Milo L. Brekke

Lessons from Experienced Guideline Implementers: Attend to Many Factors and Use Multiple Strategies

BACKGROUND Studies of clinical guideline implementation have focused almost entirely on changing individual clinician behavior with single intervention strategies and without much attention to the situational context. The goal of this project was to learn from clinic leaders, seasoned in the guideline implementation process, what contextual variables they viewed as important and whether implementation success could be expected if only a single implementation strategy was used. METHODS In 1998, 12 people with extensive experience in leading clinical guideline implementation were identified who were thought to have particularly keen insight into the process. They were interviewed to generate variables they considered important, as well as strategies they considered effective when used appropriately. A modified nominal group/Delphi process was then used for rating these variables and strategies, and the reactions of international experts were obtained to add perspective to this information. RESULTS Eighty-seven variables and 25 strategies were identified, clustering in 6 categories (ranked in order of importance by the panel): organizational capabilities for change, infrastructure for implementation, implementation strategies, medical group characteristics, guideline characteristics, and external environment. All six categories were considered to be important, key, or essential by the experienced implementers, although variables within a medical group that directly affect its ability to undertake planned change were rated as much more important than either guideline characteristics or the external environment. DISCUSSION Although the opinions of those experienced in the process of guideline implementation are primarily of value for generating hypotheses, panel members believe that implementation efforts focusing on the individual physician with a single strategy are unlikely to be successful. Rather, implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organization, and external environment.

Delivery Rates for Preventive Services in 44 Midwestern Clinics

OBJECTIVE To determine the rates at which private primary-care clinics are recommending blood pressure and cholesterol measurement, smoking cessation, clinical breast examination, screening mammography, Papanicolaou testing, and influenza and pneumococcus immunizations. MATERIAL AND METHODS We conducted a mail survey of 7,997 randomly selected patients from 44 primary-care clinics in and around Minneapolis-St. Paul, Minnesota, of whom 6,830 (85.4%) completed the questionnaire on preventive services delivery rates. The responses were analyzed statistically, including stratification by reason for the clinic visit. RESULTS On the average, about two-thirds of the patients in each clinic reported being up-to-date on preventive services before their clinic visit; an exception was pneumococcus immunization (mean rate, 33%). Except for blood pressure and smoking cessation advice, less than 30% of patients who were not up-to-date on a preventive service were offered it if the clinic visit was for a reason other than a checkup or physical examination. For patients who said that they saw their physician for a checkup or physical examination, the rate was more than 50% only for Papanicolaou smear. In contrast, nearly all responding practitioners agreed that each of the eight preventive services was very important or important. CONCLUSION Preventive services consensus goals are not being met, even for patients who report that their clinic visit was for a checkup or physical examination. This finding suggests that it may be necessary to develop clinical systems that support and enable the delivery of preventive services.

Delivering clinical preventive services is a systems problem

A steadily increasing number of research trials and prevention advocates are identifying the practice environment as the main source of both problems and solutions to the improved delivery of clinical preventive services. Although these sources are correctly focusing on office systems as solutions, there is a tendency to focus on only parts of a system and to relate this to just one or a few related preventive services.However, the effort required to set up and maintain an office system makes it difficult to justify doing so for a single clinical activity. The process and system thinking of Continuous Quality Improvement (CQI) theory suggests that there may be both efficiency and effectiveness advantages to the concept of all clinical preventive services being served by a single system with many interrelated component processes. Such a system should be usable for all age groups. This system and its literature base are described. The feasibility of applying this concept is being tested in a randomized controlled trial in 44 primary care clinics in Minnesota and Wisconsin.

The eating pattern assessment tool: A simple instrument for assessing dietary fat and cholesterol intake☆

OBJECTIVE This study describes the development of the self-administered Eating Pattern Assessment Tool (EPAT), which is designed to assess dietary fat and cholesterol intake and aid patients and health professionals in achieving control of blood cholesterol levels. DESIGN Test-retest reliability of the instrument over five visits and concurrent validity testing compared with 4-day food records. SETTING AND SAMPLE The instrument was tested at multiple sites of a large manufacturing corporation using 436 adult volunteers with approximately equal proportions of men and women from three socioeconomic levels. MAIN OUTCOME MEASURE Development of the EPAT centered on creating an instrument that was simple and easy to use in a primary-care setting, that would provide a reliable assessment of intake of dietary fat and cholesterol among adults, and that would measure frequency of consumption of foods from high-fat and low-fat categories. ANALYSES Test-retest reliability for repeated use was estimated by between-visit Pearson product-moment correlations of EPAT section scores. Concurrent validity was assessed by using product-moment correlation between EPAT section scores and mean daily B-scores obtained from 4-day food records. RESULTS Test-retest reliability estimates were 0.91 between all adjacent pairs of visits and 0.83 between visits 1 and 5 (4 months). Validity was 0.56. APPLICATIONS/CONCLUSIONS The EPAT is a simple, quick, self-administered tool using an easy scoring method for accurately assessing fat and cholesterol intake. It is a reliable and valid substitute for more time-consuming food records. EPAT also provides an efficient way to monitor eating patterns of patients over time and is arranged to provide an educational message that reinforces the consumption of recommended types and numbers of servings of low-fat foods.

The systematic practice of preventive cardiology

The Preventive Strategy Delivery of preventive services differs little from that of therapeutic services. In traditional practice we obtain the medical history, carry out the physical examination, order and interpret the laboratory work, formulate diagnoses and prescribe therapy. The ap preach to preventive cardiology is similar. Begin with a traditional work-up. This is impressive to the patient and revealing to you. It gives credibility to your summation of the evidence for risk and to your preventive recommendations. It also sets a personal tone of caring for your patient. It sharply focuses your attention on the patient as an individual. Summarize the clinical and laboratory findings. Link them to a general class of risk sufficiently real to command attention but not exaggerated for its accuracy of individual prediction. Specific recommendations for new behaviors reduce the fear and rejection that can be associated with labeling as “high risk.” Link the risk class to the patient’s personal behavior and genetic legacy, thus balancing the modifiable and unmodifiable factors of risk. Review smoking, eating, physical activity and weight change patterns in daily living. Then try to tie the risk and personal habits to family and social behaviors, giving the patient insights into the nature and causes of excess risk. Point out situations in the home and worksite that influence the eating activity and smoking patterns of the patient’s spouse, children and colleagues. Finding a relatively low risk status provides the occasion for congratulations, but also allows you to indicate the influence of the patient’s behavior on others, i.e., the development of risk in family and friends. A11 in the family need to

Physician-delivered smoking cessation advice: issues identified during ethnographic interviews

Objective-To identify the factors that physicians believe impair their ability to provide smoking cessation advice to their patients. Design - Ethnographic interviews of physicians. Setting - Non-academic primary care practice. Subjects -18 of 27 physicians who had recently participated in the intervention group of a randomised clinical trial to increase the rate at which physicians give smoking cessation advice. Main outcome measures -Factors that the interviewees reported were affecting their ability to give smoking cessation advice. Results -The interviews generated 439 statements that we sorted into 19 cate gories. We judged 10 of the categories to be statements about medical practice and smoking in general, and nine of the categories to represent barriers to giving smoking cessation advice. The barriers described by the interviewees included: lack of patient interest, lack of physician perceived self-efficacy, lack of time, lack of organisational support, lack of reward to the physician, lack of peer support, lack of staff support, and lack of interest on the part of the physician. The com mercial promotion of tobacco was also identified as a barrier to giving smoking cessation advice. Conclusions - As reported by physicians who had participated in a trial to provide smoking cessation advice in their own practices, the barriers to giving smoking cessation advice are more than a lack of knowledge that smoking is a health hazard and the lack of skills to help the patient stop smoking. These additional barriers may need to be addressed if physicians are to improve the rates at which they identify their patients who smoke and assist them in quitting.

Smoking patterns among social contacts of smokers, ex-smokers, and never smokers: the Doctors Helping Smokers Study.

Smoking status of spouses/partners and other social contacts was examined among 5,241 adults who had recently visited a family physician. Associations between smoking status and proportion of social contacts who smoke among men and women of three different age groups were assessed by analysis of covariance, with age and education as covariates. The proportion of smoking contacts was found to be greatest for smokers, less for ex-smokers, and least for never smokers. Comparison of data across four types of social contacts by smoking groups suggests that, in general, the social contacts of ex-smokers more strongly resemble those of never smokers than those of current smokers. The results suggest that smokers desiring to become nonsmokers need to enlarge their social group to include more nonsmoking contacts, as well as to learn and use coping strategies to prevent relapse in the presence of smokers.

Initiation and maintenance of patient behavioral change

If the physician is to help a patient adopt and maintain “preventive behaviors,” the processes that influence and shape both patient and physician behaviors must be understood, the physician’s role in the behavioral change process must be acceptable to both the patient and the physician, and an environment that both permits the physician to act and reinforces the physician for acting appropriately must be designed for the physician. A physician’s role that is acceptable to both the patient and the physician can be seen as six obligations. The physician must 1) evaluate the medical literature on prevention to determine which services are indicated for which types of patients, 2) when seeing an individual patient, identify the services and behaviors needed by that patient, and 3) advise the patient of the need for action. As the patient responds positively to the physician’s advice, the physician must 4) enable and assist the patient to have the indicated tests or procedures and accomplish the suggested behavioral changes, and 5) reinforce the patient’s new and ongoing preventive behaviors. The sixth obligation of the physician is to establish, support, and maintain a system to facilitate tasks 2 through 5.

Appropriate Days for Measuring Intake of Dietary Fat and Cholesterol

Seven consecutive day food records were assessed in 224 free-living adult volunteers to (1) identify the smallest number of days, and which days of the week, would provide most of the information about dietary fat and cholesterol intake (assessed by B score) and (2) whether a complex mathematical formula for weighting certain days was required to achieve reasonable validity. A factor analytic approach was used to identify 3- and 4-day sets. The correlations with the 7-day average B score ranged from 0.95 for the best 4-day (Saturday through Tuesday) average B score to 0.91 for the best 3-day (Sunday through Tuesday) average B score. Simple averaging (no weighting) was found to be adequate to achieve this level of validity.

Clinician satisfaction with a preventive services implementation trial: The IMPROVE project

OBJECT To discover how attempts to increase the delivery of preventive services affect clinician satisfaction. METHODS The IMPROVE project was a randomized clinical trial conducted in 44 clinics in and around Minneapolis-St. Paul, Minnesota. Personnel were trained in continuous quality improvement techniques to organize preventive services delivery systems. Satisfaction with delivery of these services and with the sponsoring organizations was measured before the intervention (Time 1), at the end of the intervention (Time 2), and 1 year post-intervention (Time 3). RESULTS At no time was the intervention associated with a change in the respondents satisfaction with their places of work or with their job roles. Satisfaction with preventive services delivery increased from Time 1 to Time 3 among intervention-clinic respondents. Satisfaction with the IMPROVE project and the efforts of the two managed care organizations to help the clinics deliver preventive services peaked at Time 2 and declined toward baseline at Time 3. Satisfaction with preventive services delivery tended to increase more in the 13 intervention clinics that implemented a preventive services delivery system than in the nine intervention clinics that did not implement a preventive services delivery system (p = 0.15). CONCLUSIONS Planned organizational change to create systems for preventive services delivery can be associated with increased clinician satisfaction with the way these services are delivered. However, increased satisfaction with preventive services does not necessarily indicate that service delivery rates have increased.