1. 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

2. Epidemiology of Venous Leg Ulcers
Most common cause of lower limb ulceration
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

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

4. Venous Leg Ulcer Burden

5. Venous Leg Ulcer Burden: Europe

6. 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

7. ‘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

9. 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?

11. 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 …

12. Lessons learnt from stroke guideline implementation

13. 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

14. Barriers to guideline implementation
Behrens et al 2011 Germany
Van Bodegom et al 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

15. 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

16. 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 …

17. 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

19. 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)

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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