Like the rest of medicine, the pace of clinical research and improvement in rheumatology far outstrips the pace of clinical practice improvement. Medical practitioners at all levels are far quicker to learn about innovations than they are to implement them.
“Most medical innovations take over a decade to make it into clinical practice,” said Daniel H. Solomon, MD, MPH, Professor of Rheumatology at Brigham and Women’s Hospital and Harvard Medical School. “We can’t just do a trial and show that a new medication, a new paradigm, a new strategy works. We have to improve our ability to translate that new information into clinical practice.”
Dr. Solomon will explore the science and the practice of turning clinical research into clinical practice during From Bench to Bedside: Using Implementation Science to Improve Rheumatology 7:30 – 8:30 am Monday in Room 11 B. The session will focus on using a Learning Collaborative as an effective method to explore, understand, and implement change, in clinical practice.
Healthcare professionals are not adverse to improving, but implementing change is almost always a slow process. One problem is clinical inertia.
“It is always easier to keep on doing whatever it is we already do,” Dr. Solomon said. “Doing something, even something that is demonstrably better, is hard. It takes creativity and can take reorganizing your practice. It is perceived as risky simply because it is new.”
Payers can be another barrier, resistant to cover the newest and the best because of cost or their own institutional inertia. And sometimes practitioners use payer resistance to justify their own reluctance to update clinical behavior.
“Medical practice is complicated and has a lot of moving parts that have to be coordinated,” Dr. Solomon said. “Getting a medical practice to do something new takes a huge amount of effort across many people.”
Continuing medical education is the traditional method to bring new clinical information to practitioners. CME is a necessary first step in transmitting new information, but it is a very passive process and usually fails to change behavior.
Medical educators often suggest audit and feedback, observing prescribing and treatment practices, and then feeding the information back to the practitioner in an attempt to sway behavior. Audit and feedback is more successful than CME but can still take years to change long-standing practice behaviors. It also does not offer concrete solutions.
The most effective method of changing clinical behavior is a systematic conversation with practitioners about the new information and reasons they have not yet brought their practice up to date.
“The process is called a Learning Collaborative, and it isn’t rocket science,” Dr. Solomon said. “It is basic human nature. If you get people in a room and talk enough about why they should be doing something different, i.e., that it improves care and outcomes, and how to do it, they feel bad if they don’t try it. And once they try it, they usually find that change isn’t all that difficult. When they have difficulties, they bounce them off colleagues and come up with ways to overcome the barriers. This is often achieved with rapid-cycle learning, or plan-do-study-act cycles.”
A recent trial using a Learning Collaborative to speed implementation of treat-to-target in rheumatoid arthritis showed a 46 percent increase in implementation compared to traditional methods. The traditional practice arm also showed a 46 percent improvement when it crossed over to the Learning Collaborative. More importantly, follow up showed that the new treat-to-target practice was sustained well after the active group discussion intervention had finished.
Learning something new is passive. But talking about the new learning, talking about the need for the change, the benefits of change, and strategies to overcome barriers to change transforms passive learning to active involvement.
“Attendees of this year’s ACR meeting are going to be learning a tremendous amount about new science and new treatments, but if they can’t figure out how to bring these new developments into their practices, patients will never benefit,” Dr. Solomon said. “This session is a must-attend for everyone who wants to improve patient care and not just hear about it. Implementation science is about bringing the best practice to your patients.”