what should be considered when implemenng a paent … · 2012) and a literature review on barriers...
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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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8
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