; 156: 218-226.
12. Conflicting Recommendations • 2004: Endocrinology societies sponsor a USPTF panel on whether to test and treat subclinical thyroid dysfunction • USPTF panel concludes evidence is weak • Routine public screening not justified for asymptomatic patients • Don’t treat asymptomatic patients with TSH between 0.1 and 10 • Endocrinology experts respond with guideline • Recommending routine screening in women planning pregnancy • Treat asymptomatic TSH > 4.5 • Reviewed the same data Ann Int Med 2004; 140: 128-141 J Clin Endo Metab 2004; 90: 581-585.
13. SCENIC Recommendation • When performing surveillance with high-definition colonoscopy, chromoendoscopy is suggested rather than white light endoscopy. (Low-quality evidence) Sands Gastroenterology Higgins AJG Ananthakrishnan CGH GIE 2015; 81: 489-501. Low-quality evidence Low Agreement Low Adherence
14. Success with Sepsis • Early warning systems • Clear and Simple Bundle • Reduces Mortality • Cost effective • Consensus and Effective Communication Mr. Jones has vital signs and lab values suggestive of sepsis Order Sepsis Bundle First hour Sepsis Bundle - Measure lactate - Blood Cx before Abx - Broad spectrum Abx - Rapid 30 mL/kg IVF - Vasopressors to keep MAP >= 65 Crit Care Med 2007 35: 1105-1112. CJEM 2017; 19: 112-121. Intensive Care Med 2011; 37: 444-452.
15. Success with Central Line Infections • Prevention with Bundles and Checklists • Clear and Simple Bundle • Checklist for follow-through • Monitor outcomes • Structure for success CLI Prevention Bundle - Central catheter insertion cart - Hand hygiene timeout - Maximal Barriers: drape, gown, glove, cap, mask - Chlorhexidine - Avoid femoral veins - Remove lines ASAP Crit Care Med 2007 35: 1105-1112. CJEM 2017; 19: 112-121. Intensive Care Med 2011; 37: 444-452.
16. How to make Guidelines more effective? • Fewer, high quality recs • Keep it simple and clear • Resist making recommendations when the data are weak
17. How to make Guidelines more effective? • Differentiate visually between • Strong recommendations • Weak suggestions • No recommendation Use combo anti-TNF with thiopurines over thiopurine monotherapy to induce remission in moderate to severe CD (high quality evidence) In conclusion, only low quality evidence is available. We suggest against using methotrexate to induce remission in moderate to severe CD. There is a large knowledge gap in the use of proactive anti-TNF therapeutic drug monitoring. We will make no recommendation other than to suggest the following features be included in future high-quality prospective clinical trials in an attempt to justify this practice:
18. How to make Guidelines more effective? • Focus on Implementation • How to integrate guidelines at the point of care? • Can you build recommendations into major EMRs? • Can the EMR identify patients to whom a recommendation applies? • Can the EMR present a one click order to address the gap? Mr. Jones has acute pancreatitis and is currently NPO Order Clear Liquid Diet, Advance as tolerated Order NG tube and Enteral Feeding
19. 3. Barriers to Adoption • Lack of Awareness • Lack of Agreement • Complexity • Difficult to achieve / no power to achieve • Lack of time/resources to overcome barriers • Many barriers built into EMR / health care systems • Inconsistent with patient preferences • HIV screening, colonoscopy prep • Inertia and learned helplessness Our EMR can’t do that Micklan, S., et al. Postgrad Med J 2011;87:670-679
20. 4. Barriers to Adherence • High cost to patient • Poor insurance coverage • Inconsistent with patient preferences • Patient does not know about guideline • Physician Time, resources • Inertia – investing in changing practice • Efficiency of Workflow Micklan, S., et al. Postgrad Med J 2011;87:670-679
21. Can You Increase Guideline Adherence? • Prospective study in 40 community GI practices • Evaluated adherence to IBD quality guidelines from AGA and endorsed by CMS PQRS • Random audit of 300 charts pre and post • Intervention: • Audit feedback session, adherence rates compared to peers • Identify barriers, brainstorm strategies for success with consultant • Webinar on evidence for quality guidelines • Interactive CME web videos to reinforce applying guidelines to cases • Monograph providing evidence for recommendations Awareness Agreement Adoption Adherence Sapir, T, Higgins PDR, et al. Dig Dis Sci. 2016; 61: 1862-1869.
22. Can You Increase Guideline Adherence? • Problem-solving goals • What are the barriers? • Can you fix these? Stock the vaccine? • Can you identify the patients with gaps? • Can that be automated? • Can someone else (MA, nurse) do that before clinic visits? • Can you automate the intervention? • In EMR – template, dotphrase, order set? – one click • Empower a nurse or MA – standing order / verbal order? – no clicks • Can you do this with • Fewer decisions? • Fewer clicks? • Less time? Sapir, T, Higgins PDR, et al. Dig Dis Sci. 2016; 61: 1862-1869.
23. Can You Increase Guideline Adherence? • Results 28% 43% 8% 28% 74% 89% 58% 83% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre Post Changes in Adherence to Guidelines With Intervention TB before anti-TNF HepB before anti-TNF Flu vaccine Pneumococcal vaccine Control Group +5% +16% +2% +0%
24. Lessons Learned • Lots of barriers to getting things done • Who tracks immunizations across clinical care sites? • Who stocks the vaccine? • Physicians can’t do everything • Huge cognitive load – 270+ recommendations • Which patients have which gaps? • Too many decisions • Most success – BMI obtained in 99% • “automated” – part of the workflow – build guideline adherence into workflow • Templates, dotphrases, order sets • Automate what you can • Make the EMR work for you • Empower members of your care team to help – flu shots. Sapir, T, Higgins PDR, et al. Dig Dis Sci. 2016; 61: 1862-1869.
25. Can Clinical Decision Support Systems Help? • Usually no • Factors common in CDSS that Do Improve Adherence • Integrated into clinical workflow / EMR • Not perceived to interfere with Physician/ Patient relationship • Interface is intuitive, fast • Physicians receive specific, hands-on, case-based training • Recommendations are patient-specific • Consider comorbidities, age, etc. • Recommendations are clear, specific, and can be acted upon immediately from the same screen Kilsdonk, E., et al. Int J Med Informatics. 2017; 98: 56-64.
26. Take Home Messages: Guidelines • Keep them simple and clear • Fewer recommendations • Focus on strong outcome evidence • Consider the patient perspective on costs • More interactive learning • Structure for successful implementation • Bundles • Checklists • Easy to build into workflow in EMR www.crohnscolitisfoundation.org/emr
27. Take Home Messages: Implementation • Start small – get a win • Focus on 2 guidelines that you strongly agree with • Ones that your clinical team is on board with, and that you can measure • Don’t try harder! • This is not sustainable • Invest time in structuring for success • Make your EMR work for you • Empower your team • Structure for successful implementation • Make it easy to identify gaps in adherence • Make it easy to order the fix (one click or no clicks)
28. Thank You