practices and guidelines: partners
in quality?
Piet Vanden Bussche
Luc Seuntjens
Wetenschappelijke vereniging voor
Vlaamse Huisartsen (WVVH)
• “ the naive assumption that when research
information is made available it is somehow
accessed by practitioners, appraised and
then applied in practice is now largely
discredited. “ Effective health care vol 5 nov 1 1999:
Getting evidence into practice
What is known?
• Interactive workshops can result in moderately large
changes - didactic sessions alone are unlikely to change
professional practice “
• audit and feedback: effects …can be effective in improving
professional practice. The effects are generally small to
moderate. ….. are more likely to be larger wen baseline
adherence to recommended practice is low.”
• there is some evidence that guideline driven care is
effective in changing process and outcome of care
provided by professions allied to medicine.
cochrane library issue 2 2004:
Input proces and output
• Most research: what are the features of
guidelines that are important for
implementation
• growing research on external support for
practices to help implementation
• there is very little information about the
processing of guidelines within the practices
What are Critical Factors in the individual
practice?
The proces of guideline
implementation
•
•
•
•
•
0: no use of the guideline(s)
1: reading of the guideline(s)
2: discussion of the guideline(s)
3: translation into practice-guideline(s)
4: visable (change in) practice elements
“proving” implementation
• 5: registration of indicators
• 6: evaluation
Course in quality management
for GP’s
•
•
•
•
•
Day 1: introduction critical incident etc
day 2: quality projects
day 3: implementation of guidelines
day 4: vision mission and group processes
day 5: evaluation (practice report)
• theory, work shops, home work, intervision
• 4 years, 10 to 12 participants
Evaluation of day 3
1 structural features in the practice (very high
scores)
2 implementation level(0 to 6) of Flemish
guidelines (18)
3 what are the critical factors for success or
failure?
Questionaire to 44 practices / 26 answers
Guidelines score
NIDDM
Use of urgency set
cyst it is (f emales)
Sore t hoat
Ankle dist ort ion
smoking cessat ion
coughing
Cont racept ion
Neural t ube def ect
0,0
0,5
1,0
1,5
2,0
2,5
3,0
3,5
Reading and practice change
GUIDELINE READ
Visible applications in practice
NIDDM
NIDDM
Fal prevention Valpreventie ...
Fal prevention Valpreventie ...
Contraception/ Anticonceptie
Contraception/ Anticonceptie
Middle ear infection / Acute ...
Middle ear infection / Acute ...
Sore thoat/ Acute keelpijn
Sore thoat/ Acute keelpijn
Influenza
Influenza
Breatscancer preventi(e)on ...
Breatscancer preventi(e)on ...
Ankle distortion Enkeldistorsie
Ankle distortion Enkeldistorsie
Child astma kind
Child astma kind
Acne
Acne
tetanos & difterie
tetanos & difterie
smoking cessation stoppen ...
smoking cessation stoppen ...
female cystitis vrouw
female cystitis vrouw
cervicalcancer screening ...
cervicalcancer screening ...
couphing / Acute hoest
couphing / Acute hoest
Use of urgency set / ...
Use of urgency set / ...
Vaginitis & vaginose'
Vaginitis & vaginose'
Neural tube defect / ...
Neural tube defect / ...
0
5
10
15
number practices
20
25
0
2
4
6
Number practices
8
10
What about practices and their
capacity to implement guidelines
• These are not standaard practices
• number of guidelines implemented yearly
0
10
1
8
2
6
3
4
4
5
2
6
0
7
nr guidelines
8
9
onb
Types of practices
• Poor guideline implementation (38%)
• Fair guideline implementation (34%)
• High guideline implementation (27%)
71-75
61-65
51-55
41-45
31-35
21-25
11- 15
nr practices
0-5
4
3,5
3
2,5
2
1,5
1
0,5
0
Regression analysis
Application of guidelines
according to practice type
Opleidingspraktijk /
teaching practice
0,70
yes / Ja
overall application
0,60
nee / no
0,50
• Increasing # of sources
0,40
0,30
r = 0,44 ;
Beta 0,58 (CI 0,36 ; 0,78) ; p = 0,02
0,20
• Teaching practices
0,10
0,00
Beta -0,15 (CI -0,28 ; -0,02) p = 0,02
3,00
4,00
5,00
6,00
7,00
8,00
# sources for evidence based med
9,00
Why succesfull?
Which guideline is best implemented and
why?
– Guideline features 23%
– Practice features 72%
» infrastructure (7.5%)
» people (23%)
» information (13 %)
» finance (0%)
» quality and safety (28%)
– External support 5%
What can help, offer support?
• External factors (50%)
–
–
–
–
(financial) incentives
soft ware support
peer review
reminders and feed back
• Guidelines (30%) offering implementation
material (leaflets, fow charts,…)
• changing Practice features (20%)
What problems did you have
implementing the guidelines?
• Nearly all problems had to do with internal
practice functions (87.5%)
– lack of financial reward (28%)
– problems with the way information is handled
(25%)
– problems with the quality system not
considering this to be a priority (21%)
Conclusions:
focussing on practices
• Practice management is essential and a key
for succes in implementing guidelines
• training in practice management skills is
essential (interactive work shop sessions)
participating in teaching is an important
stimulating factor
• key measures asked by practices are
– 1 financial support or rewards
– 2 electronic data support measures
• we have to validate the instrument we used
for measuring implementation of guidelines
but measuring this enables to give feed back
and make practices aware of their capacity
to implement guidelines
For guideline makers
• Don’t make to many guidelines at a time
and set priorities
• guidelines on practice management items
can be very succesfull
• preventive topics are easier to implement
then others
• topics on well defined clear cut problems
are easier to implement
• Implementation and the level of
implementation are primarly influenced by
practice features.
• Measurement of the implementation is an
important en valid way of measuring quality
in practices.
• A shift of interest and financing from
making guidelines to supporting practices in
order to make implementation succesfull is
necessary