Bridging the gap between clinical research evidence and practice : implementing the South African National Evidence-Based Asthma Guideline in Private and Public Practice in the Cape Metropole.

[摘要] ENGLISH ABSTRACT: BackgroundA need for primary care practitioners to utilise clinical research evidence in practice has been identified and is well described. However a chasm between evidence and practice still exists in primary health care (PHC). Although clinical practice guidelines have been shown to improve the quality of clinical practice and attempt to bridge the gap between evidence and practice, practitioners are often not aware of practice guidelines and fail to access, adopt or adhere to evidence-based recommendations contained in them.Central questionHow can the implementation of clinical research evidence, using the example of the national evidence-based guideline on asthma, be improved in the PHC sector in the MDHS of the Cape Town metropole?AimThis research aimed to improve the implementation of clinical research evidence in PHC, by learning from the specific example of the national evidence-based asthma guideline in PHC practice in the Metro District Health System (MDHS) of the Cape Town metropole, and to make recommendations to key stakeholders regarding the future implementation of evidence-based guidelines.Objectives To gain insight into the current quality of asthma care in PHC in the MDHS of the Cape Town metropole. To determine whether the process of implementation of the new asthma guideline contributed to an improvement in the quality of care in the MDHS. To explore ways of improving the process of implementation of the national asthma guideline in PHC in the MDHS. To gain insight into the perceptions, attitudes and knowledge of asthmatic patients regarding their asthma management. To explore how EBP is understood and perceived by doctors in PHC.Stellenbosch University https://scholar.sun.ac.za To understand how PHC doctors in the public and private health sectors gain access to and use guidelines. To explore the experiences, perspectives and understanding of family physicians (FPs) (academic, private and public sector) with regard to EBP and the implementation of guidelines in PHC practice. To gain insight into the understanding of FPs regarding the perceived problems and main barriers to EBP and their views of the process of guideline implementation in PHC. To gain insight into the knowledge, perceptions and attitudes of clinical nurse practitioners in the public sector with regard to EBP and the process of guideline implementation.MethodologyThis study was conducted in the PHC setting of the Cape Town metropole. This research was conducted in three phases and used cross-sectional surveys, quality improvement (QI) cycles, qualitative research methods, such as interviews with FPs, and participatory action research (PAR).Phase 1 involved a cross-sectional survey, which looked at the knowledge, awareness and perspectives of doctors, regarding evidence-based practice (EBP) and guideline implementation using the national evidence-based asthma guideline published in 2007. It also involved QI cycles conducted over a period of five years to assess the baseline quality of asthma care in the PHC sector and to evaluate improvement in asthma care as a result of the QI cycles and associated educational workshops.Phase 2 involved interviews conducted with FPs in academia as well as in the private and public health care sectors who were responsible for clinical governance in PHC in the Cape Town metropole. During this phase of the research the experiences, perspectives and understanding of FPs (academic, private and public sector) with regard to EBP and the implementation of guidelines in PHC practice were explored.Phase 3 involved PAR with primary care practitioners at community health centres (CHCs) using a co-operative inquiry group (CIG) to improve asthma guideline implementation in PHC. The CIG investigated how to improve the implementation of the asthma guideline in their respective CHCs and completed four cycles of planning-action-observation-reflection. The four cycles focused on implementation of an asthma self-management plan (ASMP), exploring the capability of clinical nurse practitioners to implement the guidelines, exploring the views of patients on their asthma care and implementing better patient education. A final consensus of the CIG's learning was then constructed.ResultsWith regard to quality improvement of asthma care in PHC:The first objective of the study was largely addressed through the baseline audits conducted in 2007 and 2008. This showed that the baseline quality of asthma care, with specific reference to the assessment of the patient's level of control, measuring the patient's peak expiratory flow rate (PEFR), assessing the patient's inhaler/ spacer technique, recording the smoking status, the adequate prescription of controller and reliever metered dose inhalers (MDI) refills during visits and particularly the issuing of an ASMP during visits, was poor.The second objective was addressed through the annual audits conducted in 2007, 2008, 2010 and 2011 during the period of implementation. This showed that although clear cause and effect reasoning cannot be inferred, overall statistically and clinically significant improvements in the quality of care occurred in conjunction with the process of asthma guideline implementation. Despite the improvement in structural and process criteria there was no corresponding improvement in the outcome criteria and in fact the utilisation of facilities for emergency visits significantly increased, while the hospitalisation of patients remained constant.The third objective was to explore ways of improving the process of implementation of the national asthma guideline in PHC in the MDHS. This was largely addressed through the action-research process at selected CHCs. This showed that implementation could be improved by ongoing educational support and formal interactive training workshops with the staff members who were directly involved with patients. The development and use of educational aids and ASMPs based on the guideline recommendations were useful and encouraged patient participation in decision making regarding their care.The fourth objective, specific to asthma care, addressed by means of a survey and showed that even though the majority of asthma patients participated in decisions regarding their asthma and felt satisfied with the quality of care they received, the prevalence of smoking among asthma patients was high and opportunities for smoking cessation counselling were missed. Even though documentation of peak flow recordings and patients' knowledge of the difference between the reliever and controller MDIs were good, patients' perceptions with regard to education on the inhaler technique, the assessment of the level of control, the issue of written information regarding asthma and the use of ASMPs remained poor and could be improved.With regard to EBP and asthma guideline implementation in PHC:The fifth objective of the study was addressed by means of a survey which showed that the doctors in PHC used evidence in clinical decision making and agreed on the usefulness and importance of EBP in improving the quality of patient care in South Africa. There was a difference in the engagement with activities related to EBP between the public and private sector PHC doctors and there is a need for formal training in the skills and processes of EBP.The sixth objective was addressed by means of a survey which showed that a good proportion of both public and private sector doctors in the Cape Town metropole were well aware of the asthma guideline, had used the guideline and had adopted, acted on and adhered to specific guideline recommendations. There was a high level of general awareness of the asthma guideline and recommendations were being adopted in practice, although the lack of formal disease registers, monitoring and evaluation of asthma care and the utilisation of an ASMP could be improved on.The seventh objective was addressed by qualitative research which showed how the views and perspectives of FPs regarding EBP and the process of guideline implementation contributed to the development of a conceptual framework for the process of guideline implementation.The eighth objective was addressed by qualitative research, which identified barriers present in each step of the implementation process. Time constraints, practitioner workload, lack of financial resources, lack of ownership, the lack of timeous organisational support and practitioner resistance to change were important barriers to guideline implementation in an already overburdened PHC setting. A conceptual model was developed which showed that the process of guideline implementation should be tailored to the barriers identified. The ninth objective was addressed by means of a survey which showed that the concept of EBP was fairly new to CNPs in PHC and identified a need to learn more about it. CNPs agreed that clinical research evidence is useful in the daily management of patients, that their decision making is based on evidence, that evidence-based nursing can improve the quality of patient care, that there is a place for evidence-based nursing in their practices at their respective CHCs, that EBP will make a difference in the quality of care of their patients and that evidence-based nursing practice has an important role to play in South Africa. Although the awareness of CNPs with regard to the asthma guideline was poor, the vast majority reported that they personally educated patients on the difference between reliever and controller MDIs, recorded the smoking status of patients in the records, demonstrated the inhaler technique to all their asthma patients, assessed the level of control and agreed that inhaled corticosteroids are the mainstay of treatment in patients with chronic persistent asthma. However only a small minority (mainly at the CHCs where action research occurred) started issuing patients with ASMPs.In answering the central question: 'How can the process of implementation of clinical research evidence, using the example of the national evidence-based guideline on asthma, be improved in the PHC sector in the MDHS of the Cape Town metropole?, this thesis concludes that the process of guideline implementation can be improved in the PHC sector by an in depth understanding and systematic approach to the whole process. A conceptual framework is provided as a model which attempts to guide and make sense of this process of guideline implementation. A stepwise approach is presented and provides a summary of the main research findings. The model shows that the initial process of evidence creation should not only deal with research evidence of high quality, but should incorporate research evidence that is relevant to the particular context of care. In addition the model shows that guideline development should be inclusive and involve a wider spectrum of stakeholders as well as patients; that guideline contextualisation, dissemination and implementation should be carefully planned. Special consideration should be given to local decision making about adoption or prioritisation of specific recommendations as part of ongoing quality improvement cycles and the conversion of published guidelines into practical tools for practitioners to use inconsultation, prior to dissemination. Implementation should anticipate that members of the PHC staff will differ in their readiness to change and that strategies should consciously embrace principles of behaviour change and build up a sense of ownership, choice and control over local adoption of the guidelines. Academic centres, such as universities and professional bodies, have a role to play in identifying, appraising and synthesising the evidence, and giving input into guideline development. They can also assist by innovating and evaluating practical tools as part of the contextualisation stage and by providing continuing education during implementation as part of their social responsibility. The health care organisation (HCO) should prevent unnecessary delays in guideline implementation by ensuring that policy, resources and recommendations are aligned during the contextualisation stage; that barriers encountered should be dealt with throughout the entire process, and that ongoing monitoring and evaluation of the quality of care occurs.ConclusionThis research used different methods and innovative PAR to bridge the gap between evidence and practice. A new conceptual model for guideline implementation is recommended for use to assist with implementation and knowledge translation in PHC locally, nationally and in similar Low Middle Income Countries (LMIC) in Africa.

[发布机构] Stellenbosch University