1. E-GAPPs conference, December ‘12 Regional Implementation of Guidelines: pearls and pitfalls Dave Davis, MD Senior Director, Continuing Education & Improvement, AAMC

2. Assumption: regional implementation depends on understanding regional variation….  Nothing to disclose (sort of sad, huh?)  My perspective  Acknowledgments: David Longnecker, MD, AAMC; GIN colleagues; Guidelines Advisory Committee, Ontario  Another assumption: Pearls Pitfalls = 1

3. Framing the talk… 1. Variation in practice: the clinical care gap from national and local levels 2. What causes the variation? 3. Within this framework, what have we learned about effective (and maybe not effective) implementation strategies? 4. Are there forces driving these strategies? 5.So what? Implications for CPGs; the AAMC’s initiatives in this space

4. Framing the talk… 1. Variation in practice: the clinical care gap from national and local levels 2. What causes the variation? 3. With this framework, what have we learned about effective (and maybe not effective) implementation strategies? 4. Are the forces driving these strategies? 5.So what? Implications for CPG

5. Country-country comparisons

6. And for this expenditure, what do we get?

7. Within-country variation: US data Within-country variation: US data The Dartmouth Atlas  Examines variations of care for Medicare beneficiaries with severe chronic illness in the last 2 years of life  Focuses on “supply-sensitive care”  Provides data for a variety of delivery settings including inpatient, outpatient, hospice, and home health  Characterized by misuse, overuse and underuse of health care resources  Wide variance in the care delivered in US hospitals as measured by clinical outcomes, quality measures, costs, and resource utilization rates

8. Within-country variation: US Within-country variation: US 2008 Dartmouth data

9. Dartmouth Atlas 2008…

10. Canadian variation Canadian Institute for Health Information  “regional variations in C Section rates point to underlying differences in care delivery”

11. Framing the talk… 1. Variation in practice: the clinical care gap from national and local levels 2. What causes the variation? 3. With this framework, what have we learned about effective (and maybe not effective) implementation strategies? 4. Are the forces driving these strategies? 5.So what? Implications for CPG

12. What causes the variation? Health system issues (funding, workforce, data, EHR, policies) Health professional/ Clinician issues Evidence, guideline, clinical message Educational message delivery system

13. Framing the talk… 1. Variation in practice: the clinical care gap from national and local levels 2. What causes the variation? 3. Pearls & Pitfalls: within this framework, what have we learned about effective (and maybe not so effective) implementation strategies? 4. Are the forces driving these strategies? 5.So what? Implications for CPG

14. Using the variation…. health system issues (funding, workforce, data, EHR, policies) Clinician issues Evidence, guideline, clinical message Educational, message delivery system PEARL/PITFALL #1: consider/use the environment: training capacity, existence, emphasis  training capacity, existence, emphasis  health professional mix and skill set  re-certification & other clinician levers  current policies, regulations  accreditation standards and requirements  culture

15. Medical School CME /CPD Practice plans TeachingHospital Staff development QI/PI programs UME/GME Faculty Devel’t EHR Health system data The “Typical” academic medical center* AAMC’s IQ & ae4Q initiatives *there’s no such thing Com- munity Accreditation, other input

16. Using the variation… health system issues (funding, workforce, data, EHR, policies) Clinician issues Evidence, guideline, clinical message Educational, message delivery system P/P#2:  tailor-make/adapt the guideline  adapt language to local norms  use quality measures  develop patient tools  other…

17. What causes the variation? health system issues (funding, workforce, data, EHR, policies) Clinician issues Evidence, guideline, clinical message Educational message delivery system

18. P/P #3: (not)paying attention to the research in CME/CPD - some findings… Physicians and others not self-aware: objective needs assessment, performance feedback important Knowledge necessary but not sufficient for change; didactics lousy at changing performance What works? Interactivity; sequencing; predisposing, enabling and reinforcing strategies ‘ CME’ > conferences; = practice-based tools (reminders, audit-feedback, protocols & training) Docs pass through stages of learning: awareness, agreement, adoption to adherence ………… Cochrane reviews, AHRQ/EB reviews, others

19. Effective CME: The effect of interventions on performance and health care outcomes JAMA 1995;274:700-705

20. P/P#5: thinking that lectures will change outcomes? Just plain dumb…. dissemination

21. P/P#6: don’t forget other educational interventions…

22. P/P#7 You can make even formal CME work: JAMA 1999; 282:867-874 ) Interactivity: Q&A, case discussion, reflection, MCQs, audience response systems, think-pair-share Sequencing: e.g. rounds Interactivity: Q&A, case discussion, reflection, MCQs, audience response systems, think-pair-share Sequencing: e.g. rounds

23. P/P# 3,402: Use some kind of framework Improving performance: the Pathman-PROCEED model Davis et al, BMJ, 2003 Methods/ StagesAwarenessAgreementAdoptionAdherence Predisposing Enabling Reinforcing

24. 1. Variation in practice: the clinical care gap from national and local levels 2. What causes the variation? 3. With this framework, what have we learned about effective (and maybe not effective) implementation strategies? 4. Are there forces driving these strategies? 5.So what? Implications for CPG Framing the talk…

25. IOM: “Redesigning CE in the Health Professions: a call for a CPD Institute” IOM: “Redesigning CE in the Health Professions: a call for a CPD Institute” Macy-AAMC/AACN lifelong learning Macy-AAMC/AACN lifelong learning “Unmet Needs”: quality & safety “Unmet Needs”: quality & safety Evidence-based medicine, guidelines Evidence-based medicine, guidelines Comparative effectiveness Comparative effectiveness Health Professional Education Health Professional Education Quality Chasm Quality Chasm 2000 2011 1) Reports on healthcare

26. Continuum studies Costs Bias, COI and Commercial support issues 2) Other forces… Outcomes (competency) – based education, Regulatory, Accreditation req’ts HIT, data feedback and reporting; transparency The KT- PCORI implementation research agenda Evidence of effective education, QI, implementation methods Information explosion New diseases; prevention, screening QI initiatives, PI

27. Framing the talk… 1. Variation in practice: the clinical care gap from national and local levels 2. What causes the variation? 3. With this framework, what have we learned about effective (and maybe not effective) implementation strategies? 4. Are the forces driving these strategies? 5.So what? Implications for CPG implementation

28. Implications for health systems Health system issues: alignment of clinical, quality, educational enterprises (EHR, policies) Clinician issues: training in EBM, quality, health systems, implementation science Evidence, guideline : local adaptation, message alignment, metrics and tools Educational delivery system: smart, effective, seamless, local education

29. One step at a time What’s AAMC doing in this space?

30. The clinical /health care enterprise: focus on quality metrics, patient satisfaction, costs The educational enterprise: focused on didactic courses and conferences, frequently (in CME) dependent on commercial interest, self-assessed needs what’s AAMC doing in this space? Integrating quality o Integrating Quality o Reducing Variation o ae4Q- aligning & educating for quality: using quality data to drive educational interventions: rounds, M&M conference; rounds developed from quality measures, care gaps; team training; morbidity, mortality and improvement sessions o Teaching for Quality: a national faculty development initiative o Integrating Quality o Reducing Variation o ae4Q- aligning & educating for quality: using quality data to drive educational interventions: rounds, M&M conference; rounds developed from quality measures, care gaps; team training; morbidity, mortality and improvement sessions o Teaching for Quality: a national faculty development initiative

31. More info More info: E-mail Web ddavis@aamc.org www.aamc.org/initiatives/cei www.g-i-n.net August 18-21, 2013