EVIDENCE BASED HEALTH CARE and BEST PRACTICES at Northwestern Health Sciences University Gert Bronfort DC, PhD; Michele Maiers, DC, MPH; Roni Evans DC, MS

Northwestern Health Sciences University (NWHSU) Six clinics in Twin Cities area Six clinics in Twin Cities area Conservative health care services, including Conservative health care services, including –chiropractic –acupuncture/ Oriental medicine –massage therapy –healing touch –naturopathy Teaching clinics for upper term students Teaching clinics for upper term students

Best Practices at NWHSU: Precipitating Events Council on Chiropractic Guidelines and Practice Parameters Council on Chiropractic Guidelines and Practice Parameters MN State Legislative Initiative MN State Legislative Initiative NWHSU NWHSU –Mission –Guiding principles and values –Strategic goals

Our Mission To advance and promote natural approaches to health through education, research, clinical services and community involvement Best Practices affect our ability to fulfill our mission Education: providing students with the tools they need to be effective and competitive providers Education: providing students with the tools they need to be effective and competitive providers Research: accurately documenting clinical practice Research: accurately documenting clinical practice Clinical Services: optimizing patient care Clinical Services: optimizing patient care Community Involvement: providing consistent message of our standards of care and our effectiveness Community Involvement: providing consistent message of our standards of care and our effectiveness

Several advantages for our providers: Easier access to research pertinent to their practice Easier access to research pertinent to their practice An opportunity to evaluate themselves before others do An opportunity to evaluate themselves before others do The ability to change and improve their systems of care The ability to change and improve their systems of care Provide standardized documentation of effectiveness Provide standardized documentation of effectiveness

Several advantages to our stake-holders: Evaluation system based on accurate analysis of clinical outcomes Evaluation system based on accurate analysis of clinical outcomes –Internal assessment –Patients can see progress over time Provides the ability for standardized documentation of the effectiveness of our providers’ interventions Provides the ability for standardized documentation of the effectiveness of our providers’ interventions Standards of care = consistent public message about chiropractic Standards of care = consistent public message about chiropractic

Best Practices Pilot Project Specific Aims: To optimize the quality of diagnosis and therapeutic management of patients through: application of evidence-based health care application of evidence-based health care within the context of a quality assurance system within the context of a quality assurance system …in the NWHSU clinic system

Implementation: Effective Transfer Strategies Educational outreach visits Educational outreach visits – –trained personnel visit providers in their practice settings - information / support Interactive educational sessions Interactive educational sessions – –health care providers participating in interactive, problem-based learning sessions (adult learning principles) Decision support and reminder systems Decision support and reminder systems – –automated or manual prompts to perform clinical tasks Multifaceted interventions Multifaceted interventions – –any combination of audit & feedback, reminders, local consensus processes, or marketing Bero et al (1998); Davis et al (1995); Freemantle et al (1998)

Outline of Pilot Project  Assessment of Clinical Environment  Development of Quality Assurance System  Implementation  Evaluation of Pilot Project

Assess Clinic Environment Choose pilot sites and providers Choose pilot sites and providers Identify representative clinicians to serve on project team Identify representative clinicians to serve on project team Survey current practice behaviors Survey current practice behaviors –Case vignettes (exam, imaging, treatment) –Record keeping –Use of guidelines, outcome measures

Interactive Workshop I Teach the concepts of Best Practices and Quality Assurance Teach the concepts of Best Practices and Quality Assurance Outline/ timeline for pilot project Outline/ timeline for pilot project Present and discuss of results of practice behavior survey Present and discuss of results of practice behavior survey Identify facilitating factors for implementation Identify facilitating factors for implementation Identify barriers against implementation Identify barriers against implementation

Development of QA System Select clinical indicators Select clinical indicators –structure, process, outcome (Kristensen 2001) Select standards for clinical indicators Select standards for clinical indicators –Research evidence –Consensus by participants Develop specific elements Develop specific elements –Integrate access to information within QA system –Finalize content of QA database –Develop data collection protocols –Develop test electronic patient record system –Develop centrally located database for all clinics

Quality Database Electronic Patient Record Electronic Patient Record –Standardized documentation –Prompts to ensure complete data collection –Link to resources Centralized database Centralized database –Collection of quality indicators –Compare actual outcomes to standards  Access for clinicians, researchers, administrators

Interactive Workshop II Select quality indicators and standards Select quality indicators and standards –Participant driven (rank consensus) –Minimal set of data to be included in QA database Introduce EPR Introduce EPR Electronic access to best practices documents Electronic access to best practices documents –Updated internet web-sites  hyper-links to additional information, reference materials, guidelines –“Bedside” with use of tablet PCs, etc. Problem solve perceived barriers Problem solve perceived barriers

Implementation Identify implementation strategies Identify implementation strategies –Minimize staff, provider and patient burden –Maximize efficiency Train clinicians to use Best Practices and QA system Train clinicians to use Best Practices and QA system –Case study vignettes –Data collection processes –On-site visits

Implementation: How would this look in practice? Initial Presentation Patient presents to NWHSU Clinic Patient presents to NWHSU Clinic –Completes intake forms  Standardized questions, entered into data collection system for QA purposes –Clinician performs history, exam, treatment  Clinician has access to best practice information –may inform choices of exam procedures, imaging, treatment  Exam, treatment decisions entered into data collection system for QA purposes

Implementation: How would this look in practice? Follow-up visits Patient returns to clinic for next appointment(s) Patient returns to clinic for next appointment(s) –Completes follow-up questionnaire, entered into data collection system for QA purposes –Clinician manages case as usual  Subsequent exam, treatment decisions entered into data collection system for QA purposes  Established benchmarks and Best Practice recommendations help clinician make decisions for subsequent treatment plan, care Questionnaire mailed to patient Questionnaire mailed to patient –Sent back to clinic, entered into data collection system

Evaluation of Pilot Project Compliance assessment Compliance assessment Best practices utilization Best practices utilization Results of 3 months follow up of care Results of 3 months follow up of care Assess clinicians’ experiences Assess clinicians’ experiences Determine overall feasibility Determine overall feasibility Report to NWHSU Office of Institutional Effectiveness Report to NWHSU Office of Institutional Effectiveness

Results: Assessment of Clinical Environment Who: 12 clinicians Who: 12 clinicians Where: 2 multidisciplinary NWHSU clinics Where: 2 multidisciplinary NWHSU clinics What: Each clinician follows 5 consecutive LBP patients for 3 months What: Each clinician follows 5 consecutive LBP patients for 3 months How: Outcomes tracked in centralized database with quality indicators How: Outcomes tracked in centralized database with quality indicators

Results: Develop Quality Assurance Selection of Quality Indicators Timely collection of quality indicator data Timely collection of quality indicator data Diagnostic classifications Diagnostic classifications Patient/ clinic records Patient/ clinic records Patient education Patient education Patient knowledge Patient knowledge Pain severity Pain severity Disability Disability Global improvement Global improvement Patient satisfaction Patient satisfaction Quality of life/ general health status Quality of life/ general health status

Results: Develop Quality Assurance Selection of Standards Global improvement (DC or ET for LBP) Global improvement (DC or ET for LBP) 1 month N=195Percent Cumulative Percent Completely Gone 11 Much Better 2122 Moderately Better 2749 A Little Better 3382 Same1698 A Little Worse 199 Much Worse months N=192Percent Cumulative Percent Completely Gone 55 Much Better 4652 Moderately Better 2072 A Little Better 1890 Same797 A Little Worse Much Worse

Results: Develop Quality Assurance Selection of Standards Satisfaction (DC and ET for LBP) Satisfaction (DC and ET for LBP) 1 month N=195Percent Cumulative Percent Completely Satisfied 2626 Very Satisfied 5177 Somewhat Satisfied 1592 Neither Satisfied or Dissatisfied 698 Somewhat Dissatisfied 199 Very Dissatisfied months N=195Percent Cumulative Percent Completely Satisfied 3939 Very Satisfied 4180 Somewhat Satisfied 1494 Neither Satisfied or Dissatisfied 498 Somewhat Dissatisfied 199 Very Dissatisfied 1100

Next Steps Select measurement tools for quality indicators Select measurement tools for quality indicators –Established instruments –Consensus Agree to standards for quality indicators Agree to standards for quality indicators –Research literature –Consensus standards Choose and implement EPR Choose and implement EPR

Perceived Barriers Appropriate allocation of resources Appropriate allocation of resources –Financial –Administrative Multi-disciplinary setting Multi-disciplinary setting –Access to literature –EPR and classification system Burden (staff, providers, patients) Burden (staff, providers, patients) –Minimal set of quality indicators –Benefits outweigh burden

Educational Impact Evidence based curriculum translates to clinical experience Evidence based curriculum translates to clinical experience Expose students in controlled environment to: Expose students in controlled environment to: –Electronic patient records –Standardized data collection –Pragmatic use of research literature Develop habits for evidence based practice Develop habits for evidence based practice