Implementing Change In The Health Care System

Despite the considerable amount of money spent on clinical research, relatively little attention has been given to ensuring that the findings of research are implemented in routine clinical practice. In order to implement changes in medical care, it is important to focus on interventions promoting change, and to target interventions to the appropriate audience. Traditional teaching methods (i.e., didactic lectures and continuing medical education) and other forms of passive dissemination of information (i.e., recommendations for clinical care, clinical practice guidelines, audiovisual materials, and electronic publications) have not been shown effective in changing physician behavior (20-22). The publication of new clinical trials is not a reliable method of influencing prescribing, nor is the widespread dissemination of practice guidelines (20). Government-sponsored feedback on prescribing patterns has not shown an impact on prescribing habits of general practitioners (22). Provision of drug-cost information in the computerized patient record has not been shown to affect overall mean prescription cost or prescribing patterns (23).

On the other hand, systematic reviews have documented that educational outreach visits, computerized and manual reminders, and interactive educational meetings (participation of healthcare providers in workshops that include discussion or practice) are effective in promoting behavioral changes among healthcare professionals (20). Educational outreach visits, also known as academic detailing, use a combination of techniques to improve physicians' clinical decision making (24,25). Multifaceted interventions, which include a combination of audit and feedback, reminders, local consensus processes, and/or marketing are consistently effective interventions (20). Point-of-care delivery of clinical guidelines and evidence-based recommendations has been shown to impact clinical practice (26). Peer education (physician to physician) to improve quality of care and reduce cost of antibiotic prescribing was effective in office practices (27). A multidisciplinary continuous improvement approach as been shown to increase clinical prevention efforts and improve the delivery of diabetes care (28,29). Unfortunately, these more effective methods are not routinely used in medical education (30). It should be noted that physician-to-physician interventions are extremely expensive to implement on a broad scale and thus tend to be limited to small-scale interventions.

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