Implementation of evidence in nephrology using clinical practice guidelines

Abstract

Chronic kidney disease (CKD) is becoming increasingly common in today’s society. It is estimated that 16% of the Australian population have some form of CKD. In 2007 over 16 000 were undergoing treatment for end stage chronic kidney disease (ESKD) this includes over 2000 new patients. Over 1600 died whilst undergoing treatment for ESKD in 2007. There has been a proliferation of evidence-based clinical practice guidelines for the treatment of chronic kidney disease patients, both locally and internationally. The Caring for Australasians with Renal Impairment (CARI) guidelines are guidelines produced for Australian and New Zealand practitioners. The CARI Guidelines have been written by doctors, nurses, allied health professionals and consumers on a voluntary basis. They are published on-line and in the journal Nephrology as biennial supplements. The use of these guidelines in practice is aimed at reducing mortality and morbidity for ch ronic kidney disease patients. Evidence shows that the attainment of evidence-based guideline recommendations is variable between practitioners, renal units, states and countries, often with a gap between guideline recommendations and practice. Research into the use of guidelines in practice is a new and emerging field of research. Current research into the strategies to bridge this gap has been unable to suggest one effective method to increase the rate of guideline implementation into practice. The research projects that form the basis of this thesis aimed to explore current implementation strategies used in chronic kidney disease and research best methods of implementation for evidence-based CKD guidelines within a framework of exploring barriers and enablers to this process. In chapter 2 of this thesis, to understand what is already known about the implementation of evidence-based guidelines in CKD, a systematic review of all published studies on implementation of evidence-based guidelines was ! undertak en. Twenty two studies including seven randomized controlled trials and 15 before-after studies were included. Four main interventions were evaluated in over 700 dialysis centres/hospitals or general practices: audit and feedback, computerized decision support system (CDSS), opinion leader/multidisciplinary team and passive dissemination of guidelines. Audit and feedback significantly increased 14 of the 25 study outcomes with a median improvement of 2.5% (range: -4.5-48.4%). CDSS significantly increased three of the four study outcomes with a median improvement of 12.8% (range: 1.1-42.1%). Opinion leader/multidisciplinary team significantly increased 24 of the 30 study outcomes with a median improvement of 8.2%(range: -4.0-79.8%). Dissemination of guidelines resulted in a median improvement in study outcomes of 2.7% (range 0.5-25.8). Well planned and executed interventions were able to improve CKD management to varying degrees. The achievement of quality indicators was assoc iated with improved patient outcomes. In Chapters 3 and 4, to gain a detailed understanding of the opinions of the end users of the CARI guidelines a survey was undertaken of all nephrologists and renal nurses in Australia and New Zealand. Chapter 3 outlines the results of the 211 nephrologists (70% of practising nephrologists) who responded. Over 90% agreed that the CARI guidelines were a useful summary of evidence, nearly 60% reported that the guidelines had significantly influenced their practice and 38% reported that the guidelines had improved health outcomes for patients. Only 8% indicated that the guidelines did not match the best available evidence. Older age and being male showed some association with a less favourable response for some domains. Chapter 4 discusses the results from the 173 renal nurses who responded. They were more positive in their responses, than nephrologists, in the range of 10-20% in many question domains. and improvemen ts in positive responses regarding the guidelines in the ran! ge of 10 -30% were seen in many domains between 2002 and 2006. Chapter 5 builds on the information obtained in the survey of nephrologists to further understand the role that guidelines have in clinical practice and clinical decision making. Face to face interviews with Australian nephrologists were undertaken. The results were analysed qualitatively and four major themes emerged. 1) There was a high degree of trust in the CARI process and output; 2) Guidelines had a range of functions in clinical practice, they provided a good summary of evidence, were a foundation to practice, an educational resource, could justify funding requests to policy makers, and promote patient adherence; 3) There was also non-guideline influences on clinical decision making, such as quality of life or patient needs, opinion leaders, previous experience, the clinical setting, the regulation and subsidy framework for drugs and devices, logistics, and other sources of evidence; 4) Nephrologists sug gested facilitators of guideline implementation such as audit and feedback and reminders. The process by which nephrologists engaged with and used the guidelines was noted and compared to Rogers’ diffusion of innovation theory. Some additional steps were added to this theory to make it applicable to the implementation of guidelines in CKD. Improvements in the evidence which underpins guidelines and improvements in the content and formatting of guidelines are likely to make them more influential on decision making. In chapter 6, to test strategies for implementation in CKD, we established an implementation project in six renal units in Australia. This centered on the implementation of the CARI iron guideline utilising audit and feedback, the use of an opinion leader and a purpose-designed computerised decision support system. Wide variation of iron indices was observed across the centres in the study. In the active implementation units, we saw improvements in iro n indices, especially in units that at baseline had iron sco! res well below the CARI guideline recommendations. We found that with a senior motivated opinion leader, the targeting of barriers and the use of a decision support system, implementation of a guideline can indeed be successful. Support from an external body such as CARI may be of assistance. The overarching purpose of these studies was to gain a better understanding of the place of guidelines in CKD practice and how we can ensure that evidence-based guidelines are used in practice and by doing so improve clinical outcomes for CKD patients. The findings show that guidelines hold a prominent place in clinical nephrology practice with both nephrologists and renal nurses, but there are many other competing influences on clinical decisions. Implementation of guidelines is possible and guideline groups should pursue this actively, utilising evidence-based implementation strategies. Strategies vary in their effectiveness and appropriate strategies should be used in differing si tuations. Renal nurses are an important resource in the implementation process. They should be involved in the guideline development process and their requirements for dissemination should be taken into account. Guidelines should be written using best methods that encourage implementation, such as the use of action statements, the provision of targets, be based on high levels of evidence, kept up to date and assistance given to encourage implementation into practice. Guideline groups should also foster close links with trials groups to facilitate a generation of evidence in required clinical areas. Finally, implementation requires hard work, by dedicated individuals at all levels, including the guideline producers and writers and those at the clinical level. A high level of detail regarding the implementation process is required, such as a thorough evaluation of barriers and strategies to overcome these. There is a need for guideline producers to understand their differing t arget audiences and tailor the guidelines depending on the n! eeds, us age and processes of these target groups.