Changing Professional Practice
Bridging the Gap Between Science and
Practice: How to change health care provider behaviour through
implementing clinical practice guidelines
by Thorkil Thorsen, Scientist in Charge
This is a presentation of the Changing Professional Practice project (CPP) - an international collaboration between ten partners in seven European countries. The Collaboration addressed the issue of transferring scientific knowledge into clinical routines and decision making.
Objectives and issues addressed
The project was designed to
Period
The project started at 01.03.1996 and ended ultimo
February 1999.
Funding
The project was a Concerted Action funded by the
European Union’s Research and Development Programme,
BIOMED-2. This means that the funding for co-ordination,
meetings, short term exchange, training, and common instrument
development and analysis comes from the EU, while the
participating partner projects are nationally funded.
Contents/Scope
The issue of implementation of evidence-based care into
day-to-day clinical practice has a high priority for the
development of clinically effective care.
However, literature indicates that attempts at transferring science into practice often fail and that there is an unacceptable time lag between the time of having a valid research basis for a specific procedure and the point when the procedure has been adopted in practice (1).
Nevertheless, the literature on attempts to promote the transfer of research findings into clinical practice does show mixed results. Reviews of systematic evaluations of interventions to change practice that have previously been published by partners of the collaboration have shown that some well designed and well implemented guidelines have improved practice (2). These success stories are not large in number and we do not have an empirical basis for knowing what types of implementations are best for different procedures, care providers, and settings (3). Systematic research to evaluate the effectiveness and cost of guideline implementation in a European setting is therefore needed.
The reason for studying the implementation of clinical guidelines is that such guidelines are considered a suitable vehicle for bringing information and recommendations on good clinical practice to the health professionals. Besides, clinical practice guidelines are used more and more in our health care systems.
Our common definition of clinical practice guidelines is the often cited definition from Institute of Medicine in United States, which emphasises their "systematic development" and that a clinical practice guideline should "assist the practitioner and patient decisions about appropriate health care for specific clinical circumstances" (4).
The perspective of the project was that the partners in collaboration could develop, test, and share methods, concepts and theories in the field of implementation research. Gradually a knowledge base of rigorously tested implementation strategies for specific procedures, settings, providers etc. was developed. This knowledge and the experience and findings gained in the project is disseminated in articles, reports, a book and on this web-site to ensure maximum dividend from the concertation.
CPP Inclusion Criteria
When the project proposal was developed in 1995, a
tentative set of inclusion criteria to be met by participating
partner projects was agreed upon. The studies included in the
Concerted Action should meet the following criteria:
These inclusion criteria were also the first step in the continuous development of a common theoretical framework. The framework should ensure that the partners’ research would develop in concertation and make systematic review and comparisons easier.
CPP Partners
The following institutions took part in the Concerted
Action:
The studies varied significantly in both topic, setting, provider and intervention. However, the common framework, inclusion criteria and taxonomy enhanced the possibilities of cross comparison of what works and what does not work as a strategy for implementing a guideline.
CPP Task Oriented Groups
Across the partner projects the Concertation set up
several working groups targeted at methodological, theoretical,
and conceptual issues.
Taxonomy Group
This group built a taxonomy for describing and classifying
strategies, processes of guideline development, interventions,
settings and other situational characteristics of any guideline
implementation effort. A shared taxonomy was to enhance
comparability and generalisability across different
implementation studies within as well as outside the Concerted
Action.
Interventions Group: Analysis of interventions
and strategies to implement guidelines
The aim of this group was to provide tools for describing
interventions. The deliverables agreed with this group were a
framework for planning and describing interventions and their
elements in detail, linked to the CPP taxonomy, a tool kit that
describes methods (prospective and retrospective) to monitor and
analyse the use of the planned interventions, a training
programme and instruction materials for partner participants on
planning and evaluating the intervention.
Network Resource
The task of the Network Resource was to concentrate on the
facilitators and barriers to changing professional practice. A
common instrument for studying care providers’ perceptions
of facilitators and barriers was developed by this group
consisting of social scientists from partner institutions. The
Network Resource set up and coordinated sub-groups that addressed
related topics:
Perceptions Library Group
This sub-group to the Network Resource assembled a library of
survey and interview instruments and items that have been used
for examining perceived facilitators and barriers to guideline
implementation and to change. The instruments and items were
drawn from published literature, and individual scientists were
contacted for information concerning unpublished material. The
library of items is placed on the CPP website.
Methods Group: Methods for identifying barriers and
facilitators for changing professional practice
This sub-group focused on different methods for identifying
factors that might inhibit or stimulate the change of
professional practice. Such factors might be knowledge, skills
and perceptions of individual professionals, or social,
organizational, economic and regulatory factors.
Economics Group: Economic evaluation of
interventions to change professional behaviour
The aim of this group was to advise and discuss methods for
economic evaluations of interventions and do targeted training in
these methods. Although there is little consensus among
economists on this subject, the group was to provide a
theoretical framework for deciding when it is worthwhile to
develop, introduce, and implement clinical guidelines for a
targeted clinical activity.
Statistics Group: Methods of analysis and
statistics
Design and analysis of systematic studies of complex
interventions which often involve cluster analysis and sometimes
a factorial design is a challenge to everyone. CPP therefore
established a group of statisticians and methodologists to serve
the concertation in this respect. The actual deliverables linked
to this group is presentation of statistical methods and training
in use of sample size calculator, conversion of DOS
sample size calculator to Windows based system, elaboration of a
methodology with regard to testing of analytical techniques,
preparation and production of statistical training material.
"Public Relations" Group
This group was mainly responsible for all PR activities related
to the project, hereunder the semi-annual newsletter and the
web-site. The group also prepared the publication policy of the
CPP-project.
Project Organsation
Steering Committee
One scientist from each partner
Co-ordinator
DSI - Danish Institute for Health Services Research and Development
Scientist in Charge
Dr. Thorkil Thorsen, DSI, Denmark
Associate Scientist in Charge
Dr. Marjukka Mäkelä, STAKES, Finland
Scientific Advisory Board
Hannu Vuouri, MD, PhD, WHO Representative to Turkey.
Prof. Egon Jonsson, SBU, Stockholm/ Ass. Prof. Bengt Brorsson, SBU, Stockholm .
Prof. Sally Baldwin, Social Policy Research Unit, University of York.
Dr. David L. Sackett, Centre for Evidence-Based Medicine, Nuffield Dept. of Clinical Medicine, Level 5, John Radcliffe Hospital, Oxford.
Director Trevor Sheldon, Centre for Reviews and Dissemination, University of York.
References:
Antman EM, Lau J. Kupelnick B. Mosteller F Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatment of myocardial infarction. JAMA 1992; 268: 240-8.
Grimshaw JM, Freemantle N, Wallace S, Russell IT, Hurwitz B, Watt I, Long A, Sheldon T (1995) Development and implementation of clinical practice guidelines. Quality in Health Care, 4, 55-66.
Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal 1995; 153:1423-31.
Field MJ, Lohr KN (eds). Guidelines for Clinical Practice. From Development to use. Institute of Medicine, Washington. DC.: National Academy press. 1992.