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Back to 2014 Annual Meeting Abstracts
A Multifaceted Knowledge Translation Strategy Can Increase and Sustain Compliance With Guideline Recommendations for Mechanical Bowel Preparation
Cagla Eskicioglu*2, Emily Pearsall1, Darlene Fenech1, Mary-Anne Aarts1, Allan Okrainec1, Robin S. Mcleod1
1Surgery, University of Toronto, Toronto, ON, Canada; 2Surgery, McMaster University, Hamilton, ON, Canada
Background: Transfer of evidence into clinical practice is a slow and haphazard process. Whether or not the change in practice is sustainable is unknown. This study reports the outcome of a five year knowledge translation strategy adopted to increase adherence with a guideline for mechanical bowel preparation (MBP) for elective colorectal surgery patients.
Methods: In 2008, we developed a locally tailored evidence-based guideline which recommended that MBP be omitted for all patients undergoing elective colorectal surgery except for those patients having a low anterior resection (LAR). Following completion of the guideline, a knowledge translation strategy including educational sessions given by opinion leaders was initiated at seven adult teaching hospitals affiliated with a single institution. Subsequently, between 2009 and 2013, other knowledge translation strategies including reminder cards, electronic updates and standardized orders were utilized. To assess compliance with guideline recommendations, a retrospective audit of a convenience sample of patients undergoing elective colorectal surgery at the hospitals was conducted pre-guideline implementation in 2008 (n= 78), six-weeks post-guideline implementation in 2008-09 (n= 118), and four years post-guideline implementation in 2013 (n=153). Patients were grouped according to procedure: right colon resections (RCR) including ileocolic resection and right hemicoloectomy; left colon resections (LCR) including reversal of Hartmann, sigmoid resection, sigmoidectomy, left hemicoloectomy, and finally, anterior resection; and LAR.
Results: A total of 349 patients (175 males, 174 females, mean age 60.4) were included in the study: 160 had a RCR, 107 had a LCR and 82 had a LAR. Overall, 159 (45.6%) had laparoscopic procedures. The demographic characteristics of the patients are presented in Table 1. Overall, there was a steady increase in adherence to the MBP guideline recommendations. Compliance increased from 71% to 95% (p=0.002) for patients having a RCR, 45% to 59% (p=0.34) for patients having a LCR, and 31% to 60% (p=0.10) for patients having a LAR. Table 2 illustrates compliance with guideline recommendations before and after implementation.
Conclusion: Using a tailored knowledge translation strategy, we observed increased compliance with guideline recommendations over time suggesting that a longitudinal strategy is required to increase and sustain compliance with recommendations. Furthermore, different strategies may be required at different times (ie: educational sessions initially and reminders and standardized orders to maintain adherence). While overall increased compliance was observed for all procedures, adherence with LCR and LAR recommendations was lower suggesting that patient factors may also affect physician decision-making.
Table 1. Demographic characteristics
| 1. Before (June-Oct, 2008) (n=78) | 2. After (Dec 2008-Mar 2009) (n=118) | 3. After (July-Nov, 2013) (n=153) | | Mean age | 59.8 | 60.8 | 60.7 | | Male | 38 (48.7%) | 62 (52.5%) | 75 (49.0%) | | Female | 40 (51.3%) | 56 (47.5%) | 78 (51.0%) | | Location of Anastomosis | | Right-colon resections | 31 (39.7%) | 53 (44.9%) | 76 (49.7%) | | Left-colon resections | 31 (39.7%) | 32 (27.1%) | 44 (28.8%) | | LAR | 16 (20.5%) | 33 (28.0%) | 33 (21.6%) | | Type of Surgery | | Open | 47 (60.3%) | 59 (50.0%) | 37 (24.2%) | | Laparoscopic | 26 (33.3%) | 48 (40.7%) | 85 (55.6%) | | Lap to Open | 5 (6.4%) | 11 (9.3%) | 31 (20.3%) |
| 1. Before | 2. After | 3. After (2013) | | Right-colon resections: number/% who received no MBP | | Compliant | % | Compliant | % | p-value* | Compliant | % | p-value** | | Laparoscopic | 7/11 | 63.6 | 25/31 | 80.6 | | 50/52 | 96.2 | | | Open | 13/17 | 76.5 | 13/17 | 76.5 | | 10/11 | 90.9 | | | Converted | 2/3 | 66.7 | 4/5 | 80.0 | | 12/13 | 92.3 | | | Total | 22/31 | 71.0 | 42/53 | 79.2 | 0.55 | 72/76 | 94.7 | 0.002 | | Left-colon resections: number/% who received no MBP | | Compliant | % | Compliant | % | p-value* | Compliant | % | p-value** | | Laparoscopic | 6/12 | 50.0 | 5/13 | 38.5 | | 8/17 | 47.1 | | | Open | 7/17 | 41.2 | 10/17 | 58.8 | | 10/16 | 62.5 | | | Converted | 1/2 | 50.0 | 1/2 | 50.0 | | 8/11 | 72.7 | | | Total | 14/31 | 45.2 | 16/32 | 50.0 | 0.90 | 26/44 | 59.1 | 0.34 | | Low anterior resection: number/% who received MBP | | Compliant | % | Compliant | % | p-value* | Compliant | % | p-value** | | Laparoscopic | 2/3 | 66.7 | 3/4 | 75.0 | | 11/16 | 68.8 | | | Open | 3/13 | 23.1 | 14/25 | 56.0 | | 4/10 | 40.0 | | | Converted | 0/0 | NA | 3/4 | 75.0 | | 5/7 | 71.4 | | | Total | 5/16 | 31.3 | 20/33 | 60.6 | 0.10 | 20/33 | 60.6 | 0.10 |
*p values 1 vs 2 **p values 1 vs 3
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