Evidence-based Practice In Primary Care Research Articles

Explaining variable effects of an adaptable implementation package to promote evidence-based practice in primary care: a longitudinal process evaluation

BackgroundImplementing evidence-based recommendations is challenging in UK primary care, especially given system pressures and multiple guideline recommendations competing for attention. Implementation packages that can be adapted and hence applied to target multiple guideline recommendations could offer efficiencies for recommendations with common barriers to achievement. We developed and evaluated a package of evidence-based interventions (audit and feedback, educational outreach and reminders) incorporating behaviour change techniques to target common barriers, in two pragmatic trials for four “high impact” indicators: risky prescribing; diabetes control; blood pressure control; and anticoagulation in atrial fibrillation. We observed a significant, cost-effective reduction in risky prescribing but there was insufficient evidence of effect on the other outcomes. We explored the impact of the implementation package on both social processes (Normalisation Process Theory; NPT) and hypothesised determinants of behaviour (Theoretical Domains Framework; TDF).MethodsWe conducted a prospective multi-method process evaluation. Observational, administrative and interview data collection and analyses in eight primary care practices were guided by NPT and TDF. Survey data from trial and process evaluation practices explored fidelity.ResultsWe observed three main patterns of variation in how practices responded to the implementation package. First, in integration and achievement, the package “worked” when it was considered distinctive and feasible. Timely feedback directed at specific behaviours enabled continuous goal setting, action and review, which reinforced motivation and collective action. Second, impacts on team-based determinants were limited, particularly when the complexity of clinical actions impeded progress. Third, there were delivery delays and unintended consequences. Delays in scheduling outreach further reduced ownership and time for improvement. Repeated stagnant or declining feedback that did not reflect effort undermined engagement.ConclusionsVariable integration within practice routines and organisation of care, variable impacts on behavioural determinants, and delays in delivery and unintended consequences help explain the partial success of an adaptable package in primary care.

Sustainability of knowledge implementation in a low- and middle- income context: Experiences from a facilitation project in Vietnam targeting maternal and neonatal health.

BackgroundIn a previous trial in Vietnam, a facilitation strategy to secure evidence-based practice in primary care resulted in reduced neonatal mortality over a period of three years. While little is known as to what ensures sustainability in the implementation of community-based strategies, the aim of this study was to investigate factors promoting or hindering implementation, and sustainability of knowledge implementation strategies, by means of the former Neonatal Knowledge Into Practice (NeoKIP) trial.MethodsIn 2014 we targeted all levels in the Vietnamese healthcare system: six individual interviews with representatives at national, provincial and district levels, and six focus group discussions with representatives at the commune level. The interviews were transcribed verbatim, translated to English, and analysed using inductive and deductive thematic analysis.ResultsTo achieve successful implementation and sustained effect of community-based knowledge implementation strategies, engagement of leaders and key stakeholders at all levels of the healthcare system is vital–prior to, during and after a project. Implementation and sustainability require thorough needs assessment, tailoring of the intervention, and consideration of how to attain and manage funds. The NeoKIP trial was characterised by a high degree of engagement at the primary healthcare system level. Further, three years post trial, maternal and neonatal care was still high on the agenda for healthcare workers and leaders, even though primary aspects such as stakeholder engagement at all levels, and funding had been incomplete or lacking.ConclusionsThe current study illustrates factors to support successful implementation and sustain effects of community-based strategies in projects in low- and middle-income settings; some but not all factors were represented during the post-NeoKIP era. Most importantly, trials in this and similar contexts require deliberate management throughout and beyond the project lifetime, and engagement of key stakeholders, in order to promote and sustain knowledge implementation.

Systems consultation: protocol for a novel implementation strategy designed to promote evidence-based practice in primary care.

BackgroundAdoption of evidence-based practices takes place at a glacial place in healthcare. This research will pilot test an innovative implementation strategy – systems consultation –intended to speed the adoption of evidence-based practice in primary care. The strategy is based on tenets of systems engineering and has been extensively tested in addiction treatment. Three innovations have been included in the strategy – translation of a clinical practice guideline into a checklist-based implementation guide, the use of physician peer coaches (‘systems consultants’) to help clinics implement the guide, and a focus on reducing variation in practices across prescribers and clinics. The implementation strategy will be applied to improving opioid prescribing practices in primary care, which may help ultimately mitigate the increasing prevalence of opioid abuse and addiction.Methods/DesignThe pilot test will compare four intervention clinics to four control clinics in a matched-pairs design. A leading clinical guideline for opioid prescribing has been translated into a checklist-based implementation guide in a systematic process that involved experts who wrote the guideline in consultation with implementation experts and primary care physicians. Two physicians with expertise in family and addiction medicine are serving as the systems consultants. Each systems consultant will guide two intervention clinics, using two site visits and follow-up communication by phone and email, to implement the translated guideline. Mixed methods will be used to test the feasibility, acceptability, and preliminary effectiveness of the implementation strategy in an evaluation that meets standards for ‘fully developed use’ of the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). The clinic will be the primary unit of analysis.DiscussionThe systems consultation implementation strategy is intended to generalize to the adoption of other clinical guidelines. This pilot test is intended to prepare for a large randomized clinical trial that will test the strategy against other implementation strategies, such as audit/feedback and academic detailing, used to close the gap between knowledge and practice. The systems consultation approach has the potential to shorten the famously long time it takes to implement evidence-based practices and clinical guidelines in healthcare.

A user-friendly website enabling evidence-based practice in primary care

A user-friendly website enabling evidence-based practice in primary care

Evidence-based practice in primary care—An explorative study of nurse practitioners in Norway

Evidence-based practice (EBP) has been a priority in health care in recent decades. However, few studies have investigated EBP in primary care. The aim of this study was to explore the knowledge that nurses with a bachelor’s degree use in their clinical practice of primary care. Focus group interviews were used. The sample consisted of 20 nurses in primary care practice. The data were analysed with systematic text condensation. Our findings show that most nurses use their own knowledge, their colleagues’ knowledge, knowledge acquired during nursing education, nursing literature, and guidance from expert personnel, but seldom use research. We recommend improving and developing the clinical practice of primary care. Referring to and analysing specialist and scientific data about specific topics may lead nurses to critically evaluate their clinical practice, and may enhance their theoretical and scientific knowledge related to clinical practice.

Case-Based Training of Evidence-Based Clinical Practice in Primary Care and Decreased Mortality in Patients With Coronary Heart Disease

We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD). A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners (n = 54) and patients with CHD (n = 88) were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists (n = 167) served as an internal specialist comparison group. Altogether, 255 consecutive patients were included. Cox regression analysis was used to detect any survival benefit of the intervention. At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group (P = .02), with a hazard ratio of 0.45 (95% confidence interval, 0.20-0.95). This difference was mainly due to reduced cardiovascular mortality in the intervention group (P = .01). In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist. Use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.

Developing evidence-based practice in population health at the local level: Qualitative insights can complement quantitative needs assessment.

In Australia, momentum has been steadily increasing to strengthen evidence-based policy and practice in population health, yet very little research has been reported that helps managers of population health services to change culture and reward an evidence-based approach. We had previously conducted a quantitative needs assessment with a regional population health workforce in Sydney. We then designed a complementary qualitative study to ensure that we understood underlying dimensions and perceptions. We analysed textual material and also conducted semi-structured interviews with 12 staff who were purposefully sampled. Not only was the value of qualitative enquiry recognised by staff as a complement to the previous quantitative needs assessment, we also discovered positive and negative views about the current promotion of evidence-based practice (EBP) and novel ways to overcome barriers and build capacity, including the development of core competencies, that has subsequently occurred. Furthermore, our contextualised assessment of local constructions of EBP also revealed underpinning tensions that will likely confront others who seek to build greater capacity for EBP in primary care.

Recommendations for the diagnosis and management of osteoporosis

LettersRecommendations for the diagnosis and management of osteoporosis Abdullah AlkhenizanCCFP ABHPM DCEpid Abdullah Alkhenizan Search for more papers by this author Published Online:7 Oct 2004https://doi.org/10.5144/0256-4947.2004.396SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor: I read with interest the recommendations for the diagnosis and management of osteoporosis by Hussein Raef et al published in the July/August 2004 issue. I have several concerns about the methodology used in the synthesis of these recommendations. First, the authors did not provide any systematic method for searching the literature, which makes these recommendations prone to bias in the selection of included studies. In addition, the authors did not provide any description of included and excluded studies. Second, there is no linkage of the recommendations to their level of evidence. This issue is a key feature of high quality Clinical Practice Guidelines (CPGs), as recommendations that are based on expert opinion are not as valid as recommendations based on level 1 evidence.1 It has been shown that when health care providers accept and follow CPGs, they have the potential to improve both the process of care and patient health outcomes.2,3 However, concerns about the quality of guidelines might limit their acceptance and application by health care providers.4 The cost and resources needed for the development of CPGs is huge and few practices have the resources and skills to develop valid high quality guidelines.5 The overall cost can be considerably reduced if guideline developers “locally adapt” high quality guidelines as a basis for producing their own guideline. There is a growing recognition that national guideline developers do not need to duplicate efforts and waste resources in the development of CPGs. Several developed countries (e.g., New Zealand, Germany and Iceland) encourage local adaptation of international good quality guidelines to avoid duplication of work and cost involved in guidelines development. Local adaptation of CPGs addresses local clinical issues and circumstances and gives a sense of ownership of the clinical guidelines. The Guideline International Network (GIN) suggested a comprehensive methodology for the local adaptation of clinical guidelines.6 There are several high quality osteoporosis guidelines that follow high methodological standards available in the literature.7,8 If the authors tried to “locally adapt” these high quality guidelines they would save significant time and resources, and they would produce a much more useful guidelines for practitioners in Saudi Arabia. This is not limited to osteoporosis guidelines; wherever possible, all Saudi guideline developers should work on the local adaptation of existing good quality guidelines.No Conflict of InterestARTICLE REFERENCES:1. Woolf S, Battista R, Anderson G, Logan AG, Wang E. members of the Canadian Task Force on the Periodic Health Examination. "Assessing the clinical effectiveness of preventive maneuvers: analytic principles and systematic methods in reviewing evidence and developing clinical practice recommendations: a report by the Canadian Task Force on the Periodic Health Examination" . J Clin Epidemiol. 1990; 43:891-905. Google Scholar2. Grimshaw J, Rusell I. "Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations" . Lancet. 1993; 242:1317-1322. Google Scholar3. Steinhoff MS, Abd El Khalek MK, Khallaf N, et al. "Effectiveness of clinical guidelines for the presumptive treatment of streptococcal pharyngitis in Egyptian children" . Lancet. 1997; 350:918-921. Google Scholar4. Helwig A, Bower D, Wolff M, Guse C. "residents find clinical practice guidelines valuable as educational and clinical tools" . Fam Med. 1998; 30(6):431-435. Google Scholar5. Grimshaw J, Eccles M. "Identifying and using evidence-based guidelines in genral practice" . In: Silagy C, Haines A. Evidence-based practice in primary care. London: BMJ Books; 2001;120-134. Google Scholar6. The Guideline International Network (GIN) website http://www.g-l-n.net. Google Scholar7. Brown J, Josse R. for the Scientific Advisory Council of the Osteoporosis Society of Canada. "2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada" . CMAJ. 2002; 167(10 suppl). Google Scholar8. Scottish Intercollegiate Guidelines Network. Management of Osteoporosis: A national clinical guidelineJune2003. http://www.sign.ac.uk/pdf/sign71.pdf. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 24, Issue 5September-October 2004 Metrics History Published online7 October 2004 InformationCopyright © 2004, Annals of Saudi MedicineThis work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.PDF download

Barriers to evidence-based practice in primary care.

Evidence-based practice is one of the most important underlying principles in modern health care. In the United Kingdom, successive governments have highlighted the fact that a quality health service is built upon the use of best evidence. Health professionals are becoming more accountable within clinical governance structures for the care they provide. The need to use robust research findings effectively is a critical component of their role. However, studies show that a number of barriers prevent the effective use of best available evidence. This study aimed to identify barriers to evidence-based practice in primary care. A specially designed questionnaire was used to gather respondents' perceptions of the barriers to evidence-based practice. Data were collected in 2000/2001. Findings show that general practitioners (GPs) ranked barriers differently to community nurses. GPs believed that the most significant barriers to using evidence in practice were: the limited relevance of research to practice, keeping up with all the current changes in primary care, and the ability to search for evidence-based information. In contrast, the most significant barriers to the identified by community nurses were poor computer facilities, poor patient compliance and difficulties in influencing changes within primary care. This suggests that these two groups may require different strategies for barrier removal. Identifying barriers is just the first step to addressing issues surrounding the use of evidence-based practice. Extra resources will be needed if these barriers are to be tackled. However, if the resultant change improves the health and wellbeing of people and communities, then the extra costs would be offset by more efficient use of services.

Evidence-based Practice in Primary Care

Evidence-based Practice in Primary Care

Book Review: Evidence-Based Practice in Primary Care

Book Review: Evidence-Based Practice in Primary Care

Evidence-Based Practice in Primary Care

Evidence-Based Practice in Primary Care

Evidence-based practice in primary care.

Evidence-based practice in primary care.

Evidence-based practice in primary care

Evidence-based practice comprises four fundamental steps: the formulation of clear clinical questions from a patient’s perspective; searching the literature; critically appraising the evidence and incorporating into practice. The Network for Evidence-Based Practice in Northern and Yorkshire (NEBPINY) seeks to establish a multi-disciplinary network of primary healthcare practitioners committed to evidence-based practice. Four interventions have been offered as part of an implementation programme: critical appraisal skills teaching; evidence-based guidelines; support for clinical audit and in-practice facilitation. Currently, three main issues are emerging from the nursing perspective: access to the evidence; knowledge of and confidence in applying critical appraisal skills, and the importance of teamwork. In-practice facilitation has encouraged meetings, for the common purpose of exploring the evidence-based guidelines and their potential impact upon practice. For some it has also been an opportunity to: discuss their own individual management of care with colleagues; to increase their awareness of the different roles played by each member and to exchange information and ideas.

Where have all the nurses gone?

<b>PURPOSE</b> We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD). <b>METHODS</b> A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners (n = 54) and patients with CHD (n = 88) were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists (n = 167) served as an internal specialist comparison group. Altogether, 255 consecutive patients were included. Cox regression analysis was used to detect any survival benefit of the intervention. <b>RESULTS</b> At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group (<i>P</i> = .02), with a hazard ratio of 0.45 (95% confidence interval, 0.20–0.95). This difference was mainly due to reduced cardiovascular mortality in the intervention group (<i>P</i> = .01). In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist. <b>CONCLUSIONS</b> Use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.