Implementation of Evidence Based Treatment: Factors that Promote and Impede Guideline Implementation OBSERVATIONS FROM GENERAL MEDICAL CARE R. Michael Massanari, MD MS Director, Center for Healthcare Effectiveness Research Professor of Medicine and Community Medicine Wayne State University School of Medicine

The Problem Unexplained variation in practice. –Wennberg and colleagues, Dartmouth Quality of healthcare delivered –McGlynn and colleagues, RAND Corp

The Problem Unexplained variation in practice. –Wennberg and colleagues, Dartmouth Quality of healthcare delivered –McGlynn and colleagues, RAND Corp

Adherence to Quality Indicators According to Condition VariableNo. of Indicator No. of participant Times Eligibility Met Percentage of Recommended care received (95% CI) Senile Cataract ( ) Congestive Heart Failure ( ) Depression ( ) Community- acquired pneumonia ( )

A Taxonomy of Barriers and Promoters of Practice Change Factors intrinsic to practitioner / provider. –Knowledge –Attitudes Factors extrinsic to practitioner / provider environmental factors. –Barriers –Promoters

A Model for Practice Behavior Change KnowledgeAttitudesBehavior Woolf. Practice guidelines: a new reality in medicine. Arch Intern Med 1993;153: Intrinsic Barriers to Implementation

Knowledge –Lack of familiarity due to: Volume of information Time required to stay informed Guideline accessibility –Lack of Awareness due to: Volume of information Time required to stay informed Guideline accessibility Cabana et al. JAMA 1999;282:

Intrinsic Barriers to Implementation Attitudes –Disagreement with specific guidelines Interpretation of evidence Applicability to patients Not cost-effective Lack confidence in developers of guidelines –General disagreement with guidelines “cookbook” medicine Biased synthesis Challenge to autonomy Not Practical Cabana et al. JAMA 1999;282:

Intrinsic Barriers to Implementation Attitudes –Lack of outcome expectancy Doesn’t believe that practice change will achieve outcomes. –Lack of self-efficacy Lacks where-with-all to implement and perform recommendations. –Lack of motivation Difficulty changing routines outweighs any perceived benefit. Cabana et al. JAMA 1999;282:

Extrinsic Barriers to Implementation Patient factors –Inability to reconcile patient preferences with guideline. Guideline factors –Guideline format. –Inconsistencies in guidelines addressing the same condition. Cabana et al. JAMA 1999;282:

Extrinsic Barriers to Implementation Environmental factors –Lack of time –Lack of resources –Organizational constraints –Lack of reimbursement –Perceived increase in malpractice liability Cabana et al. JAMA 1999;282:

Extrinsic Promoters of Implementation Environmental factors – factors in physician organizations associated with implementation care management processes. –External incentives Public recognition Improved contracts –Information technology Casalino, Gillies, Shortell, et al. JAMA 2003;289:

Extrinsic organizational factors associated with better performance Shared goals. Substantial administrative support. Strong physician leadership. High quality data feedback. Higher performing did not use innovative initiatives.

Conclusions Commonly used guidelines and education in the absence of other interventions are not likely to be effective in implementing evidence based practice. Implementation of evidence based medicine (guidelines) will require a substantial change in investment of resources. Successful implementation will require multiple strategies that address intrinsic and extrinsic barriers and promoters of guideline adoption.

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