Getting research into practice

Evidence-Based Practice and Continuing Professional Development

This article discusses how evidence-based practice informs the process of contracting for health and social care services and explores the difficulties that practitioners seem to have in integrating research into their work. It addresses the need for practitioners to develop appropriate skills to seek, develop and use evidence to underpin their practice and so demonstrate the effectiveness of the work they do. Strategies for skill development through continuing professional development are outlined.

Evaluating the integration of chronic disease prevention and management services into primary health care

Background

The increasing number of patients with chronic diseases represents a challenge for health care systems. The Chronic Care Model suggests a multi-component remodelling of chronic disease services to improve patient outcomes. To meet the complex and ongoing needs of patients, chronic disease prevention and management (CDPM) has been advocated as a key feature of primary care producing better outcomes, greater effectiveness and improved access to services compared to other sectors. The objective of this study is to evaluate the adaptation and implementation of an intervention involving the integration of chronic disease prevention and management (CDPM) services into primary health care.

Methods/Design

The implementation of the intervention will be evaluated using descriptive qualitative methods to collect data from various stakeholders (decision-makers, primary care professionals, CDPM professionals and patients) before, during and after the implementation. The evaluation of the effects will be based on a combination of experimental designs: a randomized trial using a delayed intervention arm (n = 326), a before-and-after design with repeated measures (n = 163), and a quasi-experimental design using a comparative cohort (n = 326). This evaluation will utilize self-report questionnaires measuring self-efficacy, empowerment, comorbidity, health behaviour, functional health status, quality of life, psychological well-being, patient characteristics and co-interventions. The study will take place in eight primary care practices of the Saguenay region of Quebec (Canada). To be included, patients will have to be referred by their primary care provider and present at least one of the following conditions (or their risk factors): diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, asthma. Patients presenting serious cognitive problems will be excluded.

Discussion

In the short-term, improved patient self-efficacy and empowerment are expected. In the mid-term, we expect to observe an improvement in health behaviour, functional health status, quality of life and psychological well-being. At the organizational level, the project should lead to coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration. Integration of CDPM services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated.

Trial registration

ClinicalTrials.gov Identifier: NCT01319656

A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol

BACKGROUND

Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.

METHODS

The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.

DISCUSSION

If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN90940049.

A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies

Context

Significant resources and time are invested in the production of research knowledge. The primary objective of this randomized controlled trial was to evaluate the effectiveness of three knowledge translation and exchange strategies in the incorporation of research evidence into public health policies and programs.

Methods

This trial was conducted with a national sample of public health departments in Canada from 2004 to 2006. The three interventions, implemented over one year in 2005, included access to an online registry of research evidence; tailored messaging; and a knowledge broker. The primary outcome assessed the extent to which research evidence was used in a recent program decision, and the secondary outcome measured the change in the sum of evidence-informed healthy body weight promotion policies or programs being delivered at health departments. Mixed-effects models were used to test the hypotheses.

Findings

One hundred and eight of 141 (77%) health departments participated in this study. No significant effect of the intervention was observed for primary outcome (p < 0.45). However, for public health policies and programs (HPPs), a significant effect of the intervention was observed only for tailored, targeted messages (p < 0.01). The treatment effect was moderated by organizational research culture (e.g., value placed on research evidence in decision making).

Conclusion

The results of this study suggest that under certain conditions tailored, targeted messages are more effective than knowledge brokering and access to an online registry of research evidence. Greater emphasis on the identification of organizational factors is needed in order to implement strategies that best meet the needs of individual organizations.

Trial Registration

The trial registration number and title are as follows: ISRCTN35240937 -- Is a knowledge broker more effective than other strategies in promoting evidence-based physical activity and healthy body weight programming?

Research-based-decision-making in Canadian health organizations: a behavioural approach

Decision making in Health sector is affected by a several elements such as economic constraints, political agendas, epidemiologic events, managers' values and environment... These competing elements create a complex environment for decision making. Research-Based-Decision-Making (RBDM) offers an opportunity to reduce the generated uncertainty and to ensure efficacy and efficiency in health administrations. We assume that RBDM is dependant on decision makers' behaviour and the identification of the determinants of this behaviour can help to enhance research results utilization in health sector decision making. This paper explores the determinants of RBDM as a personal behaviour among managers and professionals in health administrations in Canada. From the behavioural theories and the existing literature, we build a model measuring "RBDM" as an index based on five items. These items refer to the steps accomplished by a decision maker while developing a decision which is based on evidence. The determinants of RBDM behaviour are identified using data collected from 942 health care decision makers in Canadian health organizations. Linear regression is used to model the behaviour RBDM. Determinants of this behaviour are derived from Triandis Theory and Bandura's construct "self-efficacy." The results suggest that to improve research use among managers in Canadian governmental health organizations, strategies should focus on enhancing exposition to evidence through facilitating communication networks, partnerships and links between researchers and decision makers, with the key long-term objective of developing a culture that supports and values the contribution that research can make to decision making in governmental health organizations. Nevertheless, depending on the organizational level, determinants of RBDM are different. This difference has to be taken into account if RBDM adoption is desired. Decision makers in Canadian health organizations (CHO) can help to build networks, develop partnerships between professionals locally, regionally and nationally, and also act as change agents in the dissemination and adoption of knowledge and innovations in health services. However, the research focused on knowledge use as a support to decision-making, further research is needed to identify and evaluate effective incentives and strategies to implement so as to enhance RBDM adoption among health decision makers and more theoretical development are to complete in this perspective.

Pathways to "evidence-informed" policy and practice: a framework for action

Bowen and Zwi propose a new framework that can help researchers and policy makers to navigate the use of evidence.

Implementation of research findings to reduce postoperative pain at night

This study was designed to introduce and evaluate a research-based intervention to improve night-time pain management. It involved the provision of patient information and the introduction of structured night-time pain assessment. The implementation of the intervention was undertaken by local opinion leader. The study involved 417 patients from two matched orthopaedic wards in a before and after trial with comparison group. Outcomes of night-time pain control were elicited from ward documentation and patients by structured interviews on the second postoperative morning. These incorporated retrospective pain assessments, analgesic provision and nursing comfort measures provided the previous night. The intervention was associated with statistically significant reductions in both average and worst overnight pain scores. The frequency of night-time pain assessment by nursing staff increased significantly, although patients did not volunteer reports of pain more frequently and analgesics and other comfort measures were no more frequent. The intervention required an investment in educational support but no additional resources were needed for the successful reduction in pain scores.