Mark L. Willenbring, MDNIAAA/National Institutes of Health

RSA 2008, Washington, DC

Implementation: A Practical Approach

CaseManager

OR…

Scientific Inquiry

• Level I: Consensus of experts

• Level II: Small clinical trials

• Level III: Large randomized

controlled trials (RCTs)

• Meta-analysis

• are developed using systematic reviews

• use national or regional guideline development groups (including representatives of key disciplines)

• note explicit links between recommendations and scientific evidence.

» Grimshaw J, Eccles M. et al. “Developing clinically valid practice guidelines,” J Eval Clin Pract 1995;1(1):37-48

Guidelines are more likely to be valid if they:

Inclusion Criteria:

1. Has specified disorder

2. Willing to participate

3. Has home, phone, & transportation

4. Fine upstanding citizen

30-50%

Exclusion Criteria:

1. Coexisting psychopathology (incl. addictions)

2. Multiple prior treatments

3. Serious medical problems

4. Lack of housing, transportation

5. Unmotivated

6. Too busy surviving to bother

7. Taking other medications

8. History of non-compliance

9. Lives too far away

10. Serious personality disorder

50-70%

Dodo bird:Friend or enemy?

Looking in the wrong place?

0102030405060708090

0 4 8 12

Weeks

Perc

ent D

ays

Abst

inen

t

Tx 1 Tx 2

Examined change

Unexamined change

Results remarkably similar

Miller et al., J Stud Alc 62:211-220, 2001

Project MATCH Main Outcomes

Project MATCH Research Group, J Stud Alc 59:631-639, 1998

Increased drinking quantity

before entry

Immediate substantial

improvement

Treatment: instigator or result of change?

0 4 8 12 etc. week

PDA

Does change occur prior to tx?

Compared 5 different treatment approaches for cannabis use disorder in adolescents

Dennis et al., JSAT 2004

No difference across groups

UKATT Trial

• Compared 4 sessions of MET with 8 sessions of social and behavior therapy

UKATT findings

0

10

20

30

40

50

Baseline 3 mo 12 mo

PDA

DDD

No difference across groups

Dodo bird strikes again!

A broader view of change

• Therapeutic techniques may have small effects relative to extrinsic factors

A broader view of change

• Common mechanisms may account for change– Therapeutic alliance and

Empathic listening

– Social support for change

– Therapeutic rituals (cf. Jerome Frank)

– Help-seeking itself

Implications for research

There may be multiple pathways (or mechanisms of action) with similar outcomes, OR

We may have been looking in the wrong place

There’s many a slip between the cup and the lip.

• Implemented CBT (high and low standardization) in community program

• Compared to Treatment as Usual

Whoops!

Morgenstern et al., JCCP 2001

Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study

Kathleen M. Carroll, Samuel A. Ball, Charla Nicha, Steve Martinoa, Tami L. Frankfortera, Christiane Farentinosb, Lynn E. Kunkelc, Susan K. Mikulich-Gilbertsond, Jon Morgensterne, Jeanne L. Obertf

, Doug Polcing, Ned Sneadh, George E. Woodyi and for the National Institute on Drug Abuse Clinical Trials Network

Drug and Alcohol Dependence Volume 81, Issue 3, 28 February 2006, Pages 301-312

Effectiveness of MI

• Standard intake vs. MI

• Achieved desired differences in technique

• Improved engagement

• No difference in 28 day or 84 day substance use outcomes

Carroll et al., Drug and Alcohol Dependence, 2006

Take Home Message

• Multiple treatments have been shown to produce acceptable outcomes

• Caution is required– Interpretation of empirical findings– Implementation

• Careful attention to implementation and evaluation is necessary

• Focus on outcomes

73% of primary care physicians believe that they immunize a greater percentage of patients than their colleagues

Noe CA, Markson LJ, Prev Med 1998;27(6):767-72

In a closed panel academic medical center:

• 65% of the practitioners are more efficient than their peers in the same practice• 65% have sicker patients• 75% have better outcome

J Perlin, 2000

. . . and all of the children in Lake Wobegone are above average

J Perlin, 2000

Rates of Coronary Angiography

HI

LO

Rates of Coronary Angiography

HI

LO

Rates of Radical Prostatectomy

HI

LO

Rates of Radical Prostatectomy

HI

LO

Variation in Inpatient Care for COPD by VISN (Region)

Image Removed – Awaiting Copyright Permissions

Variation in Ambulatory Care for MDD by VISN (Region)

Image Removed – Awaiting Copyright Permissions

after DA Burnett, ©UHC, 1995

Reasonable Expectation

Unfortunate Experience

after DA Burnett, ©UHC, 1995

What you would want foryour family

What you would not want

Should it matter where you receive care?

after DA Burnett, ©UHC, 1995

How do we capture andsystematize these practices?

How do we drive these practicesto be more like those above?

Implementing Guidelines Requires Broad SkillsLeadership and teamwork

Negotiation and tact

“Selling” ideas to peers

Link evidence to practice guideline

Educational Strategies

Ineffective:

– Traditional CME

– Printed materials

– ?Audit and feedback

VERDICT Brief, Spring 1998

Educational Strategies

Effective: Intensive conferencing w/ interaction, discussion, & role playing

VERDICT Brief, Spring 1998

Reminders and Prompts

Pocket cards & wall charts

Formatted records

Computerized reminders

VERDICT Brief, Spring 1998

Interactive Strategies

VERDICT Brief, Spring 1998

Opinion leaders

Academic detailing (outreach)

Multiple strategies work best.

Organizational strategies

• “None of the strategies produced consistent results.”

• Professional performance was improved by revision of professional roles and computer systems

Wenning et al., 2006

Organizational strategies

• Patient outcomes improved by multidisciplinary teams, integrated care services, and computer systems.

• Cost savings [came from] integrated care services

Wenning et al., 2006

So what should a program [leader/provider] do?

• Technique

• Outcome measurement

• Quality improvement

• Implementation strategies

Implications for implementation

• Examine current system/outcomes

• Determine where you wish to improve

• Develop model for how your program improvements will translate into process and/or outcome improvements

Is treatment as usual ok?

• Examine general quality of care– Professionalism– Empathy– Training and skill– Supervision

• Determine whether implementing a new technique will be helpful, why, and how

Implementation

• Buy in by leadership critical

• Resources must be provided

• Multiple strategies

Implementation

• Monitoring performance of individuals not just systems

• Supervision

• Plan for improving performance

Summary

• Research on mechanisms of change and improvement in outcomes in the community is needed

• Until then, paying attention to monitoring performance and upgrading the skills of staff are reasonable strategies

Summary

• Community-research partnerships hold promise for gradually learning about how to improve overall community outcomes

• “Make haste slowly.”– Caesar Augustus