PHS / Department of General Practice Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Impact analysis studies and the evidence in relation to process and outcome of clinical care Emma Wallace, Susan Smith, Tom Fahey

PHS / Department of General Practice Overview Introduction Translating research into practice Impact analysis studies on CPR register Impact Analysis study outcomes

PHS / Department of General Practice Introduction

PHS / Department of General Practice Introduction Impact analysis represents highest level of evidence Evidence that CPR; -Changes physician behaviour -Improves patient outcomes -+/- reduces costs

Translating research into practice (Glasziou and Haynes, 2005)

PHS / Department of General Practice CPR Register Impact analysis studies, n=15 Clinical domain ICPC-2Number of studies CardiovascularK-936 RespiratoryR-813* MusculoskeletalL-743 GastrointestinalD-861 DermatologyS-771 DVTK-921 (* 3 studies as part of clinical guideline implementation)

PHS / Department of General Practice CPR Register Impact analysis studies Study design -RCT= 8 -Before/after=6 -On/off=1 Study outcomes -Process=12 -Patient=5* -Physician behaviour=4 (*n=3 as part of guideline implementation)

CPR Register Impact Analysis studies-examples Author/ Study year Study type Diagnostic Area/Name CPR OutcomeMeasure Kline, 2004B/ACardiovascular ‘Charlotte Rule’ 1. Evaluation rate 2. Imaging rate 3. ER Stay length Process Montgomery, 2000 Cluster RCT Cardiovascular CVS risk score 1.5 year CVS risk 2.Blood pressure 3. CVS drugs prescribing rates Patient outcomes, Physician behaviour Yealey, 2005Cluster RCT Respiratory ‘Pneumonia Severity index’ 1. Mortality rates 2. Re hospitalisation 3. Complications 4. Return to work 5. Discharge low risk pts Patient outcomes, Process Stiell, 1994B/AMusculoskeletal ‘Ottawa ankle rule’ 1. Imaging 2. Waiting time Process

PHS / Department of General Practice Impact Analysis Study outcomes 1.Physician behaviour 2.Process of care 3.Patient outcomes 4.Cost

PHS / Department of General Practice 1. Physician behaviour Use of diagnostic tests Prescribing rates Referral for imaging

PHS / Department of General Practice 1. Physician behaviour; New Zealand CVS Risk Score Patients with Type 2 Diabetes, n=323 RCT, one centre Prescribing rates of risk modifying drugs Documentation of CVS risk score-increased prescribing risk modifying drugs in high risk group, no impact in low risk group BMJ 2003:326;

PHS / Department of General Practice 2. Process of Care Imaging rates Waiting times Length of ER stay Admission rate Length of admission

PHS / Department of General Practice 2. Process of care; Glasgow-Blatchford bleeding score Patients presenting to A+E with symptoms suggestive of upper GI bleeding, n=676 Before after study Discharge of low risk patients to OPD (i.e. Decreased unnecessary admission rate) Lancet 2009;373:42-47

PHS / Department of General Practice 3. Patient Outcomes Complication rates Mortality rates Re-consultation rates Return to work/usual activities Patient satisfaction

PHS / Department of General Practice 3. Patient Outcomes; Well’s Rule DVT Patients presenting to thrombosis units/A+E with suspected DVT, n=1285 Cluster RCT No increase in missed DVT rates in the CPR group NEJM 2003;349:

PHS / Department of General Practice 4. Cost -Process of care; Reduced imaging rates, decreased ER stay, decreased admission rates, decreased length of stay -Patient; Time off work, return to usual activities, re- consultation rates

PHS / Department of General Practice Impact Analysis, multiple outcomes; Ottawa knee rule Physician behaviour -Decreased imaging orders Process of care -Decreased ER waiting time, reduction in imaging, no increase in missed fractures Patient -No decrease in patient satisfaction Cost -Hospital-imaging reduced, ER waiting times reduced -Patient-fewer days off work JAMA. 1997;278:

PHS / Department of General Practice Unsuccessful Impact Analysis; CDSS and Framingham risk score Physician -No change in cardiovascular drug prescribing Process - CDSS did not improve process of care Patient -No improvement in 5 year CVS risk vs. usual care -Improvement in SBP in ‘chart only’ group -No improvement in DBP BMJ 2000;320:686–90

PHS / Department of General Practice Discussion Relatively few impact analysis studies Clustered in certain clinical domains Mainly process based outcomes Study design-Cluster RCT/Before-after study CPRs implemented as part of guideline