Strategies to implement evidence into practice to improve palliative care: recommendations of a nominal group approach with expert opinion leaders

Palliative care is an approach that aims to improve the quality of life of patients facing problems associated with life-limiting illnesses, and their relatives [1]. A growing numbers of new insights and best practices in palliative care are being disseminated via scientific publications and presentations, yet they are often not implemented in daily practice [2]. Failure to implement research findings leads to bias, unnecessary duplication of studies and suboptimal patient outcomes [3, 4]. In the USA, for example, only about 55 % of the patients received recommended care [5].

Chalmers et al. state that about 85 % of the global annual investment in biomedical research is currently wasted, [6] even though effective strategies and models for stepwise implementation of new evidence exist. Examples of such strategies and models include the UK Medical Research Council’s framework for the development and evaluation of complex interventions to improve health, [7] the Plan-Do-Study-Act cycle, [8] or the stepwise implementation model of Grol et al. [2]. Yet the use of such implementation models is often restricted to the time frame after a research project closes. It is a challenge to continue implementation of new evidence and best practices in daily clinical practice after the research or implementation project has been completed, and it is not always seen as the role of researchers [4].

An example of such a project is IMPACT (IMplementation of quality indicators in PAlliative Care sTudy). In this EU funded 7^th Framework project, quality indicators (QIs) for the organisation of palliative care were developed, and used to assess and improve the organisation of 40 palliative care services across Europe [9]. The results and tools of this project, even though it is built around implementation may not be further disseminated, adopted and implemented as soon as IMPACT finishes, without further action.

The aim of this study was to identify strategies that can facilitate the implementation of scientific output to improve the organisation of palliative care after a large research project like IMPACT has ended.

A nominal group technique was used. This technique follows a structured and evaluative methodology, developed to facilitate group or team decision making [10]. As such, they can be used to analyse healthcare problems, [11] and bridge the gap between researchers and healthcare professionals [12, 13]. A nominal group differs from focus group interviews as these are often used to explore what individuals believe or feel as well as why they behave in the way they do [14].

Twenty participants took part in the nominal group (Table 1).

In one nominal group, 21 potential strategies were mentioned and in the second nominal group 31. These strategies could be ranked and combined into the following themes (Table 2)

This study identified specific strategies to implement the results of research projects in the field of palliative care. The nominal group technique allowed international clinicians and researchers to prioritize five common themes: dissemination of the results, unique selling points, educational activities, involvement of stakeholders and the consideration of consequences. These strategies are in line with those found in literature [4, 17‐21]. For example, in an overview by Grol and Grimshaw, [18] in which they included 54 reviews about the effectiveness of different interventions to change clinical practice, they described dissemination activities, educational activities and financial interventions. In another overview, Grimshaw et al. described educational activities as well as disincentives [4]. In a review, Giguere et al. described the effect of different strategies using printed educational materials [20]. In a report for the Danish Institute for Health Services Research and Development, Thorsen et al. described dissemination strategies, educational activities and incentives and sanctions [19]. And in his ‘Diffusion of Innovations’, Rogers described the involvement of stakeholders [21]. However, several of the strategies identified have yet to be applied to improve daily clinical practice. For instance, identifying the unique selling points of studies, and using negative consequences for services are methods that are not frequently used. As for negative consequences, in the USA the Centers for Medicare & Medicaid Services applied financial penalties to hospitals that did not improve their hospital acquired infection rate, and as a result infection rates declined in many hospitals [22]. Regarding the participation of stakeholders, it is known that ‘early adopters’ are important: [21] Rogers described that they show a high degree of innovativeness, are a role model for others and help trigger the critical mass when adopting an innovation [21]. But ‘early adopters’ hardly appear to be used when introducing changes into daily clinical practice.

Participants also considered the social media as agents of change that could be used more often. However, various health care organisations, scientific journals, researchers and healthcare professionals use different kind of social media to communicate about palliative care and disseminate new evidence into daily clinical practice [23, 24]. Examples are the EAPC blog (https://​eapcnet.​wordpress.​com/​) and reviews of palliative care services (such as available for the Netherlands: https://​palliatief.​tevreden.​nl/​). Furthermore, palliative care knowledge networks (such as CareSearch in Australia: http://​www.​caresearch.​com.​au/​) can contribute to the dissemination and implementation of new evidence in daily clinical practice.

The added value of our study is that all these strategies have been considered together and prioritised by experts.

Surprisingly, de-implementation and mandating quality improvement projects were not mentioned. De-implementation, meaning stopping ineffective or harmful interventions is particularly important as there are many suboptimal forms of care in use. In palliative care, for example, the use of artificial hydration was recently discussed in a paper by Nakajima et al [25]. They showed that artificial hydration did not improve dehydration symptoms, quality of life, or survival in terminally ill cancer patients [25]. The continuation of such ineffective and sometimes even harmful medical practices is undesirable and may result in rising healthcare costs in addition to the increased burden on patients and care givers [26]. Mandating quality improvement projects is important because without the full support of the scientific and professional organisations, the implementation of quality improvement projects will not progress [2].

However, as the participants in our study emphasised, using only one strategy to implement quality improvement activities in daily clinical practice is not sufficient. Participants recommended, in line with Grol and Grimshaw, [18] the use of a combination of strategies. It appears to be important that, for each quality improvement activity a theoretically grounded structured procedure, like the framework for the development and evaluation of complex interventions of the UK Medical Research Council, [7] the Plan-Do-Study-Act cycle, [8] or the stepwise implementation model of Grol et al.,[2] is used. These implementation models facilitate both researchers and professionals in a step-by-step guide to implement evidence based best practices into daily clinical routine. Such models also may provide users with a detailed description of the current situation, preferred situation, reasons why the preferred situation has not been reached, factors that could be used to reach the preferred situation, etc. This information facilitates the development of specific actions necessary to initiate change. For example by following the steps described in the theory of planned behaviour or behaviour change wheel [27, 28]. The recommendations stipulated in this paper can be used to tailor quality improvement activities specifically for palliative care. For example one of the recommendations has already been carried out by organizing the Palliative Care 2020 conference at which stakeholders were invited to discuss the future of palliative care in Europe and which resulted in the European Declaration on Palliative Care [29].

Research projects generate a growing amount of new knowledge. Often this new knowledge is not implemented in daily practice, particularly in an environment as complex as palliative care. Timely efforts should be made to ensure that the future application of scientific findings is integrated into the research itself, to prevent wasting resources and as an endpoint for better healthcare for patients. The recommendations reported here may be of particular use in promoting quality improvement activities in palliative care. Important stakeholders, such as scientific and professional organizations and leaders on the level where the actual implementation takes place, can perform a key role in the wider implementation of new evidence.