opinion leadership in knowledge translation efppec conference andy smith, md april 28, 2005
TRANSCRIPT
Opinion Leadership in Opinion Leadership in Knowledge Translation Knowledge Translation
EFPPEC ConferenceAndy Smith, MDApril 28, 2005
OutlineOutline
• Practice Gap Assessment– CRC lymph node problemCRC lymph node problem
• Bridging the gaps– barriersbarriers– Single institutionSingle institution– ProvinciallyProvincially
• Impact of Opinion Leaders– opportunities and limitations opportunities and limitations
Knowledge Transfer Knowledge Transfer
• Practice gaps exist– 30-40% of patients do not receive care 30-40% of patients do not receive care
complying with evidence complying with evidence 11
– 20-25% of care is not needed or harmful20-25% of care is not needed or harmful
• Bridging the gaps is hard– lectures alone don’t work!lectures alone don’t work!
• ‘Knowledge Transfer’ is the challenge– process needs to be studied process needs to be studied 2 2
1. J. Grimshaw MJA 2004 2. Davis 2003
Pathman ProcessPathman Process
• Aware– of guideline, practice innovationof guideline, practice innovation
• Agree– with importancewith importance
• Adopt– ‘‘trying it out’, irregularly at firsttrying it out’, irregularly at first
• Adhere– abiding by appropriate practice at all abiding by appropriate practice at all
appropriate times appropriate times Pathman 1996
1. Lymph Node Problem1. Lymph Node Problem
Lymph Nodes in Colon Lymph Nodes in Colon CancerCancer
Stage II – node negative
Stage III – node positive
The optimum number of The optimum number of lymph nodes that should lymph nodes that should be retrieved / identified / be retrieved / identified /
analysed is:analysed is:
What “benefits” are we talking What “benefits” are we talking about?about?
• in NODE POSITIVE patients:– 15%15% absolute improvement in 5 year absolute improvement in 5 year
overall survivaloverall survival– 30%30% absolute improvement in 5 year absolute improvement in 5 year
disease free survivaldisease free survival
• perspective: this represents one of the highest “bang for the buck” in adjuvant chemotherapy
Accurate Nodal StagingAccurate Nodal Staging
• Surgeon’s contribution:– to bring an adequate resection of to bring an adequate resection of
associated lymph nodes with the associated lymph nodes with the specimen containing the cancerspecimen containing the cancer
• Pathologist’s contribution:– to actually find all the relevant lymph to actually find all the relevant lymph
nodes needed to properly stage the nodes needed to properly stage the cancercancer
Multidisciplinary Barriers to Multidisciplinary Barriers to Lymph Node Retrieval in Lymph Node Retrieval in
Colorectal CancerColorectal Cancer
Specimen fromSurgeon A
Additional MesentericSpecimen from Surgeon B
Nodes retrieved by Pathologist AAdditional nodesretrieved byPathologist B
Colon Cancer
Stage IIStage IIwith more than with more than 7 nodes 7 nodes assessedassessed
Stage IIIStage III
Stage IIStage IIwith with lessless than than 7 nodes 7 nodes assessedassessed
Impact on survivalImpact on survival
Multimodal CME for Multimodal CME for Surgeons and Pathologists Surgeons and Pathologists
Improved Colon Cancer Improved Colon Cancer StagingStaging
A Smith, M Khalifa, E Hsieh,F Wright, C Law, P Poldre
University of Toronto
OutlineOutline
• Needs Assessment– Lymph node assessment is critical in CRCLymph node assessment is critical in CRC– Often poorly doneOften poorly done
• Intervention– Formal CEFormal CE– Opinion Leaders, Template, Feedback Opinion Leaders, Template, Feedback
from databasefrom database
• Follow-up and Future Direction
Needs AssessmentNeeds Assessment
• Retrospective colorectal cancer database – 1995-19991995-1999
• 399 consecutive cases– 101 Stage II (node negative)101 Stage II (node negative)
• Median 7 lymph nodes assessed– 77% of cases less than 12 nodes 77% of cases less than 12 nodes
Survival ImpactSurvival Impact
• Sunnybrook data demonstrated that compromised LN assessment is associated with adverse survival outcome
Sunnybrook Change Sunnybrook Change InitiativeInitiative
• Formal CE Program– surgeons, pathologists, oncologistssurgeons, pathologists, oncologists– over 8 weeks over 8 weeks
• Review of literature at GI site group rounds
• Focus on topic at retreat for GI group
Sunnybrook Change Sunnybrook Change InitiativeInitiative
– Informal discussions between opinion leaders in Informal discussions between opinion leaders in Pathology and SurgeryPathology and Surgery
– No new techniques employed in pathology suiteNo new techniques employed in pathology suite– Opinion leaders in Pathology implemented and Opinion leaders in Pathology implemented and
championed a synoptic pathology report to replace championed a synoptic pathology report to replace unstructured report for CRC reportingunstructured report for CRC reporting
Pathology TemplatePathology Template
FeedbackFeedback
• Prospective Colorectal Cancer database– full time data managerfull time data manager
• Periodic reassessment of lymph node assessment
• Results discussed formally and informally
Can we fix it ???Can we fix it ???
OutcomeOutcome
19941994
19991999 2002 2002InterventionIntervention
19991999
Pre-Pre-InterventionIntervention
1994 - 19991994 - 1999•median 7 lymph nodes retrieved
Post-Post-InterventionIntervention
2000 - 20022000 - 2002•median 17 lymph nodes retrieved (p<0.001)
•no change in the surgical specimen length (24.5 Vs. 25 cm, p=0.62)
Lymph Node Assessment Lymph Node Assessment in Colon Cancer in Ontario in Colon Cancer in Ontario
F.C. Wright, C.H.L. Law, L.D. Last, D. Ryan, A. J. Smith
Toronto-Sunnybrook Regional Cancer Centre
University of Toronto
Colon Cancer Lymph Node Colon Cancer Lymph Node Counts In OntarioCounts In Ontario
• Lymph node negativity is based on sub optimal sampling in 73% of cases (Wright 2003)
0
50
100
150
200
250
300
0/2 '5/6 '9/10 13/14 17/18 > 21
Number of Specimens
Number of Lymph Nodes Assessed
Barriers to Optimizing Lymph Barriers to Optimizing Lymph Node Retrieval and Node Retrieval and
Assessment in Colorectal Assessment in Colorectal Cancer In OntarioCancer In Ontario
F.C. Wright, D. Kumar, R. Ritacco, L.D. Last, M. Khalifa, C.H.L. Law, A. J. Smith
Toronto-Sunnybrook Regional Cancer Centre
University of Toronto
PurposePurpose
• To survey Ontario pathologists to identify perceived and unperceived barriers to adequate lymph node retrieval and assessment of lymph nodes in colorectal cancer.
Barriers to Changing Physician Behaviour
• Understanding the barriers to successful change is necessary to facilitate transition from knowledge to improved practice.
• Barriers to change can be both unperceived i.e the physician can be unaware that the barrier exists or perceived i.e. barrier is recognized
Results Results
Process Barriers
• Inadequate mesenteric resection
•Time constraints•Technical difficulty identifying
LN•43% thought it would be a
significant burden to identify 5 more LN
Knowledge Gap
•Only 25% of all Ontario Pathologists surveyed thought that assessment of 12 or more LN was necessary to meet current recommendations
Perceived BarriersUnperceived Barriers
DiscussionDiscussion
• Awareness is the first step to implementation of a guideline– Only 25% of all practicing Only 25% of all practicing
pathologists in Ontario knew that 12 pathologists in Ontario knew that 12 LN should be assessed for accurate LN should be assessed for accurate stagingstaging
DiscussionDiscussion
• Adoption of Practice often is prevented by barriers to change– Workload pressures, the degree of Workload pressures, the degree of
difficulty and time in retrieving LN was difficulty and time in retrieving LN was identified as a barrier in this surveyidentified as a barrier in this survey
– Inadequate mesenteric resection was Inadequate mesenteric resection was identified as a barrier to finding LNsidentified as a barrier to finding LNs
PurposePurpose
To increase the number of lymph nodes assessed in staging colon cancer in Ontario
WHY?
Identify those patients who need chemotherapy , improve outcomes
Identification of Opinion Leaders Amongst surgicaland pathology communities of Ontario
Assessment of present quali ty of Lymph Noderet rieval & assessment in Ontario DONE
Recruitment Intervent ion- lecture and educat ional materialsre: importance of lymph node assessment given to
pathologists and surgeons
Lecture/MaterialsControl Group
(1) Follow- up data given r e: lymphnode retrieval at their hospital at 6and 12 months post lecture
Treatment group
(1) Follow- up data given r e: lymphnode retrieval at their hospital at 6and 12 months post lecture and
(2) Opinion Leader Intervention
Non recrui ted hospitals
NoIntervention
Control
random select ion of 3 sets of hospitals
Intervention Summary
Re-Assessment of Lymph Node Numbers assessed inStage I I CRC in Cont rol group and treatment groups
Step 1
Step 2
Step 3
Step 4
Step 5
Discussion PointsDiscussion Points
• What is the Gap?– Should we keep it simple?Should we keep it simple?
• What are the Barriers?• Who are the targets of intervention?
– OL influence of OL influence of • curriculum plannerscurriculum planners• teachers (docs, nurses etc)*teachers (docs, nurses etc)*• students and/or residents students and/or residents
4. Opinion Leaders in KT4. Opinion Leaders in KT
Changing Physician Behaviour
• Behaviour change may not occur even with overwhelming data or practice guidelines
• Formal learning alone is ineffective
• Multi-faceted plans using combinations of formal and informal education techniques more successful Davis 93,95,99
Other KT MethodsOther KT Methods
• Didactic lectures• Workshops, presentations• Mailed unsolicited print materials• Audit and feedback• Reminder systems• Combination of methods
Identification of Opinion Leaders Amongst surgicaland pathology communities of Ontario
Assessment of present quali ty of Lymph Noderet rieval & assessment in Ontario DONE
Recruitment Intervent ion- lecture and educat ional materialsre: importance of lymph node assessment given to
pathologists and surgeons
Lecture/MaterialsControl Group
(1) Follow- up data given r e: lymphnode retrieval at their hospital at 6and 12 months post lecture
Treatment group
(1) Follow- up data given r e: lymphnode retrieval at their hospital at 6and 12 months post lecture and
(2) Opinion Leader Intervention
Non recrui ted hospitals
NoIntervention
Control
random select ion of 3 sets of hospitals
Intervention Summary
Re-Assessment of Lymph Node Numbers assessed inStage I I CRC in Cont rol group and treatment groups
Step 1
Step 2
Step 3
Step 4
Step 5
When E.F. Hutton speaks, people
listen …
Informal LearningInformal Learning
• Deliberate attempt to increase knowledge without a taught course, workshop, program
• Hallway or doctor’s lounge consultation
• Tumour Board discussions
Prevalence of WorkplacePrevalence of WorkplaceInformal LearningInformal Learning
• “Submerged part of the iceberg”
• New Approaches to Lifelong Learning– Employment-related informal learning Employment-related informal learning – 92% of professionals had participated in 92% of professionals had participated in
informal learning informal learning – 66% formal learning program66% formal learning program
Livingstone Livingstone 20012001
Opinion Leader IssuesOpinion Leader Issues
• Opinion Leader interventions– should they work?should they work?– do they work?do they work?– can they be ‘appointed’?can they be ‘appointed’?
• or must they be naturally selectedor must they be naturally selected
– what do OLs do?what do OLs do?– are they “fluid”?are they “fluid”?
• change with time and domainchange with time and domain
– are specialists different than generalists?are specialists different than generalists?
Should OL interventions Should OL interventions work?work?
• Theoretical basis– Theory of diffusion of Theory of diffusion of
innovations and Social innovations and Social influences model of behaviourinfluences model of behaviour
• Hiss– Original work withOriginal work with generalist MDsgeneralist MDs
• Lomas– Impact on patientImpact on patient related outcomerelated outcome
• VBACVBAC
Opinion Leader Identification-Opinion Leader Identification-Hiss MethodHiss Method
Identified by their peers as physicians who:
1. Encourage learning and enjoy sharing their knowledge
2. High level of clinical expertise and always seem up-to-date
3. Treat others as equals
Colon Cancer OL Colon Cancer OL identification processidentification process
• A previously-validated survey for opinion leader identification was sent to 1228 surgeons and pathologists
• Designated leaders i.e. head of department, were also identified by respondents
Results Results
• Response rate 37% for surgeons– Total eligible surgeons (593)Total eligible surgeons (593)
• Response rate 41% for pathologists– Total eligible pathologists (363)Total eligible pathologists (363)
• Average age 50 years old, 15 years in practice
Opinion Leaders Identified Opinion Leaders Identified
• 54 Surgical Opinion Leaders for colorectal cancer have been identified
• 6 Pathology Opinion Leaders have been identified
Where are the Opinion Where are the Opinion Leaders? Leaders?
• 43 medical centres had opinion leaders for colorectal cancer
• 47 medical centres did not identify an opinion leader for CRC
• Some centres identified opinion leaders in other cities
Characteristics of Opinion LeadersCharacteristics of Opinion Leaders
• Surgical Opinion Leader was the designated leader 44% of the time– 52% of surgical OL worked at 52% of surgical OL worked at
academic centres academic centres
• Pathology Opinion Leader was designated leader 66% of the time – 66% worked in an academic centre66% worked in an academic centre
Characteristics of Opinion LeadersCharacteristics of Opinion Leaders
• They had “Hiss” characteristics!
SummarySummary
• Opinion Leaders for colorectal cancer have been identified in Ontario
• More surgical OL than pathology OL have been identified
• Not all centres have opinion leaders– No opinion leaderNo opinion leader– In another city In another city
SummarySummary
• The majority of CRC is treated in the community but surgical OLs disproportionately work in academic centres
• Formal positional physicians are not always the informal OL
Do OL interventions work?Do OL interventions work?
• Hiss et al– Educational influentialsEducational influentials– Impact on community hospitals in MichiganImpact on community hospitals in Michigan– COPDCOPD
• Quantitative and qualitative method to identify OL– Used by other investigatorsUsed by other investigators
• It worked!!
Do OL interventions work?Do OL interventions work?
• Lomas et al• Guidelines for C-section not followed• RCT using OL intervention
– Hiss criteriaHiss criteria– 16 hospitals16 hospitals
• 85% increase vaginal births– Decreased LOSDecreased LOS
JAMA 1991
Do OL interventions work?Do OL interventions work?
• Cochrane review of opinion leadership – 19991999– 8 RCTS8 RCTS– MI, Cancer painMI, Cancer pain11, OA, RA, urinary catheters, OA, RA, urinary catheters
• Mixed results– 6/7 improved at least 1 variable6/7 improved at least 1 variable– 2 statistically and clinically important2 statistically and clinically important– 1/3 impact on patient outcome1/3 impact on patient outcome
1. Elliott 1997
Can you ‘appoint’ effective Can you ‘appoint’ effective OLs?OLs?
• Positional leaders effectiveness may be related to their having Hiss characteristics
• Formalization of role may not be good– Some Hiss OL felt “embarrassed, Some Hiss OL felt “embarrassed,
awkward……that they were discovered”awkward……that they were discovered”• Hiss method is recommended
because of empiric validationRyan, D. P.
What do OLs do?What do OLs do?
• Effective for contextually situated change
• Actual activities not clear• Hiss, Ryan suggest best not to tell
them what to do• Can have a NEGATIVE impact
– Misinformation, attitudesMisinformation, attitudes
Are OLs “fluid”?Are OLs “fluid”?
• Do OLs change over:– TimeTime
• E.g. Young people and new technologyE.g. Young people and new technology
– Domain of interestDomain of interest• E.g. Breast vs. colon cancerE.g. Breast vs. colon cancer
– Method used to identify themMethod used to identify them• E.G. Hiss vs appointmentE.G. Hiss vs appointment
• Area of active research
Are specialists different?Are specialists different?
• Mixed outcomes more evident in specialist populations and OL interventions
• Domain expertise may be more important role in specialists
• OL may still steer ‘culture’
SummarySummary
• OL can be identified and engaged
• Effectiveness not clear for all KT– May vary with contextMay vary with context
• Construct validation needed– Rigorous assessment Rigorous assessment
of OL intervention of OL intervention necessarynecessary
Discussion pointsDiscussion points
• Who are your OLs?– Identification processIdentification process
• How formalized are the OL roles?• Who is the target?
– Teachers, administrators, studentsTeachers, administrators, students• Are other modalities of change at
work?– How do you optimize ‘infiltration’?How do you optimize ‘infiltration’?
