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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
What do we consider an exposure to an evidenced-based tool use?
Adherence to Guidelines in General is Disappointing
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Karen Homa, Lebanon, USA Improvement Specialist, Dartmouth Hitchcock Leadership Preventive Medicine Residency Program
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I believe exposure is an important element to consider – what is the exposure to the tool relative to the patient and to the provider or system in charge of the patient’s care? When we consider the medical record as the exposure we miss out on the guiding principle of health care improvement work, which is about the patient and the provider changing his/her behavior and a system making that possible. In Hahn and colleagues’ study, patients were placed in the flow sheets used group if their medical record contained a flow sheet and “had at least 1 piece of information recorded on them.” So they considered a mark on a flow sheet as the exposure thus an adoption of the flow sheet. I am extremely wary of this definition. If we are to consider whether flow sheets make a difference then we need to consider whether an organization really had ample opportunity to engage in the adoption process of the tool sheet. What if we considered another definition of flow sheet used? For example, the tool was used at every patient visit. Only 21 out of the 54 practices were using flow sheets and then the average usage of the sheet across these practices was 21 percent. This information makes me wonder whether any of these 21 practices changed their processes and adopted the flow sheet. Therefore, I wonder whether this is the right time to assess whether flow sheets improved process and outcome measures. These 21 practices give us an incredible opportunity to understand why some practices and providers adopted the tool. It would be beneficial to understand whether the providers changed or refined the tool and really had time to gain experience with it. Did the providers complain about the flow sheets and challenge the implementation process? The providers are not the only element in the implementation process so the interaction of the practices’ culture, leadership, prior change history, and any external influences need consideration. This needed information would help us build knowledge about how health care systems adopt and interact with quality improvement initiatives. Competing interests: None declared |
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Natalie E. Ceccato, Toronto, Ontario CANADA University of Toronto, Lorraine E. Ferris, Professor of Public Health Sciences, University of Toronto
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This study makes an important contribution to understanding the relationship between evidence-based tool use and patient outcomes. Examining factors associated with guideline use (e.g. flow sheets) is a key step for improving our understanding of guideline utilization in primary care settings. One of the striking findings is that regardless of whether the diabetes flow sheet was used, adherence to the guidelines was low and likely clinically significant. We agree with the authors about the low adherence scores for target attainment, however, it is also worth looking at the adherence scores for assessment as 50.13 to 55.38 is disappointing. Arguably, 74.71 to 79.59 for treatment may be unsatisfactory and worthy of attention as well. It is Hahn et al’s innovative methodology of generating scores to reflect processes and outcomes that has made it possible to identify these important findings <1>. We all know there are no easy answers on how to increase uptake of clinical guidelines. We have previously discussed how guideline development and dissemination are key steps in the process of physician change however, knowledge through dissemination is not sufficient. Identifying factors that influence the implementation of practice tools (e.g. guidelines) including perceptions of the guideline itself, knowledge, beliefs, attitudes, and other motivational factors (e.g. confidence to implement) among stakeholders with consideration of the practice context (e.g. size, ownership, patient load) are important pieces of the process <2>. Once significant variables are identified, strategies can be systematically selected and implemented to target these facilitators and barriers. Identifying and addressing a few variables will not automatically make it possible to implement tools effectively; rather what is needed is a systematic approach of assessing the user population and practice setting (e.g. staff, technology) in addition to the tool itself <2>. There are many innovative studies that aim to understand factors associated with the uptake of clinical guidelines and some important intervention studies in this area. We hope the authors of this paper will continue with their important work. The authors point to the need for additional research “to explore patient and physician variables that mediate the relationship between use of the diabetes flow sheets and intermediate outcome targets for diabetes”. We wonder if perhaps the focus ought to be on the relationship between patient and physician variables with adherence to the NDEP guidelines since the differences between the flow sheet and no-flow sheet groups were small and both process and outcome targets for diabetes seem to warrant attention. Natalie E. Ceccato (MSc). Dept of Public Health Sciences, University of Toronto Lorraine E. Ferris (PhD., C.Psych., LL.M). Dept of Public Health Sciences, University of Toronto; Clinical Epidemiology Unit, Sunnybrook Health Sciences Centre, Toronto, Ontario, CANADA References 1. Hahn Karissa A, Ferrante Jeanne M, Crosson Jesse C, Hudson Shawna V, & Crabtree Benjamin F. Diabetes Flow Sheet Use Associated with Guidelines Adherence. Ann Fam Med 2008;6:235-238. 2. Ceccato Natalie E, Ferris Lorraine E, Manuel Douglas & Grimshaw Jeremy M. Adopting Health Behavior Change Theory Throughout the Clinical Practice Guideline Process. Journal of Continuing Education in the Health Professions 2007; 27:201-207. Competing interests: None declared |
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