Getting evidence into
practice
How can we influence health professionals’ behaviour to promote evidence-based practice?
How can we help organisations develop the appropriate structures, systems and values to support evidence-based practice?
What does an ‘evidence-based organisation’ look like?
Why are health professionals slow to adopt
evidence-based practice?
How much avoidable suffering is caused by failing to implement evidence?
Woolf and Johnson (Annals of Family Medicine): ‘The break-even point: when medical advances are less important than improving the fidelity with which they are delivered’.
example: A systematic review by the Antithrombotic Trialists Collaboration: use of aspirin by patients who had previously experienced a stroke or transient ischemic attack reduces the incidence of recurrent nonfatal strokes by 23%. McGlynn et al.1 reported, however, that antiplatelet therapy is given to only 58% of eligible patients. That is, in a population in which 100,000 people were destined to have strokes, only 13,340 strokes would be prevented, whereas achieving 100% fidelity in offering aspirin would prevent 23,000 strokes.
Marteau and colleagues
flawed assumption that people behave in a particular way because (and only because) they lack knowledge, and that imparting knowledge will therefore change behaviour
psychological theories that might inform the design of more effective educational strategies
Social cognition
Stages of change models
Behavioural learning
What sort of educational approaches have actually been shown to be effective for promoting evidence-based practice?
conventional EBM teaching in undergrad
classroom-based EBM training in qualified doctors--> little or no impact on their knowledge or critical appraisal skills; maybe bc
‘integrated’ EBM teaching (e.g. during ward rounds or in the emergency room) or intensive short courses using highly interactive learning methods
improves students’ EBM knowledge and attitudes
impact on their performance in dealing with real cases not convincingly demonstrated
both the training and the tests are non-compulsory
the training itself is too little, too superficial, too formulaic,
too passive and too removed from practice
--> significant changes in knowledge, skills and behaviour
no direct impact yet been demonstrated from such courses
on any patient-relevant outcomes
Green
EBM teaching should occur in the clinic and at the bedside (adult learning theory)
real-world practical barriers (lack of time, evidence inaccessible when it is needed, unforgiving organisational culture, etc.) account for much of the theory–practice gap in EBM implementation
key factors associated with a person's readiness to adopt health care innovations
Context-specific psychological antecedents
General psychological antecedents
Meaning
Nature of the adoption decision
Concerns and information needs
Rogers: interpersonal contact is the most powerful method of influence
The main type of interpersonal influence relevant to the adoption of evidence-based practice: the opinion leader
Another important model of interpersonal influence: one-to-one contact between doctors and drug company representatives whose influence on clinical behaviourmay be so dramatic that they have been dubbed the ‘stealth bombers’ of medicine.
this tactic has been harnessed by non-commercial change agencies in what is known as academic detailing: the educator books in to see the physician in the same way as industry representatives, but in this case the ‘rep’ provides objective, complete and comparative information about a range of different drugs and encourages the clinician to adopt a critical approach to the evidence [that in a real-world setting,
consistent [29], positive changes to patient care may be hard to demonstrate]
use of computerised decision support systems that incorporate the research evidence and can be accessed by the busy practitioner at the touch of a button
less important: the structure of the organization
more important: absorptive capacity: the organisation’s ability to identify, capture, interpret, share, reframe and re-codify new knowledge, to link it with its own existing knowledge base, and to put it to appropriate use; pre-requisites:
a ‘learning organisation’ culture
proactive leadership directed towards
enabling this knowledge sharing
the organisation’s existing knowledge and skills base, and pre-existing related technologies
receptive context for change
clear strategic vision
good managerial relations
strong leadership
visionary staff in key positions
absorptive capacity
positions, a climate conducive
to experimentation and risk-taking
effective data capture systems
Gustafson’s determinants of successful change projects in health care organisations
tension for change
balance of power
perceived advantages
flexibility
time and resources
different models of professional and organisational
change in relation to effective clinical practice
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