to practice even docs （and nurses and pas and 实践研究（甚至医生护士和pas和课件

Research to Practice:Research to Practice: Turning What We Know into Turning What We Know into What We DoWhat We Do Dana Best, MD, MPH, FAAPDana Best, MD, MPH, FAAP The Smoke Free ProjectThe Smoke Free Project Childrens National Medical Center, Washington, DCChildrens National Medical Center, Washington, DC Strong EvidenceStrong Evidence Clinicians should counsel all tobacco Clinicians should counsel all tobacco users to quitusers to quit First edition of First edition of Treating Tobacco Use and Treating Tobacco Use and DependenceDependence published in 1996 published in 1996 Few clinicians counsel!Few clinicians counsel! Why Not?Why Not? Why Not?Why Not? KnowledgeKnowledge Why Not?Why Not? KnowledgeKnowledge AttitudesAttitudes Why Not?Why Not? KnowledgeKnowledge AttitudesAttitudes BehaviorBehavior Why Not?Why Not? KnowledgeKnowledge Clinicians may be unaware of or Clinicians may be unaware of or unfamiliar with recommendationsunfamiliar with recommendations Information volume Information volume Time to stay informed Time to stay informed Access to recommendations Access to recommendations Why Not?Why Not? KnowledgeKnowledge AttitudesAttitudes Why Not?Why Not? AttitudesAttitudes Dont agree with the recommendationDont agree with the recommendation Because of interpretation Because of interpretation Not applicable to a specific patient Not applicable to a specific patient Not cost-beneficial Not cost-beneficial Lack of confidence in the authors Lack of confidence in the authors Why Not?Why Not? AttitudesAttitudes Dont agree with recommendations or Dont agree with recommendations or guidelines in generalguidelines in general “Cookbook” medicine “Cookbook” medicine Too rigidToo rigid Biased preparation Biased preparation Challenge to autonomy Challenge to autonomy Impractical Impractical Why Not?Why Not? AttitudesAttitudes Dont expect successDont expect success Dont expect to be able to perform taskDont expect to be able to perform task Not motivated (inertia, habit, routine)Not motivated (inertia, habit, routine) Why Not?Why Not? KnowledgeKnowledge AttitudesAttitudes BehaviorBehavior Why Not?Why Not? BehaviorBehavior BarriersBarriers Time Time Resources Resources Organizational constraints Organizational constraints Reimbursement Reimbursement Malpractice liability Malpractice liability Why Not?Why Not? KnowledgeKnowledge AttitudesAttitudes BehaviorBehavior Cabana MD, Rand CS, Powe NR, et al. Why dont physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-1465. What Can Be Done?What Can Be Done? Change PolicyChange Policy Implement policies that support Implement policies that support counselingcounseling Reimbursement (carrot)Reimbursement (carrot) Quality measures (both carrot and stick)Quality measures (both carrot and stick) Change PracticeChange Practice TrainingTraining Quality improvement methods for clinical Quality improvement methods for clinical practice changepractice change Increase demand for counseling servicesIncrease demand for counseling services Policy FirstPolicy First its actually easier to change its actually easier to change policy than to change human policy than to change human (i.e., clinician) behavior(i.e., clinician) behavior Policies Can Change CulturePolicies Can Change Culture Clean airClean air CostCost Social normsSocial norms And have!And have! National PoliciesNational Policies EvidenceEvidence Treating Tobacco Use and DependenceTreating Tobacco Use and Dependence RecommendationsRecommendations American Academy of Pediatrics, American Academy of Pediatrics, American Academy of Family Practice, American Academy of Family Practice, Society for Adolescent Medicine, many Society for Adolescent Medicine, many othersothers Quality MeasuresQuality Measures NCQANCQA Joint CommissionJoint Commission Federal SupportFederal Support Electronic health recordsElectronic health records Medicare policies and fundingMedicare policies and funding Quit linesQuit lines Patient and clinician resourcesPatient and clinician resources AHRQ, etc.AHRQ, etc. Veterans AdministrationVeterans Administration Military and tobaccoMilitary and tobacco StateState Clean airClean air LitterLitter Insurance regulationsInsurance regulations Medicaid policyMedicaid policy Health care licensingHealth care licensing FacilitiesFacilities IndividualsIndividuals Medicaid BenefitsMedicaid Benefits 38 state Medicaid programs cover at 38 state Medicaid programs cover at least some stop-smoking treatmentsleast some stop-smoking treatments 14 cover some form of tobacco-14 cover some form of tobacco- cessation counseling for all Medicaid cessation counseling for all Medicaid participantsparticipants 12 more pay for counseling of 12 more pay for counseling of pregnant womenpregnant women Most dont cover pharmacotherapies Most dont cover pharmacotherapies if age 18 yearsif age 18 years LocalLocal Access to resources Access to resources for patients and for patients and familiesfamilies Enforcement of Enforcement of clean air regulations, clean air regulations, licensing, etc.licensing, etc. No Guinea pigs were harmed for this talk. Policy FrontiersPolicy Frontiers Coding for tobacco useCoding for tobacco use Even in the child and adolescent Even in the child and adolescent healthcare settinghealthcare setting Reimbursement followsReimbursement follows At least we hope it does!At least we hope it does! Changing the Way Changing the Way Clinicians PracticeClinicians Practice A Brief HistoryA Brief History Variations in practice notedVariations in practice noted Clinical guidelines will solve the Clinical guidelines will solve the problem!problem! David Eddy, Mark David Eddy, Mark ChassinChassin No, they wont!No, they wont! Its the doctors they need to be pushedIts the doctors they need to be pushed Its the system it needs to be changedIts the system it needs to be changed Its the guidelines they need to be Its the guidelines they need to be disseminateddisseminated MeasurementMeasurement More outcomes basedMore outcomes based Potentially punitivePotentially punitive E.g. the surgeon who takes all the “tough” E.g. the surgeon who takes all the “tough” cases who has worse outcomescases who has worse outcomes Audit and feedbackAudit and feedback Developing into an effective toolDeveloping into an effective tool IOM Quality ReportIOM Quality Report Changed the landscapeChanged the landscape Although it took a whileAlthough it took a while Maintenance of CertificationMaintenance of Certification Physicians whose speciality is certified Physicians whose speciality is certified by a Board certified by the American by a Board certified by the American Board of Specialties are required to Board of Specialties are required to maintain their certificationmaintain their certification By performing a quality improvement By performing a quality improvement “project”“project” Quality Improvement for Quality Improvement for Practice Level ChangePractice Level Change Key componentsKey components MeasurementMeasurement TeamworkTeamwork Support from leadershipSupport from leadership A “Champion”A “Champion” Key conceptsKey concepts Systems thinkingSystems thinking Cycles of changeCycles of change ToolsTools Collaboratives and quality Collaboratives and quality improvement teamsimprovement teams Based on Wagners Chronic Care ModelBased on Wagners Chronic Care Model MeasurementMeasurement Audit and feedbackAudit and feedback Integrated policiesIntegrated policies Human resources, employee benefits, Human resources, employee benefits, work environmentwork environment Healthcare setting environmentsHealthcare setting environments In SummaryIn Summary The problem isnt disseminating The problem isnt disseminating knowledgeknowledge Although its a part of the problemAlthough its a part of the problem The problem is how to change clinician The problem is how to change clinician behaviorbehavior And thats really hard to doAnd thats