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Getting a Grip on Guidelines. A public lecture on the Science & Art of Implementing Evidence. Dave Davis, MD, CCFP, FCFP, FRCPC (hon) University of Toronto Faculty of Medicine Associate Dean, Continuing Education Principal Investigator, Knowledge Translation Program

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a public lecture on the science art of implementing evidence
Getting a Grip on Guidelines

A public lecture on the Science & Art of Implementing Evidence

Dave Davis, MD, CCFP, FCFP, FRCPC (hon)

University of Toronto Faculty of Medicine

Associate Dean, Continuing Education

Principal Investigator, Knowledge Translation Program

Ontario Guidelines Advisory Committee, Chair

if you don t like that title
If you don’t like that title…
  • Translating Guidelines into Practice
  • Putting Guidelines in Place
  • Using Evidence-based educational principles to help clinicians put evidence into practice
  • Knowledge Translation:
    • old concept + new tools = better effect?
vanessa young 1985 2000
Vanessa Young, 1985-2000
  • Mild eating disorder (early satiety) diagnosed in 1998, in Oakville, Ontario
  • Seen by child psychiatrist and family doc., prescribed cisapride, with excellent results
  • 1990; massive drug launch, all the bells & whistles
  • 1992-98; subsequent, sporadic findings of cardiac arrhythmias released by drug company bulletins, federal warnings (via print materials)
  • 2000; Vanessa dies suddenly
  • 2001; coroner’s inquest: family doctor especially expresses inability to ‘keep up with the information overload’, like an ‘avalanche’
an outline knowing when to nap
An outline; knowing when to nap
  • Definitions
  • The Care Gap
    • evidence for the gap in care – its extent & nature
  • Causes of the gap
    • problems with the learner, the message, the system
  • A Possible Solution
    • The creation and best use of guidelines
    • the question of translating knowledge into practice
  • “Knowledge translation is the effective and timely incorporation of evidence-based information into the practices of health professionals in such a way as to effect optimal health care outcomes and maximize the potential of the health system”
        • Adapted from the Canadian Institutes for Health Research definition, 2001
Diffusion: distribution of information and the practitioners’ natural unaided adoption of policies and practices
  • Dissemination: communication of information to clinicians to improve their skills
  • Implementation: putting a guideline in place, involves effective communication, overcomes barriers by administrative and educational techniques
  • (after Lomas)...
what do cme cpd mean any all ways by which physicians learn change ama 1972
What do CME & CPD mean?’any & all ways by which physicians learn & change’ AMA 1972





mailed materials,


outreach visits





AV aids

continuing professional development
Continuing professional development
  • “…broader than ‘CME’, continuing professional development permits a consideration of many non-clinical topic areas, allows for a broader range of methods and settings. Further, it is more adult-learner centered….”
          • Davis, Barnes, Fox, eds., The Continuing Professional Development of Physicians, AMA Press, 2003
  • Clinical practice guidelines are consensus and/or evidence-based statements of care intended to provide direction and assist decision-making in clinical care for both patients and clinicians..
      • Adapted from the Institute of Medicine, 1990
the clinical care gap
The clinical care gap

Ideal, evidence-based practice

clinical care gap

Current practice

warning this is the interactive part
WARNING!!:this is the interactive part
  • Think about a gap in your practice, setting or experience
  • Define it
  • Figure out the why question – what are the barriers to full implementation of the guideline, evidence, whatever
  • (Figure out the ‘how to fix it’ question)
exercise 1

Exercise #1

Identify a clinical gap in practice/health care with which you’re familiar

Acute pharyngitis

Fahey 1998

Acute Otitis Media

Delmar 1997

Acute bronchitis

65-80% vs 20%

Gonzales 1997

?PSA screening

?Mammography for low risk women age 40-50

Gotzsche, 2000


(Ministry of Health, Ontario data, 2001-04):


Repeat C-Sections

Modified radical mastectomy in breast CA

Routine, pre-op chest X-rays, EKGs

Lumbosacral X-rays for acute low back pain

*Routine q6-12month echocardiograms in stable CHF

*? Sleep studies

Pap Smears: Pirkis, 1998

CHF & ACE inhibitors Hickling 2001

and beta blockers in the elderly; McAlister 1999

Post MI patients

Lipid lowering: Kong, 1998; Aronow, 1998


Beta blockers

Atrial Fib & anticoagulation

Mendelson, 1999

Diagnosis of mental disorders

Craig and Boardman, 1997

?Screening for colorectal cancer >50

…and misuse

Beta blockers in diabetics, asthmatics

Tricyclic antidepressants in the presence of cardiac arrhythmias

Cisapride (knowing what we know today)

exercise 2

Exercise # 2

Describe the causes of the gap

what causes the gap the evidence to practice puzzle
What causes the gap?The evidence-to-practice puzzle

The evidence/guideline

The clinician

The educational delivery


  • Health Care
  • System issues
    • Patient
    • Team members
problems with the learner clinician
age, experience, time



emphasis on knowledge, not knowledge management

inability to detect needs, evaluate performance

self-directed learning

critical appraisal

type of practice



too narrow a definition of ‘learner’

learning cycle: awareness, agreement, adoption, adherence

problems with the learner-clinician
no time
No time…

No, Thursday’s out. How about never-is never good for you?

dave s top 10 reasons for not buying into cpgs
Dave’s top 10 reasons for not buying into CPGs
  • 10) They change all the time
  • 9) Guidelines, what guidelines?
  • 8) I am too busy to adopt this new stuff
  • 7) Patient problems don’t fit neatly into those little boxes
  • 6) They were made in Washington (Ottawa, Saskatchewan), wouldn’t apply here
dave s top 10 cont d
Dave’s top 10, cont’d
  • 5) I don’t trust all this EBM stuff
  • 4) There were no family docs (left-handed psychiatrists, etc) on the panel
  • 3) MY patients expect ME to make decisions!
  • 2) I already DO abide by the guidelines, yup, yessirree, 100%, all the time; that’s me - Mr. Guidelines.....and
  • 1) MY patients are different!!
problems with the guideline evidence itself
….problems with the guideline, evidence itself
  • compatibility
  • complexity
  • cost
  • relative advantage
  • accessibility
  • format
  • patency of evidence, process of development
  • opportunity; trial-ability
  • Note the AGREE instrument
producing disseminating guidelines
Producing & disseminating guidelines
  • 1) selection of clinical question
  • 2) literature searching
  • 3) distillation/synopsis of literature
  • 4) agreement by consensus, review
  • 5) development of statement
  • 6) endorsement of statement
  • 7) distribution/dissemination
“Information managementis like having your mouth to a firehose” David Naylor, Dean, Faculty of Medicine, University of Toronto


“It’s pretty simple, really: just review the world literature every two weeks”

Sharon Straus, KT program,

University of Toronto

Last week

problems with the delivery system for cme cpd does it work
…problems with the ‘Delivery System’ for CME & CPD: does it work?
  • “Does CME work, Dave?
  • All these short courses - do they change how physicians practice?”Fraser Mustard

(not the guy in CLUE)

Dean, Faculty of Health Sciences, McMaster University

July 1977

three reviews of educational interventions

Three Reviews of ‘educational’ interventions


Randomized Controlled Trials

Replicable, educational interventions: meetings, feedback, audiotapes, reminders, lectures, etc

>50% practicing physicians/professionals

Objective outcomes of physician performance or patient/health care status

Educational materials

Formal educational meetings

Outreach visits

Local opinion leaders

Patient mediated strategies



Mass media

Combination strategies

other overall findings
Other overall findings…
  • Needs Assessment (‘social marketing’) appears to be important – the more the better (subjective needs, objective, gaps and barrier analysis)
  • No evidence much about long-term effects
  • Enabling materials – helpful?
others findings 1999 2004 cochrane reviews thompson o brien grimshaw others
Others’ findings (1999 –2004):[Cochrane Reviews- Thompson-O’Brien, Grimshaw, others]
  • Most effects pretty much small to moderate at best, INCLUDING
    • Multiple methods
    • Mailed materials
  • Reminders still mostly moderate-large effects, but few/no long-term studies
  • Methodology better understood, but studies often very messy, lack details, poorly designed


  • Quantitative methodology necessary but not sufficient to understand change
  • NO common theoretical base – mostly kitchen sink research
Reason for the gap #4769: the ‘CME Process’A Database of Physician Education & Changewww.cme.utoronto.ca/rdrb
  • The Research and Development Resource Base in CME
    • educational, clinical & health services literature
    • supported by the

AMA, ACME, SACME, Royal College of Physicians and Surgeons of Canada, the University of Toronto

some comments on these reviews

publication bias

screening bias

reporting gaps

very narrow, quantitative, EBM-ish RCT bias

focus of this review - change, not learning




nature of field

What we do doesn’t work

What we don’t do does

Some comments on these reviews….
exercise 3

……..Exercise #3

What are the implications of this gap, and its causes, for us as practitioners?

a critical look at guideline development


The AGREE instrument –

The Not-all-guidelines-are-equal Guideline








Scope and purpose
  • concerned with the overall aim of the guideline, the specific clinical questions and the target patient population.
  • Item 1. The overall objective(s) of the guideline is (are) specifically described
  • Item 2. The clinical question(s) covered by the guideline is(are) specifically described
  • Item 3. The patients to whom the guideline is meant to apply are specifically described
2. Stakeholder involvement

focuses on the extent to which the guideline represents the views of its intended users.

Item 4. The guideline development group includes individuals from all relevantprofessional groups

Item 5. The patients’ views and preferences have been sought

Item 6. The target users of the guideline are clearly defined.

Item 7. The guideline has been piloted among target users.

3. Rigor of development

relates to the process used to gather and synthesize the evidence, the methods to formulate the recommendations and to update them.

Item 8. Systematic methods were used to search for evidence

Item 9. The criteria for selecting the evidence are clearly described

Item 10. The methods used for formulating the recommendations are clearly described

3. Rigor of development (continued)

Item 11. The health benefits, side effects, and risks have been considered in formulatingthe recommendations

Item 12. There is an explicit link between the recommendations and the supporting evidence

Item 13. The guideline has been externally reviewed by experts prior to its publication

Item 14. A procedure for updating the guideline is provided

4. Clarity and presentation

deals with the language and format of the guideline.

Item 15. The recommendations are specific and unambiguous

Item 16. The different options for management of the condition are clearly presented

Item 17. The key recommendations are easily identifiable

Item 18. The guideline is supported with tools for application

5. Applicability

pertains to the likely organizational, behavioral and cost implications of applying the guideline.

Item 19. The potential organisational barriers in applying the recommendations havebeen discussed.

Item 20. The possible cost implications of applying the recommendations havebeen considered

Item 21. The guideline presents key review criteria for monitoring and/or audit purposes

6. Editorial independence

concerned with the independence of the recommendations and acknowledgement of possible conflict of interest from the guideline development group.

Item 22. The guideline is editorially independent from the funding body

Item 23. Conflicts of interest of guideline development members have been recorded

The clinical care gap: possible theory-to-practice solutions, probable research questions

Ideal, evidence-based practice

The information


The learner-target

knowledge translation strategies

Current practice

1 solving the information problem one example
1) ‘Solving’ the information problem – one example
  • The Guidelines Advisory Committee, Ontario
    • Joint body of the Ontario Medical Association and the Ministry of Health and Long term Care, Ontario
    • Chooses a topic area; reviews all guidelines in that area; scores them by the Cluzeau/AGREE instrument
    • Mounts them on a website
        • Quick, 30 second synopsis
        • Parallel patient synopsis
        • Other links to QA tools, algorithms
    • Simultaneous distribution/dissemination/implementation through medical schools, licensing body, professional associations, hospitals, etc
  • Other Efforts: Skolar, Cochrane, Ovid, Bandolier
Methods/ Stages






- Print material,

- Lectures,

- Academic detailing - Media campaigns


-Small groups,

- Opinion leaders

- Pt. Education,

- Opinion leaders



Audit/ feedback


Audit/ feedback

2) Solving the ‘CME’/Intervention Problem – a possible modelBMJ 2003

Solving the learner problem #3: Consumers can drive change, too: why not educate them?

NHS Consumer Health Information Web Site December 2001 5.2 million hits – 171,900 visitors (Powell & Clarke, 2002)

Fifty-eight per cent of GPs have been approached by patients with Internet healthcare information. Sixty-five per cent of the information presented by patients was new to GPs. (Wilson, 1999)

NOTE: communication skills

a few final words
A few final words
  • Large body of educational/change literature – largely unused in guideline implementation
  • NO single effective change agent (except maybe reminders); multiple methods may work best if they include the awareness-to-agreement continuum; methods work at different levels of change - predisposing, enabling & reinforcing
  • Need to re-conceptualize ‘CME’, in order to incorporate models of ‘knowledge translation’, or guideline implementation; need to re-think targets
  • Hope for the future: better models, more practical tools, information systems,Commonwealth initiatives in health, NICS, others, and
  • Remember Vanessa
For more information…….