What should be considered when implemenng a paent … · 2012) and a literature review on barriers...

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What should be considered when implemen4ng a pa4ent decision support interven4on?: policy maker and healthcare providers’ views Wen Ting Tong 1 , Yew Kong Lee 1 , Chirk Jenn Ng 1 , Ping Yein Lee 2 1 Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 2 Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia e-mail: [email protected]

Transcript of What should be considered when implemenng a paent … · 2012) and a literature review on barriers...

Page 1: What should be considered when implemenng a paent … · 2012) and a literature review on barriers and facilitators to implemenng PDAs. • The TDF is a framework synthesized from

Whatshouldbeconsideredwhenimplemen4ngapa4entdecisionsupportinterven4on?:

policymakerandhealthcareproviders’views

WenTingTong1,YewKongLee1,ChirkJennNg1,PingYeinLee2

1DepartmentofPrimaryCareMedicine,FacultyofMedicine,UniversityofMalaya,KualaLumpur2DepartmentofFamilyMedicine,FacultyofMedicineandHealthSciences,UniversityPutraMalaysia,Serdang,Malaysia

e-mail:[email protected]

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Introduc4on

•  EvenwhenaresearchfindingissuccessfullytranslatedintoaprogrammeorintervenKon,someofthemmaynotbeeffecKvewhentransferredtothereal-worldseRng.

•  StudieshaveshownthatsomeresearchintervenKonshavenotbeensuccesfullyimplementedandproblemliesinthedeliveryoftheintervenKon(Talibet.,2012;Hill,2009;WHO,2007).

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BarriersandfacilitatorstoimplementaKonofhealthintervenKons

BARRIERS

Cliniciansand

paKents’aRtude–donottrusttheintervenKon

UsingofinnovaKon

disruptsexisKngworkflow

Poor

organizaKonteamwork

Lackofresources

FACILITATORS

ProvisionoftrainingandskillsforHCPs

Champion

HavingasystemtosupporttheuseoftheintervenKon

BeliefthattheintervenKonisthepreferredpracKcestyle

(Elwynetal.,2013–systemaKcreview;Schroyetal.,2014)

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Introduc4on

•  MajorityofthestudiesonbarriersandfacilitatorstoimplementaKonwereconductedintheWestandthefindingsmaynotbetransferabletoAsianseRngs.

•  InAsiaPacificregion,parKcularlyinthecontextofadevelopingcountry,fewstudieshavelookedintoimplementaKonofevidence-basedhealthcareintervenKons.

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Objec4ve

•  ToexplorethefactorsthatinfluenceimplementaKonofanevidence-basedintervenKonintheMalaysianhealthcareseRng.

InsulinPaKentDecisionAid(insulinPDA)

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Introduc4on

•  PaKentdecisionaids(PDAs)areevidence-basedtoolsthatcanbeusedbyhealthcareproviderstohelppa4entsmakeinformeddecisionaboutdifficulthealthcareop4ons.

•  PDAsprovideinformaKonaboutthe1.decision,2.theavailableopKonsand3.thebenefitsandrisks(Staceyetal.,2014).

•  PDAsarepartoftheshareddecisionmaking(SDM)processwherebycliniciansandpa4entsmakehealthcaredecisionstogetheraferconsideringevidence-basedinformaKonabouttreatmentopKons,risksandbenefitsandoutcomes(Coulter&Collins,2011).

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Introduc4on•  BenefitsofPDAs:Ø ImprovedecisionqualityØ GetpaKentstobemoreinvolvedintheirhealthcaredecisionmaking

Ø HelppaKentstoachieveinformeddecisionsthatisalignwiththeirpersonalvalues. (Staceyetal.,2014–CochranesystemaKcreview)

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NgChirkJenn,LeePingYein,LeeYewKongetal.2012.ShouldIStartInsulin?UniversityofMalaya,KualaLumpur.

Introduc4on

Booklet

MalaysianinsulinPDAhlp://dmit.um.edu.my

Tablet(iPad) Website

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MethodologyStudydesign•  QualitaKveapproachStudyseRng•  PrimarycareclinicinapublicteachinghospitalinKuala

LumpurStudyparKcipants•  Hospitalpolicymaker

•  Medicalofficer•  Diabetesnurse•  Staffnurse

involvedinmakingdecisionsonwhetheraparKcularhealthintervenKonshouldbe

implementedinthehospital

involvedinadvisingpaKentsaboutinsulininiKaKon

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MethodologyStudyinstrument•  Semi-structuredinterviewguidebasedontheTheoreKcalDomainsFramework(TDF)(Cane,O’Connor,&Michie,

2012)andaliteraturereviewonbarriersandfacilitatorstoimplemenKngPDAs.

•  TheTDFisaframeworksynthesizedfrom33behaviourchangetheories.

•  ImplementaKonsuccessislargelydependentonthebehaviourchangeoftheusersinvolvedonwhethertoadoptorrejecttheinnovaKon.

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Datacollec4onandanalysisprocess

•  Appointmentsweremadetoconducttheinterviewswithselectedindividuals∨

•  Informedconsentwereobtained∨

•  Anydiscrepanciesinthecategoriesandthemeswereresolvedbydiscussionsamongresearchers

Methodology

•  TheresearchershowedandexplainedaboutthePDA,itsfuncKons,andthevariousmodaliKes(booklet,tablet,website)

∨•  Duringtheinterview,theresearchersusedtheinterviewguidetofacilitatetheinterview

session.∨

•  Theinterviewswereaudio-recordedandtranscribedverbaKm∨

•  ThedatawasmanagedusingNVivoversion10.∨

•  TheinterviewswereanalyzedusingathemaKcapproach.∨

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Results

Socio-demographicandprac4ceprofile No(N=25) Mean±SD(Range)

Age 42.24±(31-57)

Yearsofprac4cesincegradua4on 17.56±(3-35)

Noofpa4entcounseledoninsulinini4a4onforthepastonemonth

23.72±(0-150)

Posi4onHospitalpolicymaker(Manageriallevel) 6Medicalofficer(MO) 13Diabetesnurse 5Staff/registerednurse(RN) 1

InsulinPDAuseYes 6*No 19

NineIDIsand3FGDs(25respondents)

*SixparKcipantshavehadexperiencesinusingtheinsulinPDAasthedevelopmentoftheinsulinPDAwasconductedinthestudyseRng.

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ResultsFactorsinfluencingimplementa4onoftheinsulinPDA

1.  LackofSDMculture

2.  Roleboundary

3.  ImpactonconsultaKonKme

4.  Remindernetwork

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ResultsLackofSDMculture•  HCPs’paternalis4caZtudeinthedeliveryofthehealthcaresKll

prevailintheAsiancontextwherebytheymaketreatmentdecisionforpaKents.

•  Pa4ents’trus4ngaZtudeinphysiciansinmakingtheright

decisionforthemandsubmissivebehaviorrenderedSDMchallenging.

•  LackoffamiliarwiththeconceptofSDMandhowtoimplementthePDA.

“IthinkinourAsiancontext,wes4llhavethisideaofdoctortellingyouwhattodo.IthinkthisshareddecisionapproachisaconceptthatdevelopedcountrieshavebutIdon'tknowwhetherourculturehasreachedtothisstageornot.”-Diabetesnurse_havenotusedinsulinPDA

Thepa4entss4llhavethemindsetof“Youtellmewhattodola.Ijustfollowyou”.Idon'tknowwhetherourpa4entisuptothatyetfortheshareddecisionpart”.-Diabetesnurse_havenotusedinsulinPDA

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ResultsRoleboundary

•  TheexisKngroleboundaryamongHCPsdeterminewhoplaysaroleintheimplementaKonofthePDA.

•  DoctoristhekeypersontointroduceorusetheinsulinPDAwithpaKentsbecauseonlydoctorwouldknowwhentoiniKateandhavetheauthoritytoprescribeinsulintopaKents.

“IthinktheiniKaKon[touseinsulinPDA]parthastobefromthedoctorbecausewearetheoneswhowillknowwhetheritisappropriateornottotalkabout

insulininiKaKon.”-MO_haveusedinsulinPDA

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Results:EmergingthemesRoleboundary•  However,therigidroleboundarymaymakesomeHCPunwillingtocollaborateintheimplementaKonofthePDA

•  RNswhoconfinedtheirtaskstoadministraKveduKessuchasregistraKonofpaKentsandtakingheightandweightmeasurementsandwouldnotperceivetheuseofinsulinPDAtobepartoftheirroleorjobscope.

“‘I’manursewhat…whyshouldIdothis,thisisnothingconcerningme,thisisdoctorsjob.Notmyjob’.//‘Ohanotherbooklet.Anotherthingtotalktothepa4entnow’.Anythingisalwaysaddedwork.”-RN_havenotusedinsulinPDA

•  TheuseofinsulinPDAwouldalsobeperceivedasanaddedworkload.

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ResultsImpactonconsulta4on4me•  Therewereconcernsaboutthefeasibilityofgoingthroughthe

insulinPDAwithpaKentsduringconsultaKon,whichwouldtakeupextra4me.

“Timeisaproblembecausetherearemanypa4ents.Whetherwehaveenough4meto

gothrough(theinsulinPDA)withthepa4ent.”-MO_havenotusedinsulinPDA

•  However,someparKcipantsfeltthattheinsulinPDAwouldhelptoreduceconsulta4on4meifthepaKentscanreadthePDAbeforeconsultaKonsuchasduringwaiKngKmeintheclinicorathome.

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ResultsRemindernetwork•  Forpeerreminders,HCPswouldremindoneanothertousethe

insulinPDA.

•  TheuseofElectronicMedicalRecord(EMR)tonoKfydoctorsthattheinsulinPDAshouldbegivenouttothatparKcularpaKentwhoisasuitablecandidateforthePDA.

“IftheirHbA1cisabovecertainlevel,thenhavetheEMRgoesalert.“PDA,

PDA!”.–Primarycarepolicymaker_havenotusedinsulinPDA

“Doctorsamongdoctors[toremindoneanother].Actuallythenurseswhoareworkingintheclinic,theycanreminddoctor’”.-Diabetesnurse_havenotusedinsulinPDA

“LikepuZngpostersintheclinicsothatpa4entsortheircarerscansee.Thenpa4entcanreminddoctorsaboutthebook”.–MO_have

usedinsulinPDA

•  AnothertypeofreminderisbypuZnguppostersorno4cesabouttheinsulinPDA.ThiswillhelpHCPsremembertousetheinsulinPDAaswellascreaKngawarenessabouttheinsulinPDAamongpaKents.

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Discussions

•  FindingssimilartowesterncountriesweresuchasHCP’sandpa4ent’saZtudeandbehaviour(Legareetal.,2008;Stapletonetal.,2002;Uyetal.,2014)andimpactonconsulta4on4me(Legareetal.,2008;Shultz&Jimbo,2015).

•  Findingsthatwerenotcommonlyfoundintheliteraturebutwerefoundinourstudywereroleboundaryandremindernetwork.

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Discussions

LackofSDMculture•  TheconceptofSDMiswellestablishedintheUSA,UK,Germanyand

NetherlandsthatthepromoKonofSDMandtheuseofPDAshavereachedtopolicyandlegislaKonlevel(DepartmentofHealth,2010;Härteretal.,2011;SenateandHouseofRepresentaKves,2010;WashingtonStateLegislature,2007)

•  AsiaisseeingaslowerprogressinSDMandPDAbutneverthelessincreasing(Ambigapathy,Chia,&Ng,2016;Sekimotoetal.,2004)

•  Strategy:TofacilitatetheuseofPDAs,theconceptofSDMneedstobepromotedamongHCPsandpaKents.

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DiscussionsRoleboundary•  ParKcipantsofthisstudyfeltthatdoctoristhekeypersontousethe

insulinPDAwithpaKentswhilenotsomuchfornurses.

•  ManywesternstudieshaveshownHCPsotherthandoctorssuchassocialworkers,psychologists,andalliedhealthprofessionalshavetakenupmainrolesandwerededicatedinprovidingdecisionsupporttopaKentsanduseofPDA.

•  Strategy:ByadopKnganinterprofessionalapproach(Dioufetal.,2016),can

helptouKlizethestrengthsofeachteammemberstocreateamorecoordinatedandefficientPDAimplementaKonprocess.

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Discussions

Impacton4me•  TimeisthemostcommonlyreportedbarrierintheimplementaKon

ofSDMaswellasPDA(Légaré&Wileman,2013;Shultz&Jimbo,2015).

•  OnestudyhasproventhatconsultaKonKmecanbeshortenedby8minuteswithacomputer-basedPDA(Greenetal.,2004).

•  Strategy:ProvidedemonstraKontoHCPsbyamentororpeerexpertonhowtoincorporatetheuseoftheinsulinPDAintostandardclinicalconsultaKon(Frenchetal.,2012;O'Brienetal.,2014)withouttakingmoreKmeandtoemphasizethatthedeliveryofPDAonlybecomeseasierandpossiblyfasterwithtrainingandpracKce.

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Discussions

•  TheuseofEMRandIThasbeenraisedasaneffecKvestrategyintheimplementaKonofSDMandPDAsuchastoidenKfyeligiblepaKentsforPDAs(Légaré&Wileman,2013)beforetheirclinicvisit,toprescribe,aswellastocueforPDAuse(O'Connoretal.,2007).

•  TheintegraKonofPDAintotheEMRwillrequiretechnologysupport,whichmaybeabarrierforsomehealthcarepracKceindevelopingcountriesthataresKllusingpaper-basedsystems(WHO,2012).

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StudyLimita4ons

•  OnlyinoneseRng–notgeneralizable

•  DidnotincludepaKents'perspecKves

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Conclusions

•  ThisstudyshedlightontheuniquechallengesthatinfluenceimplementaKonofevidence-basedintervenKoninaMalaysianprimarycareseRng,whichareprobablyalsofacedbyotherdevelopingcountriesintheAsiaPacificregion.

•  ThesefactorsmustbeconsideredandaddressedwhendevelopingimplementaKonstrategiesforevidence-basedhealthcareintervenKons.

•  Basedonthesefindings,implementaKonstrategiescanbedevelopedtoensureeffecKveimplementaKonoftheinsulinPDA.

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Thankyou


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