John Gabbay

No Magic Targets! Changing Clinical Practice to Become More Evidence Based.

This article focuses on the diffusion and adoption of innovations in clinical practice. The authors are specifically interested in underresearched questions concerning the latter stages of the creation, diffusion, and adoption of new knowledge, namely: What makes this information credible and therefore utilized? Why do actors decide to use new knowledge? And what is the significance of the social context of which actors are a part? This article first appeared in Health Care Management Review, 27(3), 35-47.

Understanding the role of opinion leaders in improving clinical effectiveness.

We present findings from evaluations of two government-funded initiatives exploring the transfer of research evidence into clinical practice--the PACE Programme (Promoting Action on Clinical Effectiveness), and the Welsh Clinical Effectiveness Initiative National Demonstration Projects. We situate the findings within the context of available research evidence from healthcare and other settings on the role of opinion leaders or product champions in innovation and change--evidence which leaves a number of problems and unanswered questions. A major concern is the difficulty of achieving a single replicable description of what opinion leaders are and what they do--subjective understandings of their role differ from one setting to another, and we identify a range of very different types of opinion leadership. What makes someone a credible and influential authority is derived not just from their own personality and skills and the dynamic of their relationship with other individuals, but also from other context-specific factors. We examine the question of expert versus peer opinion leaders, and the potential for these different categories to be more or less influential at different stages in the innovation process. An often neglected area is the impact of opinion leaders who are ambivalent or hostile to an innovation. Finally, we note that the interaction between individual opinion leaders and the collective process of negotiating a change and reorienting professional norms remains poorly understood. This raises a number of methodological concerns which need to be considered in further research in this area.

A multidimensional conceptual framework for analysing public involvement in health services research

Objective To describe the development of a multidimensional conceptual framework capable of drawing out the implications for policy and practice of what is known about public involvement in research agenda setting.

Performance indicators for primary care groups; an evidence-based approach

In England primary care groups will have a key role in promoting the health and improving the health care of their local population.1 By April 1999 these groups, involving all primary care professionals, will provide and commission health care for roughly 100 000 people in each locality. Primary care groups will be accountable to health authorities and “will agree targets for improving health, health services and value for money.”1There will be several primary care groups in each district health authority. This new approach offers primary care the opportunity to further integrate health promotion and health care at the individual and population levels. The present UK government intends to manage the performance of the “new NHS”; the word performance appeared 88 times in its recent white paper.1 It has published a national framework for assessing performance as a consultation document,2and primary care groups within health authorities will be judged to have “performed” well on the basis of the indicators listed in table 1. Most are attributable in part to primary care, but only some are linked to interventions that will necessarily lead to improved health outcomes. The government has also proposed four targets for England in its green paper Our Healthier Nation .3 Approaches taken by health authorities, and presumably by primary care groups, will be “fully monitored by the Regional Offices of the NHS Executive.”3 These targets for reduced death rates from heart disease and stroke, cancer, suicide, and accidents are all outcome indicators but, again, are only partly attributable to primary care. ### Summary points The NHS Executive and Department of Health have proposed a wide range of performance indicators many of which are applicable to future primary care groups Some of these indicators reflect access and efficiency, but few of the effectiveness …

Practice-based evidence for healthcare : clinical mindlines

1. Introduction: evidence in practice 2. From formal knowledge guided complexity 3.Clinical thinking and knowledge in practice 4. Growing mindlines: laying the foundations 5. Growing mindlines: cultivating contextual adroitness 6. The place of storytelling in knowledge sharing 7. A community of clinical practice? 8. Co-constructing collective mindlines 9. Co-constructing clinical reality 10 Conclusions and implications

A Case Study of Knowledge Management in Multiagency Consumer-Informed `Communities of Practice': Implications for Evidence-Based Policy Development in Health and Social Services

We report a study that facilitated and evaluated two multiagency Communities of Practice (CoPs) working on improving specific aspects of health and social services for older people, and analysed how they processed and applied knowledge in formulating their views. Data collection included observing and tape-recording the CoPs, interviewing participants and reviewing documents they generated and used. All these sources were analysed to identify knowledge-related behaviours. Four themes emerged from these data: (1) the way that certain kinds of knowledge became privileged and accepted; (2) the ways in which the CoP members transformed and internalized new knowledge; (3) how the haphazard processing of the available knowledge was contingent upon the organizational features of the groups; and (4) the ways in which the changing agendas, roles and power-relations had differential effects on collective sense making. We conclude by recommending ways in which the process of evidence-based policy development in such groups may be enhanced.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Involving consumers in a needs-led research programme: a pilot project

Objectives To describe the methods used for involving consumers in a needs‐led health research programme, and to discuss facilitators, barriers and goals.

Implementation of evidence-based medicine: evaluation of the Promoting Action on Clinical Effectiveness programme

Objectives: To evaluate the Promoting Action on Clinical Effectiveness (PACE) programme, which sought to implement clinically effective practice in 16 local sites. Methods: 182 semi-structured interviews, usually by telephone, with project team members, clinicians, and senior managers and representatives from the Department of Health and the Kings Fund. Results: The most influential factors were strong evidence, supportive opinion leaders and integration within a committed organization; without these factors, projects had little chance of success. Other factors (context analysis, professional involvement and good project management) emerged as important, supporting processes; their presence might be an additional help, but on their own they would not be enough to initiate change. A serious problem with any of them could have a strong adverse impact. Conclusions: Although there is no simple formula for the factors that ensure successful implementation of research-based improvements to clinical practice, certain principles do seem to help. Time and resource need to be devoted to a period of local negotiation and adaptation of good research evidence based on a careful understanding of the local context, in which opinion leader influence is an important component of a well managed and preferably well integrated process of change.

Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators

Objectives—To test the feasibility of deriving comparative indicators in all the practices within a primary care group. Design—A retrospective audit using practice computer systems and random note review. Setting—A primary care group in southern England. Subjects—All 18 general practices in a primary care group. Main outcome measures—Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators. Results—It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of effective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was £5300. Conclusion—Comparative evidence-based indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the populations health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staff, and appropriate funding. (Quality in Health Care 2000;9:90–97)