Improving Delivery of Preventive Interventions in Clinical Practice:
Practical Implications and Future Research Directions

June 11-12, 2009
Natcher Conference Center, NIH Campus, Bethesda, MD

Background
The delivery in clinical practice of interventions that have been proven efficacious in improving health is less than optimal, as is adherence by patients to their prescribed treatment regimens.  To address this problem, this workshop focuses on implementation approaches to improve care for hypertension, cholesterol, and obesity.  These topics are selected because of the activity at NHLBI to update the prevention clinical guidelines for CVD, which focuses on these 3 CVD risk factors.  The workshop will address both primary and secondary prevention – i.e., reduction or prevention of these risk factors in people both without and with existing cardiovascular diseases. 

Our definition of “implementation”– which is modified from a recent definition in an NIH Program announcement on Dissemination and Implementation Research – is as follows:  Implementation is the use of strategies to enhance the adoption and integration of evidence-based health-care interventions into practice patterns within specific settings.  This workshop will focus on the clinical practice setting, and will include outreach and collaboration between clinical practice settings and other settings (e.g., community and home).  Although the primary interest is the ambulatory care setting, the transition from hospital to outpatient care is also relevant.

NHLBI has sponsored several RFAs, and has a substantial portfolio of investigator-initiated research, for studies testing innovative approaches to help improve implementation in clinical practice of interventions to help prevent CVD in adults.  Interventions are being tested at the patient, clinician, and system level, including approaches connecting the clinical to other settings, such as home and community.  It is hoped that the results of these studies and other similar studies can be used in improving care and ultimately the public’s health.

Purpose
The goals of this workshop are to examine evidence in the literature in order to: (1) identify implementation approaches that have been proven effective that could be employed in practice now; and (2) identify promising approaches to improving implementation that need additional study and gaps in implementation research that need to be addressed.  Workshop recommendations will provide input into the NHLBI CVD prevention guidelines development process, as well as recommendations for future research directions for the NHLBI.

Workshop Outcomes & Products
Products of the Workshop will include:

  • A Workshop report to appear on the NHLBI website
  • A journal article summarizing the Workshop proceedings
  • One or more initiatives to guide future research (RFA/PA)

Dates, Location, Attendees

The workshop will be held June 11-12, 2009 on the NIH Campus in the Natcher conference center.  Attendance is by invitation, and will include chairs, invited speakers and discussants, and selected NHLBI and NIH staff.

Charge to the 3 Groups

Improving Delivery of Preventive Interventions in Clinical Practice:
Practical Implications and Future Research Directions

Within the broader workshop, three smaller working groups will be established to examine issues in three related implementation areas, one group per area:  (1) patient adherence, (2) clinician adoption and implementation in the clinic setting, and (3) approaches connecting the clinical to other settings.  Various approaches to education, behavioral approaches, and various systems approaches all may be relevant to each group.

Each group will meet ahead of time by phone and email to:

  1. Develop a review of the evidence regarding what types of implementation interventions have been examined and are effective
    1. this could include reviewing prior reviews
    2. the strongest level of evidence should be considered, including evidence from RCTs testing implementation interventions
  1. Identify issues important to consider in translating research evidence to real world practice and in studying how to do so
  1. Develop preliminary recommendations:
    1. practice recommendations, i.e., what implementation strategies have sufficient evidence to be employed in practice now (these recommendations should take into account evidence as well as challenges to implementation)?
    2. research recommendations, i.e., what topics in implementation research need additional study; what research methods should be used or further developed?
  1. Determine who will take which presentation role in the session (see AGENDA for the presentations that should be delivered)

In reviewing the evidence and considering practice and research issues, each group should consider similarities and differences across the 3 CVD risk factors being targeted in this workshop (i.e., hypertension, dyslipidemia, obesity), and across primary and secondary prevention, as well as issues that relate to disparities.  Examples from other areas, such as smoking cessation, could be used when deemed appropriate and relevant.

NHLBI staff on the workshop planning committee will be assigned to each group to facilitate group operations, including meeting scheduling, providing information from the NHLBI, and clarifying any questions that may arise.

During the Workshop meeting, all attendees will engage in discussions following presentations from each working group.  Thus, the preliminary recommendations developed by the groups will be modified based on the larger group discussions. 

All speakers will be expected to attend the entire 2-day conference so that they can be involved in follow-up discussions and in refining the recommendations.

Examples of Intervention Approaches
That may be tested in Implementation Research

Approaches addressing patient adherence to medications and/or lifestyle (diet, PA, weight)

  • Education – providing written materials, lectures, or one-on-one communication to impart information about a disease, treatment, and/or prevention approaches
  • Behavioral approaches and counseling – motivational interviewing, self-monitoring, goal setting with problem solving
  • Skill building – education on reading food labels, how to schedule and track medication-taking to improve adherence, how to self-monitor)
  • Prescribing approach – medication regimens simple vs complex
  • Reminders – to attend appointments, to fill prescriptions, to follow up with referral
  • Delivery modalities – interpersonal directly with a patient (individual sessions), interpersonal group sessions, technology (e.g., email, website)

Approaches addressing clinicians’ delivery of evidence-based care in the clinic setting  

  • Education – CME/CEU sessions (educating physicians and nurses about findings on a disease and its treatment through lecture, reading, online, other)
  • Academic detailing – “thought leaders” going to clinical sites to give educational sessions to clinicians based on academic research findings
  • Skills training – training physicians, nurses, clinical office staff for various aspects such as patient encounters in skills (such as taking BP properly), behavioral counseling approaches, diversity awareness, et al.
  • Modifying patient flow – e.g., every patient gets weighed and BMI charted with obesity noted on the Problem list in the chart
  • Reminders or cues – reminding clinicians prior to or during a patient visit about evidence-based recommendations based on patient characteristics, such as need for cholesterol testing, etc.; could be electronic or checklists; could be web systems or handheld devices with algorithms for treatment goals (e.g., algorithms based on patient characteristics, laboratory results)
  • Monitoring & feedback – systems to monitor delivery of care or outcomes in patient groups and providing feedback to clinicians (e.g., percent of a physician’s hypertensive patients with BP <140/90 mmHg; may include a comparison with other physicians in the practice or with otherwise defined peer group)

Approaches connecting the clinical to other settings to improve delivery and receipt of evidence-based care

  • Referrals – advising patient to see a specialist, such as another physician, a dietician, or go to a community program such as Weight Watchers or the gym; could be direct referrals (making an appointment for the patient), or indirect referrals (relying on patient to make appointment)
  • Community health workers – training and use of community health workers or promotoras for outreach into patients homes, with feedback to the clinician and patient (e.g., to check BP & adherence to HTN meds at patients home with feedback to patient and clinician)
  • Technology connecting clinic to home – telemedicine, interactive websites, email communication, electronic case management or telemanagement systems to convey home-obtained information (e.g., home BP monitoring in HTN, weight monitoring in HF)
  • Communication systems between healthcare providers – e.g., communication between pharmacists, nurses, and physicians regarding medication prescription refills and adherence

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