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![3D"Text](3D"master46_image002.png")
05_stag fin report v3(cl)1
Impleme=
nting
evidence-based practices in
reproductive health
Metin Gülmezoglu M.D., Ph.D
Department of Reproductive Health and Research
=
;
World Health Organization
Training Course in
Reproductive Health / Sexual Health Research
Geneva 2006=
![3D"Text](3D"master45_image003.png")
PGC implementation 2006
Implementation research – is it something <=
/span>new?
Operations research
Knowledge translation
Behaviour change
Programmatic resear=
ch
Usually indicates getting practices, activities pr=
oven
to be beneficial (in previous effectiveness research) into use
PGC implementation 2006
Backgrou=
nd
<=
span
lang=3DEN-GB style=3D'font-size:88%'>Clinical research is consistently pro=
ducing
new findings that may contribute to effective and efficient patient care&#=
13;•
•Grimshaw, Ward, Eccles.
Oxford Handboo=
k of
Public Health.
PGC implementation 2006
Background
=
=
Consistent evidence of failure to translate research findings into clinical practice
=
–30-40% patients do not get treatments of proven effectiveness
=
–20–25% patients get care that is not needed or potentially harmful
=
Increased policy interest in knowledge translation activities to promote evidence =
based practice
Schuster,
McGlynn, Brook (1998). <=
i>Milbank
Memorial Quarterly
•Grol R (2001). M=
ed Care
PGC implementation 2006
Informat=
ion
management is insufficient
=
Health care professionals still have limited time =
=
to read
=
Health care professionals only recognize a =
minority of information needs
PGC implementation 2006
Corticosteroids be=
fore
34 weeks
![](3D"slide0062_image007.png")
Intervention
Control
![](3D"slide0062_image008.png")
PGC implementation 2006
No episiotomy with spontaneous vaginal birth
![](3D"slide0063_image011.png")
Intervention
Control
![](3D"slide0063_image012.png")
PGC implementation 2006
Antibiotics at cae=
sarean
section
Intervention
Control
PGC implementation 2006
Background
<=
span
lang=3DEN-GB style=3D'font-size:94%'>Increased policy interest in active <=
/span>implementation strategies
=
•Grol (1997). British Medical Journal.=
PGC implementation 2006
Changing provider
behaviour
Commonly
educational approaches have been us=
ed in
attempts to change provider behavio=
ur.
=
These assum=
e that
key barriers relate to indivi=
dual
professionals’ knowledge, attitu=
des
and skills.
Usually the=
re is
more than one barrier operating at mult=
iple
levels.
<=
span
style=3D'visibility:hidden'>
=
PGC implementation 2006
=
Structural (e.g. financial
disincentives)
=
Organisational (e.g. inappropriate sk=
ill mix,
lack of facilities=
or
equipment)
=
Peer group (e.g. local standards of c=
are not
in line =
with
desired practice)
=
Individual (e.g. knowledge, attitudes,
skills)
=
Professional - patient interaction (e=
.g. =
problems with information processing)=
Potent=
ial
barriers to evidence based practi=
ce
PGC implementation 2006
Cochrane Effective Practice and Organisation of Care (EPOC) Group
=
=
•EPOC aims to undertake systematic reviews of interventions to improve practice
including:
=
Professional interventions (e.g. cont=
inuing medical education, audit and feedback=
)
=
Financial interventions (e.g. profess=
ional incentives)
<=
span
lang=3DEN-GB style=3D'font-size:88%'>Organisational interventions (e.g. th=
e expanded role of pharmacists)
<=
span
lang=3DEN-GB style=3D'font-size:88%'>Regulatory interventions
•
=
Alderson, Bero, Grilli, Grimshaw, MaC=
auley,
Oxman, Zwarenstein (2002). Cochrane Library.
PGC implementation 2006
Progress to date - register and reviews
Collaborating with over 120 researchers from 12 countries
<=
span
class=3DBB>Register of 4200+ primary studies
Register of 4200+ primary studies
<=
span
class=3DBB>35 reviews, 25 protocols
35 reviews, 25 protocols
Collaborating with over 120 researchers from 12 countries
•
<=
span
style=3D'mso-special-format:nobullet;display:none;color:#CC0000;font-size:=
50%'>•Alderson, Bero, Eccles, Grilli, Grims=
haw,
Mayhew, Oxman, Zwarenstein (2004). =
Cochrane Library.
Cochrane Effective Practice and Organisation of Care (EPOC) Group
PGC implementation 2006
Systematic
review of guideline dissemination and implementation strategies
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C, (Av=
ailable
from: http://www.hta.nhsweb.nhs.uk/)
PGC implementation 2006
Systematic
review of guideline dissemination and implementation strategies
•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 psycho=
logical
constructs 29.4% compa=
risons
reported any economic data
=
=
PGC implementation 2006
Systematic
review of guideline dissemination and implementation strategies
–1.0%,
+34.0%
+1.3%,
+16.0%
+3.6%,
+17.0%
Ra=
nge
+14.1%
14
Rem=
inders
+7.0%
5
Audit
and feedback
+8.1%
5
Educational
materials<=
/span>
Median
effect size
Number
of CRCTs
Int=
ervention
Results – sing=
le
interventions
PGC implementation 2006
Results –
multifaceted interventions
=
•Multifaceted
interventions including educational outreach
13 CRCT
13 CRCT
<=
span
style=3D'mso-special-format:bullet;color:#CC0000;position:absolute;left:-3=
.44%;
top:.1em;font-size:90%'>–Median effect +6.0% (ra=
nge
–4% to +17.4%)
PGC implementation 2006
Guideline
dissemination and implemen=
tation
strategies
<=
span
style=3D'font-size:94%'>Improvements in direction of effect in 86% of =
comparisons
Reminders most consistently observed to be =
effective
=
Educational outreach, audit and feedback =
and dissemination of educational materials =
<=
span
style=3D'font-size:94%'>may lead to potentially important effects
=
PGC implementation 2006
Improving evidence base of =
professional
behaviour change
=
Need better understanding of:
Need better understanding of:
–Professional
and organisational behaviour change
–Causal
mechanisms of interventions
PGC implementation 2006
Choosing interventions
The bad news - Little empirical
evidence to guide choice of intervention to address =
different
barriers -considerable judgement needed!
<=
span
style=3D'visibility:hidden'>
<=
span
style=3D'visibility:hidden'>
<=
span
style=3D'visibility:hidden'>
PGC implementation 2006
Conclusions=
=
Interventions addressing barriers at
different level=
s may
influence provider behaviour.
=
Evidence that it is possible to change
provider behav=
iour
although effects are modest.
=
Poor theoretical understanding of pro=
vider
and organ=
isational
behaviour.
PGC implementation 2006
Towards evidence =
based
practice
Most clinic=
al
care occurs within the context of a pr=
ovider
– patient relationship.
Provider beh=
aviour
is the most proximal determinant of ev=
idence
based practice.
Changing pro=
vider
behaviour is (one of) the right objecti=
ve(s)
to promote evidence based behaviour.&=
#13;
<=
span
style=3D'visibility:hidden'>
PGC implementation 2006
Moving forward
<=
span
class=3DBB>Set priorities
Set priorities
<=
span
class=3DBB>Measure current practice
Measure current practice
Select intervention based on priorities and <=
span
class=3DBB>Evaluate interventions systematically
Evaluate interventions systematically
PGC implementation 2006
Future directions<=
/span>
=
Larger knowledge gap in implementatio=
n
=
More implementation research
–Both
quantitative and qualitative
=
Multidisciplinary research teams
=
–Doctors,
midwives, social scientists, educationists
=
Appropriate levels of
–Scientific
rigour
–Consultation
from the beginning
<=
span
lang=3DEN-GB style=3D'font-size:83%'>Policy-makers
<=
span
lang=3DEN-GB style=3D'font-size:83%'>Providers
<=
span
lang=3DEN-GB style=3D'font-size:83%'>Consumers
PGC implementation 2006
Implications
for health
services research
services research
Implementation research agenda=
is substantial
and inherently transdisciplinary
No individual country’s health
services research program can address this agenda
comprehensively
Considerable opportunities for=
international
collaboration
<=
span
style=3D'font-size:88%;visibility:hidden'>
PGC implementation 2006
Assess + Monitor +
Evaluate
barriers & support=
s strategy application &a=
mp;
degree of use outcomes=
=
Pr=
actice
Environment
•structural
•social
•patients
•economic
=
Potential Adopters
•attitudes
<=
/span>
•knowledge
<=
/span>
•skill
=
Evidence - Based Recommendations
•development process=
3;
•innovation attributes<=
/span>
St=
rategies
•barrier
•transfer
•uptake
Adoption
•intention
•use
•patient
•practitioner
•system
•
<=
/div>
<=
/span>
Logan & Graham, 2002
Ottawa Model of Research Use
‹header›
‹date/time›
Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
‹footer›
‹#›
CCEPP will conduct systematic revie=
ws
of studies of interventions designed to improve pro=
fessional
practice including: professional interventions (eg continuing medical
education, audit and feedback, reminders); financial int=
erventions
(eg professional incentives); organisational interventions (eg the
expanded role of pharmacists); and regulatory int=
erventions.
We have about 50 collaborators
worldwide. To ens=
ure
quality in this difficult area, we have adopted a standa=
rd
methodology.
Our first reviews will appear in the
next edition of the Cochrane Database of Systematic Reviews If anyone wants fur=
ther
details about CCEPP, please contact me after the talk.
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if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
------=_NextPart_01C63C93.8F12A260
Content-Location: file:///C:/F009C636/Implementing_evidence-based_practices_Gulmezoglu_2006_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="windows-1252"
Implementing evidence-based practices in reproductive health - Metin
Gülmezoglu
------=_NextPart_01C63C93.8F12A260--
When the barriers related to the
practice environment, potential adopters and innovation have been addresse=
d,
strategies are designed to disseminate the new practice for use.
------=_NextPart_01C63C93.8F12A260
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