Implementering av forskning barrierer og utfordringer

Transkript

1 UNIVERSITY OF OSLO Implementering av forskning barrierer og utfordringer Allmennmedisinsk Forskning relevans for individ og samfunn Forskningsrådets konferanse 3.nov 2009 Jørund Straand, professor i allmennmedisin /leder AFE Oslo, Universitetet i Oslo Jørund Straand, General Practice Research Unit; Institute of General Practice and Community Medicine. 2009

2 UNIVERSITY OF OSLO Eksempel: Kollegabasert terapiveiledning (KTV) Vitenskapelig evaluering (= forskning) på effekter av et kvalitetsforbedringsprosjekt der (mer eller mindre) forskningsbasert kunnskap om legemiddelbehandling implementeres i allmennpraksis Relevans for individ og samfunn kfr dagens tema Vitenskapelig evaluering av prosjektet er støttet av vårt vertskap: programområdet klinisk forskning i Forskningsrådet 2 ph.d prosjekt (Svein Gjelstad og Sture Rognstad) Begge har fått aksept til å konvertere dette fra (3 x 1) til (5 x 0.6 årsverk) Jørund Straand, 2009 Institute of General Practice and Community Medicine

3 UNIVERSITY OF OSLO Eksempel: Kollegabasert terapiveiledning (KTV) Etterutdanning (via etablerte etterutdanningsgrupper) Kvalitetsforbedring/audit Pløye forskningsbasert kunnskap inn i praksis To pedagogiske intervensjoner (kurs gjennomført på en spesiell måte) i allmennlegers etterutdanningsgrupper: Tryggere farmakoterapi for eldre (70+) Mer hensiktsmessig bruk av antibiotika ved luftveisinfeksjoner Forskning (clusterrandomisert effektstudie og kvalitativ prosessevaluering) Forskningsspørsmål: endrer kurset deltagernes forskrivningspraksis? Hvordan opplevde KoKo-er og deltagere prosjektet? Jørund Straand, 2009 Institute of General Practice and Community Medicine

4 Hvordan forbedre praksis uten lov & tvang eller økonomiske insentiver? Kvalitetssirkelen Ber ytterligere kvalitetsforbedring? Hva er min nåværende praksis? Forbedret praksis? Hvordan er praksis nå? Teaching,learning and reflection Implementering av ny praksis

5 UNIVERSITY OF OSLO "It is hard to evaluate or to improve the quality of something that you do not know how look like. Most physicians know remarkably little about their own practice. Simple things like the distribution of own patients according to gender and age groups, how many patients on treatment for hypertension, or how many who are regular users of benzodiazepines or strong analgesics, usually remains obscure guesswork." Rutle O. EDB-journalen i allmennpraksis et uutnyttet redskap. Tidsskr Nor Lægeforen 1994; 114: Jørund Straand, 2009 Institute of General Practice and Community Medicine

6 UNIVERSITY OF OSLO Only rarely GPs write prescriptions by hand All GPs are using electronic medical record (EMR) systems The list system (in Norway since 2001) provides each GP a practice denominator Performance data from practice computers EMR systems are not yet designed for feasible provision of meaningful statistics at the practice- or physician level Performance data from prescription statistics: 2004: Norwegian Prescription database (NorPD) Jørund Straand, 2009 Institute of General Practice and Community Medicine

7 Rx-PAD Study I Protocols: BMC Health Services Research 2006; 6: 72 & 75 Randomization 80 CME groups Baseline-data Intervention Feedback Analysis (~500 GPs) Antibiotics/ RTI Control for Drugs/ elderly Drugs/ elderly Control for antibiotics/ RTI Retrospective data extraction from all GPs (both groups) and from the NorPD Two CME peer group sessions led by trained PADs. Reflection on own performance (individual report - baseline) 1 day CMEcourse Retrospective data extraction from all GPs (both groups) and from the NorPD CME peer group session: Reflection on own performance (individual report achieved effects) Evaluation Research Autumn 05 Jan/March 06 Winter/spring 06 Jan/March >

8 A single blinded, tophat-flowerpot clusterrandomized study

9 UNIVERSITY OF OSLO The PADs (Peer Academic Detailers) Norwegian: kollegakonsulenter Experienced GPs (n= 26); each responsible for visiting ~3-4 CME groups (i.e. half were elderly-peers and the rest were antibiotic peers ) Two 2-days training sessions in group paedagogics, the content of the intervention, methods etc Fee for service according to standards established by the Norwegian Medical Association. Plus CME-credit for being a Rx-PAD Jørund Straand, 2009 Institute of General Practice and Community Medicine

10 Data sources for quality assessment We 1 designed a software for simple extraction of prespecified data from the various EMRsystems used in Norway 1 ie. Svein Gjelstad Capured electronic medical record (EMR)-data were linked with corresponding data from the Norwegian Prescription Database (NorPD) Captured data were used for making individual feedback reports to the participating GPs throughout the project. The reports included individual performance data as compared to the total average

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12 Data flowchart Participant s EPR system Statistics Norway Patients data linked to project IDs (de-identified personal IDs) Project IDs linked to patients CPR number and doctors HPR numbers Project ID s linked to pseudonymous CPR and HPR numbers Project site University of Oslo Prescription data linked to project IDs Norwegian Prescription Database - NorPD (Pseudonymous)

13 The quality circle for improving practice in CME group setting Need for further improvements? Teaching and learning in CME group setting After one year: What is new practice? (new report) Group setting One day course Change in practice? Reflection on todays practice based on individual reports, group setting

14 UNIVERSITY OF OSLO The medical content of the Rx for the elderly intervention (i.e. one out of two courses) Focus on why and how to avoid using some listed drugs with poor safety records, as well as potentially harmful drug combinations Harms and side effects of medications are in general less well documented in the medical litterature than the effects 13 rules of the thumb ( avoid using drug X unless a valid reason is given ) were used as quality indicators (QIs) Alternative and safer treatment options were given in relation to each QI Jørund Straand, 2009 Institute of General Practice and Community Medicine

15 UNIVERSITY OF OSLO Rx targeted during the Rx-PAD intervention 1. First generation tricyclic antidepressants 2. First generation antihistamines 3. First generation low potency antipsychotics 4. Long-acting benzodiazepine hypnotics 5. Muscle relaxant karisoprodol (now withdrawn from market) 6. Three elderly opioid anagesics 7. Theofyllamin by mouth Details: Scand J Prim Health Care 2008; 26: 80-5 Jørund Straand, 2009 Institute of General Practice and Community Medicine

16 UNIVERSITY OF OSLO Drug-combinations to be avoided for eldrely patients Concurrent use of 1. betablocker + non selective ca-blocker 2. NSAID + warfarin 3. NSAID + diuretic 4. NSAID + SSRI 5. NSAID (or CoxII) + ACE-inhibitor (or ARB) 6. 3 or more psychotropics (opioids, antipsychotics, hypnotics, sedatives, antidepressants) Details: Scand J Prim Health Care 2008; 26: 80-5 Jørund Straand, 2009 Institute of General Practice and Community Medicine

17 Personal report to each GP: 1. baseline Based on NorPDdata Reflecting GP s prescription practice before the educational intervention as compared to average figures for all participants (~450)

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20 One year prevalence of inappropriate Rx issued for elderly patients (70+) by 454 GPs (= baseline data) Drugs or combinations of drugs to be avoided for elderly patients due to reasons of safety Mean (95 % CI) Rx / 1000 patients Tricyclic antidepressants (Amitryptiline, Doxepin, Trimipramine, Clomipramine) 22 (20-23) 1st generation (low potency) antipsychotics (Chlorpromazine, Chlorprotixene, Levoprometazine, Prochlorperazine) 26 (24-28) Long acting benzodiazepines (Nitrazepam, Flunitrazepam) 46 (43 49) Strong analgesics (Propoxyphene, Pethidine, Opioids with spasmolytics) 11 (10 12) 1st generation antihistamines (Dexchlorphenamine, Promethazine, Alimemazine, Hydroxycin) 25 (23 26) Long time oral use of Theophylline 5 ( 5 6) Carisoprodol (muscle relaxant) 10 ( 9-11) Beta blocking agent + unselective calcium channel blocker 6 ( 5 6) NSAID + Warfarin (any concomitant use) 3 ( 3 4) NSAID+ ACE-inhibitor or A2-blocker (any concomitant use) NSAID + SSRI (any concomitant use) 34 (32 36) 8 ( 7-9) NSAID + diuretic (any concomitant use) 24 (22 25) 3 + psychotropics (analgesics containing opioids, psycholeptics, hypnotics, antidepressants) for > 3 months 28 (26 30) Total 247 ( )

21 UNIVERSITY OF OSLO Baseline data (the year before intervention): inappropriate Rx (n= 454 GPs) hits per 100 patients > 70 y : Long acting benzodiazepines: 4.6 Risky NSAID- combinations: 6.9 Concurrent use of > 3 psychotropic drugs: 2.8 In total: 24.7 (23.7 to 25.6) Scand J Prim Health Care 2008; 26: 80-5 Jørund Straand, 2009 Institute of General Practice and Community Medicine

22 CME peer group session: GPs reflecting on own performance

23 2.nd report: 1 year later and after a one day course (evidence update course)

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26 UNIVERSITY OF OSLO Desired change? YES! Prescriptions for all targeted drugs went down in intervention group as compared with control group. Overall reduction (all indicators together) was about 7% (or >15% in relative terms) The results correspond to that about elderly patients get safer medications from their GP due to the Rx-PAD study Jørund Straand, 2009 Institute of General Practice and Community Medicine

27 KTV-indikator-liste som er utvidet og relevansvalidert Norsk motstykke til Socialstyrelsens liste (Sverige) og Beers kriteriene (USA)

28 UNIVERSITY OF OSLO Rx-PAD Study II ( ) Switching intervention theme between the CMEgroups participating in Rx-PAD I study Objective: to assess long term effects of Rx-PAD I intervention The one day course substituted by a group session including reflection and discussion regarding 4 cases from each participant Improved data extraction methods from EPR system Jørund Straand, 2009 Institute of General Practice and Community Medicine

29 UNIVERSITY OF OSLO Hvem betaler for KTV-studien? Gjennomføringen HOD/Helsedirektoratet Legeforeningen (Kvalitetssikringsfond) [Ingen har så langt gitt økonomisk støtte i 2009] UiO (indirekte kostnader: personell, infrastruktur) Forskningen Forskningsrådet /klinisk forskning 2 x ph.d Allmennmedisinsk Forskningsfond 2 ph.d (hvorav 1 formelt opptatt) Søknad inne til ytterligere 1 ph.d Jørund Straand, 2009 Institute of General Practice and Community Medicine

30 UNIVERSITY OF OSLO Rx-PAD Study III? Rx-PAD Study III ( ): New educational intervention Objective: Implementing new national guidelines for diabetes II vs. Asthma/COPD[and heart failure?] in general practice Using corresponding methods and similar setting as in previous Rx-PAD studies Without funding no study Jørund Straand, 2009 Institute of General Practice and Community Medicine

31 UNIVERSITY OF OSLO Hvorfor virker KTV-modellen? Faglig relevans Faglig aksept Omfattende i tid/omfang, mangefasettert metode Kollegial ikke truende : KoKo skjønner våre dilemma Teaching, learning and reflection Audit (utgangspunkt i egne nærhet Frich JC, Høye S, Lindbæk M, Straand J. General practitioners and tutors experiences with peer group academic detailing: a qualitative study. (Submitted 2009) Jørund Straand, 2009 Institute of General Practice and Community Medicine

32 UNIVERSITY OF OSLO KTV-prosjektet: andre gunstige effekter Flying start for AFE-Oslo og ASP Fremmer forskningssamarbeid på tvers av Seksjonen, Forskningsenheten og Antibiotikasenteret. KoKo-korpset viktig arena til rekruttering av nye allmennmedisinske forskere Styrket kontakt mellom akademiet og Allmennlegekorpset Legeforeningen Helseforvaltningen Vi mener modellen bør videreføres i allmennlegers videre og/eller Jørund Straand, 2009 etterutdanning Institute of General Practice and Community Medicine