Evidence, Governance, Performance Challenges for Education and - - PowerPoint PPT Presentation

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Evidence, Governance, Performance Challenges for Education and - - PowerPoint PPT Presentation

Dec 25, 2022 42 likes •863 views

Evidence, Governance, Performance Challenges for Education and Research Nino Cartabellotta GIMBE Foundation "All healthcare decisions should be evidence-based" www.ninocartabellotta.it To patients this is a natural expectation For

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Evidence, Governance, Performance

Challenges for Education and Research

Nino Cartabellotta

GIMBE Foundation

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"All healthcare decisions should be evidence-based"

www.ninocartabellotta.it

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To patients this is a natural expectation For professionals this is an impossible dream

Glasziou P, Haynes RB. ACP J Club 2005

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Gaps between knowledge and practice

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2001: IOM identified 3 types of gaps

  • Overuse
  • Underuse
  • Misuse
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  • 1. Overuse of ineffective health interventions

26%

  • 2. Fraud and abuse

21%

  • 3. Pricing failures of health technologies

19%

  • 4. Underuse of effective health interventions

12%

  • 5. Administrative complexity

12%

  • 6. Failures of care coordination

10%

6 categories of wastes… …more than 20% of healthcare expenditures

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Performance EBHC

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Producing and using high-quality and trustworthy EVIDENCE

  • Primary research
  • Systematic reviews

All healthcare systems need…

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Delivering an evidence-based, high-value, cost-conscious healthcare applying the systemic approach to clinical GOVERNANCE, which integrates synergic tools:

  • Evidence-based Practice
  • Clinical practice guidelines and care pathways
  • Clinical audit and quality measures
  • Risk management
  • Health technology assessment
  • CME and CPD
  • Patient involvement
  • …

All healthcare systems need…

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All healthcare systems need…

Measuring the PERFORMANCE of healthcare for accountability and openness, through multidimensional sets of indicators:

  • Safety
  • Efficacy
  • Appropriateness
  • Patient involvement
  • Equity and accessibility
  • Efficiency
  • Productivity
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What challenges for education and research about

  • Evidence
  • Governance
  • Performance
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What challenges for education and research about

  • Knowledge generation
  • Knowledge management
  • Knowledge translation

in health care?

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Outline

  • 1. Knowledge generation
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Necessary Research

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Necessary Research

Planned Research

Published Research

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Necessary Research

Omission bias

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OMISSION BIAS

  • Shifting sponsored research agenda from industry interests to

health needs

  • Sustaining public-private research projects
  • Encouraging international alliances for research governance
  • Enhancing comparative effectiveness research
  • …
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OMISSION BIAS

  • Setting research priorities using "sources of grey zones"
  • DUET: Database of Uncertainties about the Effects of

Treatments

  • Cochrane reviews with inconclusive results
  • Weak recommendations of clinical practice guidelines
  • Involving patients and clinicians to identify research priorities
  • James Lind Alliance "top 10 uncertainties"
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Necessary Research

Planned Research

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Planned Research

Publication bias

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PUBLICATION BIAS

  • Requiring, by incentives and regulation
  • the registration and publication of

protocols for all clinical trials at inception

  • the publication of full reports of

completed trials

  • Promoting the registration of observational

studies

  • …
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Published Research Published Research

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Preliminary Not applicable

Best evidence

Not relevant Not valid

BIAS COIs Critical appraisal

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BIAS

  • Improving the quality of primary research
  • Design
  • Conduction
  • Analysis
  • Reporting
  • …
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CONFLICTS OF INTEREST

  • Exploring better ways to manage COIs, more than disclosure
  • Improving integrity and transparence of research with new

means

  • …
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Outline

  • 1. Knowledge generation
  • 2. Knowledge management
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Cartabellotta A. Rec Prog Med 1998 (modified)

Needs

Keep updated Clinical problem solving

KM strategy

Proactive Reactive

Tools

Pre-appraised resources Databases

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Muir Gray JA. Churchill Livingstone 1997 (modified)

Knowledge Management

Scanning Searching

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Studies

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Synopses of Studies

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Syntheses

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Synopses of Syntheses

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Summaries

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KNOWLEDGE MANAGEMENT

  • From the first years of undergraduate education:
  • instilling attitudes to recognize own knowledge gaps and to

fill them by reactive KM strategies

  • teaching and formally verifying KM skills
  • Improving usability of evidence through new "formats"
  • Exploring new technologies to get evidence during clinical

consultation (mHealth)

  • Confirming the CDSS worth staying the apex of the 6S pyramid
  • …
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Outline

  • 1. Knowledge generation
  • 2. Knowledge management
  • 3. Knowledge translation
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Some innovations are adopted very quickly, even without evidence. Other innovations are rarely and unlikely adopted despite good evidence.

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ACP J Club 2005;142:A8-10 Evid Based Med 2005;10:4-7 Evid Based Nurs 2005;8:36-8

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Leakage in the pipeline

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Leakage in the pipeline

80% transfer at each of 7 stages 21% (0.87 = 0.21) Even with high rates of transfer between stages, there may be little impact on patient outcomes

Glasziou P, Haynes RB. ACP J Club 2005

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  • All reported knowledge management challenges
  • …
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  • "Persuade" professionals with means other than unbiased

evidence

  • Identifying methods to “vaccinate” clinicians against poor

evidence

  • …
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  • Switching from explanatory to large pragmatic trials
  • Validating tools for applying generic recommendations of

guidelines to individual patients

  • Teaching decision-making strategies to balance benefits and

harms of application of evidence to individual patients

  • …
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  • Improving description of health interventions in clinical trials
  • Training on health innovations integrated in CME and CPD

activities

  • Evaluating standards of professional competence to deliver

complex health interventions

  • …
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  • Tailoring multifaceted strategies to change professional and
  • rganizational behaviors
  • …
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Cochrane Effective Practice and Organisation of Care Group conduct systematic reviews of interventions designed to improve the delivery, practice and organisation of health care services

Cochrane EPOC Group

  • Professional
  • Financial
  • Organisational
  • Patient-oriented
  • Structural
  • Regulatory
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  • Using patient decision aids to get an evidence-based

persuasion

  • Incorporating patient preferences in clinical practice guidelines
  • Financial incentives to patients ?
  • …
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  • Using effective strategies to improve adherence to drugs and
  • ther health interventions
  • Teaching these strategies to increase treatment adherence at

undergraduate level

  • …
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Evidence Governance

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  • 1. KNOWLEDGE CREATION
  • 1st generation: primary studies
  • 2nd generation: systematic reviews
  • 3rd generation: products, tools
  • clinical practice guidelines
  • patients decision aids
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  • 2. ACTION CYCLE
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  • Involving all stakeholders
  • Scoring problems relevance
  • Using formal consensus methods
  • …
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  • What knowledge? CPG, SR, HTA
  • How to select knowledge? Using AGREE, AMSTAR, INAHTA

Checklist

  • Integrating various sources of knowledge  medico-legal

risks?

  • …
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  • Avoiding that "adapting" is intended as "legitimating local

practices"

  • Validating the ADAPTE and CAN-IMPLEMENT instruments
  • Defining the lowest threshold of local adapting
  • Defining a taxonomy for adapting variables: structures,

technologies, organizations, professionals, etc

  • …
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  • Increasing knowledge from qualitative research
  • Reaching a consensus of taxonomies and frameworks for

barriers and facilitators

  • …
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  • Developing systematic approaches for mapping barriers to

interventions

  • Filling grey zones about KT interventions and improving their

applicability

  • …
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  • Reporting clinical details in medical charts
  • Developing high quality clinical databases
  • Validating process indicators
  • Defining targets of appropriateness related to evidence levels
  • …
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  • Linking outcome research and KT research
  • Standardizing outcome measurements
  • Developing high-quality clinical databases
  • Improving risk-adjustment
  • …
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  • Identifying effective methods to sustain the use of knowledge
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Evidence Governance Performance

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Outline

  • 1. Knowledge generation
  • 2. Knowledge management
  • 3. Knowledge translation
  • 4. Conclusions
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An ideal evidence-based world, addressing all challenges would allow to:

  • Commission, conduct and publish more relevant and high-

quality research, reducing wastes

  • Improve individual knowledge management
  • Implement the whole KT process to improve:
  • appropriateness of health interventions, reducing wastes

due to overuse and underuse

  • patient outcomes
  • sustainability of health systems
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