Carolina Weller (Australia) on behalf of Peter Franks (England) and Judith Barker (Australia)  Mark Collier (England), Georgina Gethin (Ireland), Arkadiusz Jawien (Poland), Severin Läuchli (Switzerland), Giovanni Mosti (Italy), Sebastian Probst (Switzerland) Adherence to clinical practice guidelines: barriers and facilitators to embedding research in health care

Epidemiology of Venous Leg Ulcers Most common cause of lower limb ulceration 1.5 - 3.0 in 1000 people have active leg ulcers cycle of healing and recurrence diabetes and obesity Prevalence increases with age 20 in 1000 people aged over 80 years Passman M, Elias S et al. Non-medical initiatives to decrease venous ulcers prevalence. J. Vasc. Surg. 2010 Nelson EA, Adderly U. Venous leg ulcers. BMJ Clin Evid.2016

Additional healthcare resources and service innovation are needed globally by a rapidly increasing senior population

Venous Leg Ulcer Burden

Venous Leg Ulcer Burden: Europe

Evidence based clinical practice guidelines Many versions available in several countries variation in clinical practice continue routine practice of guideline uptake remains a challenge often not used after dissemination

‘All breakthrough, no follow through’ Woolf (2006) Washington Post Much of the US $100 billion/year worldwide investment in biomedical and health research is wasted because of dissemination and implementation failures

Best practice: healing venous leg ulcers Compression increases healing rates compared with no compression Multi-component compression more effective than single bandage Multi-component systems with elastic bandage more effective No agreement or clarity on the optimum level of compression O'Meara et al. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews. 2012 Blattler et al. Compression therapy in venous disease. Phlebology. 2008 Partsch et al. Classification of compression bandages: practical aspects. Dermatol Surg. 2008 What do we know?

SIX barriers to clinical practice guideline use in other areas of health practice Structural: financial Organisational: inappropriate skill mix, lack of facilities and equipment Peer group: local standard of care not aligned with desired practice Health Professional: knowledge, attitudes, skills Professional-patient interaction: information processing Patient: knowledge, attitudes, skills Some examples …

Lessons learnt from stroke guideline implementation

Introducing stroke clinical guidelines at a national level 2013 Ireland not sufficient to improve health care quality Facilitators Dedicated resources user-friendly guidelines relevant at local level supportive advocates Barriers inadequate resources poor guideline characteristics and clarity insufficient training and education

Barriers to guideline implementation Behrens et al 2011 Germany Van Bodegom et al 2012 Netherlands organisational factors lack of reimbursement (84%) lack of time (51%) poor patient compliance (70%) contradictory recommendations published by different societies (54%) lack of time hampered by external barriers lack of agreement about roles and responsibilities of professionals involved in the care of the same patient

Physician adherence to guideline recommendations Lugtenberg et al 2009 Netherlands Peters-Klimm et al 2012 Germany Doctors: procedural knowledge communication and time management Patients: Treatment adherence Communication barriers individual case-related problems: comorbidity and expectations lack of agreement with guideline recommendations perceived lack of applicability environmental factors: organisational constraints lack of knowledge of guideline recommendations unclear or ambiguous recommendations

SIX barriers to clinical practice guideline use in venous leg ulcer health practice Structural: financial Organisational: inappropriate skill mix, lack of facilities and equipment Peer group: local standard of care not aligned with desired practice Health Professional: knowledge, attitudes, skills Professional-patient interaction: information processing Patient: knowledge, attitudes, skills Some examples …

Identified Barriers in wound care practice Health policy and the delivery of evidence-based wound care using regional wound teams Campbell et al 2006 Lack of awareness Guideline adoption inconsistent Education minimal/absent across disciplines Institutions lack infrastructure and financial resources to support optimal healthcare delivery Significant inconsistencies to wound care access in Ontario

Guidelines for the management of venous leg ulcers: a gap analysis Van Hecke et al 2008 multidisciplinary approach include patient in guideline development incorporate pain, lifestyle advice and treatment adherence (QoL)

Validation of venous leg ulcer guidelines in the United States and United Kingdom McGuckin et al 2002 United States patients were 6.5 times and United Kingdom 2 times more likely to heal if a guideline was followed (P <0.001). Guideline implementation resulted in: improved diagnosis improved healing time increased healing rates lower costs

Patient-related Barriers And Facilitators Patient compression adherence improves healing guidelines need to take into account what patients want and value Clinicians may perceive conflict between patient preferences and guideline recommendations Clinical practice variations among clinicians, hospitals and healthcare systems are influenced by many factors Evidence Consumer values Clinical judgement

Reasons for patient non-adherence to best practice venous leg ulcer treatment Competing claims and advice from clinicians Adverse effects or fear of recommended treatment Lack of funding, e.g. unable to pay for compression treatments Trust in clinician

HEALTHCARE Professionals Barriers to Guideline implementation Different professionals responsible in different countries Provider inequalities: access and knowledge Practice environment not reflected in guidelines Limited product access Reimbursement: patients and healthcare organisations Health systems: payment structure difference Costs of dressings, compression, medical devices Cost of type of professionals who administer care can define reimbursement cost in different countries

Estimated economic cost savings of $166 million per year if all eligible venous leg ulcer patients are treated with compression Assumption: all clinicians will use CPG to guide practice and patients will adhere to treatment Challenge: no individual approach for translating evidence to clinical practice is superior in all situations

Conclusion Venous leg ulcers prevalence will continue as the population ages Costs will continue to escalate Several national and international guidelines exist for the management of venous leg ulcers no performance measures to facilitate translation of VLU guidelines into clinical practice research is required to develop practical methods of identifying barriers and facilitators outside an academic context

Carolina.Weller@monash.Edu