Dr Brian Mittman, USA
Senior Social Scientist, Center for the Study of Healthcare Provider Behavior, Veterans Affairs, USA
 Dr Brian Mittman, Senior Social Scientist at the Center for the Study of Healthcare Provider Behavior, Department of Veterans Affairs, USA , is an internationally recognised expert in the implementation and evaluation of clinical practice guidelines.
In his role with Veterans Affairs (VA), he seeks to promote better health and health care for veterans by understanding health care provider behaviour, the factors that influence it, and the health systems interventions that will improve it.
As a core investigator for VA's Quality Enhancement Research Initiative (QUERI), Dr Mittman is involved in implementing research findings and evidence-based clinical practices, including guidelines, to achieve better health care outcomes for patients. QUERI focuses on high risk/high volume conditions including cardiovascular disease, diabetes, mental health and cancer.
Dr Mittman is also co-editor of the new electronic peer-reviewed journal, Implementation Science, which publishes research about methods to promote the uptake of evidence into routine clinical practice.
Here, he outlines why the US Department of Veterans Affairs has developed coordinated strategies that address multiple levels and targets, why clinical practice guidelines and other tools for improving health care – and frameworks for studying health care delivery – must be broadened.
Using guidelines to improve care
Despite over 30 years of implementation research, successful implementation initiatives remain rare. One of the major causes is the over-emphasis on a single implementation strategy or target rather than a broader approach that targets multiple levels of the health care delivery system and its environment using multiple, coordinated strategies.
The US Veteran Health Administration has worked to develop a body of broad, co-ordinated strategies that address multiple levels and issues and we believe this model underpins our success to date.
Addressing complexity
Health care practitioners and their patients exist in a complex environment and patients vary widely in their characteristics and needs. To date, most clinical guidelines have been developed to address a single clinical condition or disease and offer clinical recommendations that are optimized for patients without extensive comorbidities or other features that complicate treatment of the focal disease. While a ‘one size fits all' clinical guideline looks attractive, it does not necessarily meet the needs of complex patients who comprise the majority of veteran using health care services.
Rather than just focusing on particular conditions or illnesses, guideline developers need to focus on common groups of co-occurring conditions and other socioeconomic characteristics that complicate treatment. Similarly, implementers need to engage with patients to fully understand their emotional and social problems, how they access care, and the other factors that influence their lives and needs.
Implementers and researchers must also broaden their scope and focus regarding improvements in health care delivery. In the US and abroad health care is increasingly delivered by organisations and organized systems and not just individual clinicians, so it is critical to understand how organisations think and work. Health care providers also need training in management and organisational behaviour so that they understand the environment in which they work and can influence organizations and organizational procedures to optimize care.
Updating the tools
In the short term, we need to focus on making full use of available resources and tools, applying these at multiple levels using a coordinate package of strategies to achieve improvement. Where it is acknowledged that ‘first generation' improvement tools don't meet the needs of complex patients, efforts to supplement these tools are needed to ensure that guidelines are effective and applicable to the care of complex patients.
In the longer term, more sophisticated guidelines are required that consider multiple diseases as well as important demographic and sociological influences. We also need to engage with those who sit outside the conventional boundaries of health care to strengthen our ability to affect care and reach patients, clinicians, health care organizations and other stakeholders involved in determining the quality, efficiency and outcomes of care.
Link to Brian Mittman's Symposium presentations |
