Knowledge Transfer Experiences in Obstetrics: A Systematic Review of Evidencebased Strategies to eff

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Knowledge Transfer Experiences in Obstetrics A
Systematic Review of Evidence-based Strategies to
effectively change behaviors
Nils Chaillet, Ph.D Département Obstétrique et
GynécologieUniversité de Montréal(Alexandre
Dumont, MD, PhD William Fraser, MD, M.Sc, FRCSC)
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Introduction

• Background
• Clinical Practice Guidelines implement best
  evidence into practice (Evidence based medicine)
• The challenge now lies in implementing these
  guidelines
• Strategies for implementing CPGs in Medicine
• Ineffective Mailing and Didactic traditional
  medical education
• Mixed effect Opinion leader, Audit and Feedback,
  and Continuous quality improvement
• Generally effective Manual or computerized
  reminders, Academic detailing, and Multifaceted
  interventions

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Introduction

• Most common strategies used in obstetric services
  as a routine activity
• Educational activities
• Audit activities (Confidential enquiries, Audit
  and Feedback)
• Hypothesis
• Key factors of effective strategies in obstetric
  differs from those of other medical specialties
• Objective
• To estimate effective strategies for implementing
  clinical practice guidelines in obstetric care

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Material and method

• Data sources
• Cochrane Library, EMBASE, MEDLINE
• Reference lists from identified studies and
  expert suggestions
• Identification of studies
• MeSH terms Guideline, Obstetrics, Guideline
  adherence and Practice guideline
• Text words Relevant strategies for implementing
  CPGs
• Mailing, Education, Audit, Opinion leader,
  Academic detailing, Quality improvement,
  Reminder, Multifaceted strategy

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Material and method

• Inclusion criteria
• RCT, CCT, CBA, ITS from 1990 to 2005
• Cochrane and EPOC criteria in respect with the
  design
• C-RCT / RCT Random allocation of units in each
  group
• CCT Quasi-Random allocation of units in each
  group
• CBA 2 inclusion criteria
• ITS 4 inclusion criteria
• EPOC Quality criteria in respect with the design
• C-RCT, RCT, CCT and CBA 7 quality criteria
• ITS 7 quality criteria
• Exclusion criteria
• Studies from other than obstetrics specialties
• Studies with no clear relation to CPGs
  implementation
• Opinion letters or studies including less than
  100 patients
• Qualitative studies

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Material and method

• Data extraction
• According to Cochrane and EPOC criteria standard
  Checklist
• 2 reviewers independently abstracted specific
  information from full text studies
• Discordances between the 2 reviewers were
  resolved by consensus
• An efficacy qualitative scale was ascribed to
  each study (Ineffective, Mixed effect and
  Effective)

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Study eligibility ?ow chart
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Results

• Characteristics of included studies (33)
• Design
• 10 C-RCT, 6 RCT, 1 CBA, 16 ITS (1 081 006 women)
• Strategies in obstetric
• EDUC Educational strategies (4)
• AF Audit and feedback (11)
• OL Opinion leader (2)
• QUAL Quality improvement (4)
• ACAD Academic detailing (1)
• REM Reminders (2)
• MULTI Multifaceted strategies (9)
• Including combination of the following
  sub-interventions EDUC / AF / OL / ACAD / REM

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Results

• Nature of the desired change among the 33 studies
• Reduction of cesarean sections (53 of studies)
• Management of mild hypertension
• Reduction of infections
• Promotion of active management of labor
• Promotion of VBAC
• Reduction of maternal mortality in low-income
  countries
• Reduction of suboptimal cares in low-Apgar babies
• Reduction of unnecessary clinical visits
• Enhance use of antenatal corticosteroid for fetal
  maturation
• Enhance use of antibiotics
• Breastfeeding support
• Antenatal corticosteroid use for pulmonary fetal
  maturation
• Reduction of the pregnant smokers rates

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Results

• Educational strategies (1 C-RCT, 2 RCT, 1 ITS)
• Generally ineffective to directly change
  physicians or patients behavior (Management of
  mild hypertension / Verbal patient education to
  promote VBAC)
• Present mixed effects to change nurses behavior
  (Decrease use of EFM)
• Present effective effects to change patients
  behavior by trained prenatal care providers
  nurses, social workers, nutritionists (Reduction
  of pregnant smoker rate)
• Audit and feedback (3 C-RCT, 1 CBA, 7 ITS)
• Generally effective In obstetric context to
  change professional behavior (9 studies)
• Key factors
• Intensive feedback
• Participation of local health professionals in
  the Audit process

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Results

• Opinion leaders (2 C-RCT)
• Ineffective to change patient behaviors
  (Improvement of breast feeding rates)
• Present mixed effects to change physicians
  behavior (promotion of VBAC to reduce cesarean
  section, 1991 context)
• Key factors
• Opinion leader act as a facilitator to improve
  acceptation of a local intervention
• The leadership of the local opinion leader must
  be assessed
• Quality improvement (3 RCT, 1 ITS)
• Continuity of midwifery care generally effective
  to reduce cesarean section rate
• Key factors
• Consistent relationship developed between mother
  and their midwives and obstetrician
• Availability of midwives to provide advice and
  information to women
• Active management of labor seems ineffective to
  reduce cesarean section rate
• Can be effective if the implementation is
  improved by local initiatives and when the
  program is locally standardized according to each
  provider (1 ITS only)

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Results

• Academic detailing in obstetrics (1 C-RCT)
• Present mixed effects to change physicians
  behaviors (Enhance use of Antibiotics in Cesarean
  Section, and Steroids in preterm deliveries)
• Key factors
• An optimal determination of the duration and
  frequency of visits
• Clear description of leadership and roles of
  senior obstetric staff
• Reminders in obstetrics (1 C-RCT, 1 ITS)
• Generally effective to change Health
  professionals and patients behaviors (Reduction
  of cesarean rates, and reduction of clinic visits
  in middle income countries context)
• Key factors
• Reminders developed from CPGs and from
  prospective studies of the barriers to change
• Local staff agreement
• Intensive feedback due to the local diffusion of
  the evidences
• Inclusion of local physicians in the study to
  locally adapt the reminders

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Results

• Multifaceted strategies (2 C-RCT, 1 RCT, 6 ITS)
• Generally effective to change Health
  professionals and patients behaviors (100 of
  studies are effective)
• Identified effective sub-interventions
• Educational activities (generally used to improve
  providers knowledge of CPGs and intervention)
• Audit and feedback (used to target clinical
  practices and involving health professionals in
  the audit process)
• Opinion leader (used as facilitator of the
  programs implementation)
• Academic detailing (used in association with
  education and opinion leader to promote breast
  feeding among women)
• Reminders (used in association with audit and
  feedback and developed from the recommendations
  of the audit process)
• Key factors
• Prospective study to determine the most adapted
  sub-interventions
• Intensive feedback (ensured by OL or AF by the
  involvement of local professionals)
• Barriers of each strategy are balanced by other
  strategies involved in the program

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Conclusion

• Efficacy of each strategy in obstetric cares

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Conclusion

• CPGs as evidence based medicine
• Sensitize Health professionals
• Not sufficient to effectively change behavior
• In obstetrics, multifaceted strategy based on a
  training component, an audit and feedback, and
  facilitated by an opinion leader seem effective
  to change health professionals behaviors.
• Key factors
• Ensure intensive feedback (EDUC OL)
• Involve Health professionals in the audit process
• Provide local evidences for reinforcing the
  effect of CPGs and effectively change behaviors
• Use of reminders is also advised to reinforce the
  audit committee recommendations and feedback