mark l. willenbring, md niaaa/national institutes of health rsa 2008, washington, dc implementation:...
TRANSCRIPT
Mark L. Willenbring, MDNIAAA/National Institutes of Health
RSA 2008, Washington, DC
Implementation: A Practical Approach
CaseManager
OR…
Scientific Inquiry
• Level I: Consensus of experts
• Level II: Small clinical trials
• Level III: Large randomized
controlled trials (RCTs)
• Meta-analysis
• are developed using systematic reviews
• use national or regional guideline development groups (including representatives of key disciplines)
• note explicit links between recommendations and scientific evidence.
» Grimshaw J, Eccles M. et al. “Developing clinically valid practice guidelines,” J Eval Clin Pract 1995;1(1):37-48
Guidelines are more likely to be valid if they:
Inclusion Criteria:
1. Has specified disorder
2. Willing to participate
3. Has home, phone, & transportation
4. Fine upstanding citizen
30-50%
Exclusion Criteria:
1. Coexisting psychopathology (incl. addictions)
2. Multiple prior treatments
3. Serious medical problems
4. Lack of housing, transportation
5. Unmotivated
6. Too busy surviving to bother
7. Taking other medications
8. History of non-compliance
9. Lives too far away
10. Serious personality disorder
50-70%
Dodo bird:Friend or enemy?
Looking in the wrong place?
0102030405060708090
0 4 8 12
Weeks
Perc
ent D
ays
Abst
inen
t
Tx 1 Tx 2
Examined change
Unexamined change
Results remarkably similar
Miller et al., J Stud Alc 62:211-220, 2001
Project MATCH Main Outcomes
Project MATCH Research Group, J Stud Alc 59:631-639, 1998
Increased drinking quantity
before entry
Immediate substantial
improvement
Treatment: instigator or result of change?
0 4 8 12 etc. week
PDA
Does change occur prior to tx?
Compared 5 different treatment approaches for cannabis use disorder in adolescents
Dennis et al., JSAT 2004
No difference across groups
UKATT Trial
• Compared 4 sessions of MET with 8 sessions of social and behavior therapy
UKATT findings
0
10
20
30
40
50
Baseline 3 mo 12 mo
PDA
DDD
No difference across groups
Dodo bird strikes again!
A broader view of change
• Therapeutic techniques may have small effects relative to extrinsic factors
A broader view of change
• Common mechanisms may account for change– Therapeutic alliance and
Empathic listening
– Social support for change
– Therapeutic rituals (cf. Jerome Frank)
– Help-seeking itself
Implications for research
There may be multiple pathways (or mechanisms of action) with similar outcomes, OR
We may have been looking in the wrong place
There’s many a slip between the cup and the lip.
• Implemented CBT (high and low standardization) in community program
• Compared to Treatment as Usual
Whoops!
Morgenstern et al., JCCP 2001
Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study
Kathleen M. Carroll, Samuel A. Ball, Charla Nicha, Steve Martinoa, Tami L. Frankfortera, Christiane Farentinosb, Lynn E. Kunkelc, Susan K. Mikulich-Gilbertsond, Jon Morgensterne, Jeanne L. Obertf
, Doug Polcing, Ned Sneadh, George E. Woodyi and for the National Institute on Drug Abuse Clinical Trials Network
Drug and Alcohol Dependence Volume 81, Issue 3, 28 February 2006, Pages 301-312
Effectiveness of MI
• Standard intake vs. MI
• Achieved desired differences in technique
• Improved engagement
• No difference in 28 day or 84 day substance use outcomes
Carroll et al., Drug and Alcohol Dependence, 2006
Take Home Message
• Multiple treatments have been shown to produce acceptable outcomes
• Caution is required– Interpretation of empirical findings– Implementation
• Careful attention to implementation and evaluation is necessary
• Focus on outcomes
73% of primary care physicians believe that they immunize a greater percentage of patients than their colleagues
Noe CA, Markson LJ, Prev Med 1998;27(6):767-72
In a closed panel academic medical center:
• 65% of the practitioners are more efficient than their peers in the same practice• 65% have sicker patients• 75% have better outcome
J Perlin, 2000
. . . and all of the children in Lake Wobegone are above average
J Perlin, 2000
Rates of Coronary Angiography
HI
LO
Rates of Coronary Angiography
HI
LO
Rates of Radical Prostatectomy
HI
LO
Rates of Radical Prostatectomy
HI
LO
Variation in Inpatient Care for COPD by VISN (Region)
Image Removed – Awaiting Copyright Permissions
Variation in Ambulatory Care for MDD by VISN (Region)
Image Removed – Awaiting Copyright Permissions
after DA Burnett, ©UHC, 1995
Reasonable Expectation
Unfortunate Experience
after DA Burnett, ©UHC, 1995
What you would want foryour family
What you would not want
Should it matter where you receive care?
after DA Burnett, ©UHC, 1995
How do we capture andsystematize these practices?
How do we drive these practicesto be more like those above?
Implementing Guidelines Requires Broad SkillsLeadership and teamwork
Negotiation and tact
“Selling” ideas to peers
Link evidence to practice guideline
Educational Strategies
Ineffective:
– Traditional CME
– Printed materials
– ?Audit and feedback
VERDICT Brief, Spring 1998
Educational Strategies
Effective: Intensive conferencing w/ interaction, discussion, & role playing
VERDICT Brief, Spring 1998
Reminders and Prompts
Pocket cards & wall charts
Formatted records
Computerized reminders
VERDICT Brief, Spring 1998
Interactive Strategies
VERDICT Brief, Spring 1998
Opinion leaders
Academic detailing (outreach)
Multiple strategies work best.
Organizational strategies
• “None of the strategies produced consistent results.”
• Professional performance was improved by revision of professional roles and computer systems
Wenning et al., 2006
Organizational strategies
• Patient outcomes improved by multidisciplinary teams, integrated care services, and computer systems.
• Cost savings [came from] integrated care services
Wenning et al., 2006
So what should a program [leader/provider] do?
• Technique
• Outcome measurement
• Quality improvement
• Implementation strategies
Implications for implementation
• Examine current system/outcomes
• Determine where you wish to improve
• Develop model for how your program improvements will translate into process and/or outcome improvements
Is treatment as usual ok?
• Examine general quality of care– Professionalism– Empathy– Training and skill– Supervision
• Determine whether implementing a new technique will be helpful, why, and how
Implementation
• Buy in by leadership critical
• Resources must be provided
• Multiple strategies
Implementation
• Monitoring performance of individuals not just systems
• Supervision
• Plan for improving performance
Summary
• Research on mechanisms of change and improvement in outcomes in the community is needed
• Until then, paying attention to monitoring performance and upgrading the skills of staff are reasonable strategies
Summary
• Community-research partnerships hold promise for gradually learning about how to improve overall community outcomes
• “Make haste slowly.”– Caesar Augustus