Staffordshire and Stoke-on-Trent Partnership NHS Trust

Evidence based care - translating Research into Changes in Clinical Practice


Summary

The work of local critically appraised topic (CAT) groups have led to a number of evidence-based improvements to day-to-day clinical practice in the Stoke-on-Trent Musculoskeletal Interface Service (MIS). By growing the evidence-based culture within the clinical environment and enhancing the links between clinical and academic partners, this approach has the potential to further reduce the gap between current knowledge and daily practice both in musculoskeletal and other conditions.
  • Integrating  research findings into day-to-day clinical practice takes 6 months, rather than the estimated average of 17 years
  • CAT groups have low running costs at an estimated £5,063 per year 
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The Challenge

  • The practice of evidence-based medicine is fundamental to ensuring that good quality health care is delivered to patients; however, delays in integrating research findings into day-to-day clinical practice mean that patient care may be inconsistent or contrary to the current evidence.

The Solution

  • Clinicians from the Musculoskeletal Interface Service (MIS) at Haywood Hospital established the Musculoskeletal Research Facilitation Group (in collaboration with academics from the Research Institute for Primary Care and Health Sciences, Keele University) to improve how evidence is translated into practice in the MIS. The group has set up a number of critically appraised topic (CAT) groups with the aims of:
    • Identifying areas where the evidence behind clinical practice is poor
    • Informing the research agenda
    • Implementing clinical change
  • Together, the members of the CAT groups appraise the available evidence base in order to answer questions relating to current clinical practice in the MIS. If current clinical practice is found to not be aligned with the evidence, the results can be used to inform clinical algorithms and/or assist in change management (to support the change or removal of services).  If evidence is lacking then these clinical questions can inform new innovative research questions for trials.
  • CAT groups include clinicians, clinical researchers, librarians and managers. This multidisciplinary collaboration increases the research awareness of clinical staff, grows the evidence-based culture within the clinical environment and creates and enhances links between clinical and academic partners, further facilitating the translation of research into clinical practice.
  • To allow as many staff as possible to attend, three different structures of CAT groups have been developed:
    • Half day meetings, four times per year
    • One day workshops, offering an introduction to the concepts behind evidence based medicine and an opportunity to undertake a critical appraisal
    • ‘Satellite’ groups, led by individuals who have participated in the half day meetings or workshops, with academic support from Keele University

Service Performance and Outcomes

  • In the MIS, it takes around 6 months for research findings to be integrated into day-to-day clinical practice, which is dramatically lower than the estimated average of 17 years.
  • In a number of instances, evidence found by the CAT groups has been incorporated into clinical practice in the MIS:
    • Autologous blood injections are only offered after discussion with patient regarding the current evidence and NICE recommendations.
    • Urinalysis is no longer routinely offered to patients attending the Day Case Unit for intra-articular corticosteroid injection.
  • Two clinical studies have been initiated following the poor level of evidence identified by a CAT question.
  • CAT groups were included as one of the 10 principle Trust-wide strategic research aims in the Staffordshire and Stoke-on-Trent Partnership (SSOTP) NHS Trust 2014–2015 Research Strategy, and the Trust Clinical Effectiveness Committee has expressed interest in rolling out the methodology beyond MSK conditions.
  • Where relevant, CAT groups work to highlight information relevant to commissioning decisions. For example, a paper was written to highlight the latest evidence for management for patients with degenerative meniscal tears of the knee to commissioners and other key stakeholders.

Financial Performance and Outcomes

  • The estimated cost of running the CAT groups is £5,063 per year, which is absorbed by the NHS Trusts and the academic institution in terms of ‘matched funding’ e.g. staff attending these groups, provision of facilities and access to library services.
  • Cost-effective changes have been made to clinical practice following CATs and the subsequent evidence generation. For example, based on the results of the STarT Back trial, stratification of patients according to their prognosis in primary care for back pain was introduced, which has led to an estimated annual direct cost saving to the local back pain service of £119k.
  • Furthermore, in a number of cases where the CAT group has identified a poor evidence base relating to a particular clinical question, the funding for a study to develop the evidence has then been sourced through the Research Institute for Primary Care & Health Sciences, Keele University

Patient Focus and Satisfaction

  • Efforts are made to ensure that patients are aware of the evidence from trials resulting from the work of the CAT groups. Additionally, the Chair of the research facilitation group assists the local Arthritis and Musculoskeletal Alliance Group at the Haywood Hospital, which provides the opportunity to regularly feedback to patients the evidence behind their care.

Commissioning Implications


Research and its evidence translated into practice is vital in transforming services and improving patient outcomes across the NHS; fully integrating research into organisations will lead to better quality care and improved use of resources. The CAT group approach adopted by the Stoke-on-Trent MIS service is an outstanding best practice model for all services as it can:
  • Increase the alignment of daily practice with current evidence (including NICE guidelines), which has the potential to meet any number of commissioning priorities, for example:
    • Active support for self-management  – as a result of the CAT group finding that the evidence supporting clinical guidelines regarding self-management of hand osteoarthritis was poor, the SMOotH (Self-Management in Osteoarthritis of the Hand) trial2 was initiated.
    • Managing elective activity – referral quality – as a result of the CAT group finding that there was no evidence that suggests an oxford hip or knee score alone can be used as a predictor for surgery, practice was adjusted so that these scores are no longer used as part of onward referral to orthopaedics.
  • Create opportunities for patients to participate in research by initiating further research where evidence is lacking.
  • Create partnerships for clinicians to engage in research by exposing clinicians to evidence and offering an opportunity for clinicians to become research active through this collaboration.  This model has been replicated with Keele University leading both a GP and practice nurse evidence based practice groups as well as supporting ‘hubs’ of the MIS CAT model across Shropshire, Cheshire and Staffordshire.

Service diagram