Traditionally the transfer of information was verbal from a discharge planner in the hospital to the appropriate community agency. At best, it has been sketchy written referral notes. Now, in some countries, the use of technology allows information to be downloaded from a hospital record to community services.

　Devices such as Palm Pilots are carried by nurses which contains essential patient information and are updated. Large amount of data are stored on CD ROM which can be transferred between institutions, and make the exchange of information faster and more efficient. As previously mentioned patients and their families are increasingly using the internet as a source of information to answer questions about problems they are encountering at home as they attempt to care for chronically ill patients. At this point the most common form of communication between hospital and agencies is the telephone and fax machine. Traditionally the patient information that is transferred is minimal and not enough to do comprehensive planning. Assessment tools that we will be discussing in a future session are suitable to electronic entry and transfer. The Province of Quebec has set an objective to computerize every home by 2005. This type of network will enhance the possibility of using electronics to maximize its effect in ensuring continuity of patient care. One Japanese study (Kitamura, 1998) recommended the use of a stroke registry to obtain the overall characteristics of stroke patients and be able to use the registry to promote community wide programs and to predict home care needs

　Telemedicine systems (Kee, 1998) have been used by nurses in home health care. Telephone intervention is typically used in combination with other interventions and has shown some positive impact on health outcomes (Effective Public Health Practice Review, December, 2000) There is literature which discusses the effectiveness of telephone reassurance programs as an adjunct to discharge planning. Additional support such as in-home monitoring devices transmits data that uses the telephone to respond to a series of assessment questions.

　I have had a very good lunch, thank you. Sometimes people feel sleepy after lunch and sometimes people think research is a sleepy topic. I hope this combination will not be too sleepy for you!

　

Picture This photograph of McMaster University is shown to emphasize how much we value integration of Research, Education and Service.

　

　I would like to talk with you about:

　

　In the early 1990's in Canada there were many discussions about how the health care system was getting to be too expensive. Nurses were getting improved wage settlements, there was an increased emphasis on purchasing very expensive technological equipment like magnetic resonance imaging (MRI) machines and there was an apparent oversupply of nurses. Also there was residual tension between doctors and nurses who had differing opinions about some of the issues raised in the Canada Health Act in 1985. For nurses there was pressure "to prove" that what they did was effective in improving health outcomes.

　

　At the same time, our Public Health Unit in Hamilton was in the early stages of development as a Teaching Health Unit. Modelled after teaching hospitals, our mandate was to integrate research and education with service delivery. We accepted the challenge "to prove"that nursing interventions do improve health outcomes. One of our first systematic reviews of the nursing literature was on the topic of home visiting. I will tell you more about the results of that study in a few minutes, but first, I would like to talk about how we decide what information we use.

　

WHAT TYPES OF EVIDENCE OR INFORMATION DO WE USE?

　

　In this part of this lecture I will rely heavily on some materials that were prepared by my colleagues in Canada, Dr. Jenny Ploeg, Dr. B. Huchison and colleagues.

　

　In planning programs, we draw on information from research, textbooks, and policy sources:

　This information may be available in journals, textbooks, or agency developed reports.

　These policies always include budget constraints and opportunity costs

　

　The mix of factors that contribute to management decisions will vary from day to day, depending on the situation and the decision-maker. In general, however, we know that the proportion of scientific or research evidence in the mix has increased over time, in part because of the explosive increase in the amount and quality of scientific evidence.

　A primary study refers to the original research report as prepared by the investigator(s) who conducted the study.

There are a number of advantages and disadvantages associated with using either primary studies or systematic reviews. I will return to this topic in a few minutes.

　As professionals we practice within a theoretical base that is derived from a variety of disciplines. We use literature in textbooks and journals to inform our care and program plans. The ethnocultural studies help us to understand context and health practices of our patients.

　

　Philosophical and ethical literature ensures a holistic and sensitive approach to community and individual needs.

　Needs assessment involves finding facts about what the needs are and how great they are. Some of the types of data we use are:

　Best practice evidence is derived from assessing the results of implementing the actions in other places. Evaluation is usually formative or summative. Formative evaluation assesses the extent to which the action was implemented as planned. Summative evaluation assesses the extent to which the objectives were met by the implementation of the actions. Pilot studies become evidence for implementation.

　

　For Example: An evaluation of a Community Interservice Team project included in-depth interviews with providers and administrators who participated in the program, and interviews with clients regarding satisfaction and other issues related to team care model.

　

　The evidence from this evaluation has been used to design interservice teams in other geographic locations.

　Policy documents include the federal, provincial and municipal legislation and position papers directly relevant to our programs. We also seek policy perspectives from other jurisdictions nationally and internationally. Further, we are conscious of local standards and values.

　

　Example: The Community Interservice Team arose in response to provincial policy initiatives to reform long-term care, to ensure internal quality improvement, and to respond to population trends in home care utilization and practice.

　Example: A very large $67 million Canadian dollar program in the province of Ontario was largely modelled after a Hawaii state government initiative. The program is designed to improve health outcomes of babies and children.

　Now I would like to talk more about research evidence.

　By looking at diverse information across the various primary studies, a review has the potential to help broaden the understanding of the nature of the intervention/outcome of interest.

　A systematic review applies an objective framework to the selection, appraisal and reporting of studies to reduce bias.

　

　Systematic reviews prepresent an efficient means for busy staff managers to keep up to date.

　

　They identify beneficial or harmful interventions based on aggregate information.

　Provide more information regarding the application of results to specific subgroups of patients.

　

　Can help to define the boundaries of what is known and what is not known about that topic.

　

　The good news is the number of reviews in existence will only increase with time.

　We concur with Oxman and other members of the Cochrane Collaboration that it Is important to critically appraise a systematic review (Oxman et al, 1994):

There are a number of sources of synthesized evidence available.

　The Cochrane Collaboration is an international organization that aims to help people to make well informed decisions about health care by preparing, maintaining and ensuring the accessibility of rigorous, systematic, and up-to-date reviews (and where possible meta-analyses of the benefits and risks of health care interventions (Jadad & Haynes, 1998). A Cochrane Collaboration site is located at McMaster University.

　

　There are a variety of evidence-based health care organization websites available. Three examples from McMaster University are:

　

　This project has produced many systematic reviews of the effectiveness of public health interventions.

　

　There are a variety of evidence-based journals available:

　When planning programs based on research evidence, it is important to recognize that the strength of the evidence varies. Certain study designs and methods provide stronger evidence for decisions than other. Criteria have been developed to assess the quality of evidence for research. A manager can use such sets of criteria to determine the strength of the evidence available for program decisions.

　

　Example: One of our projects involved the completion of three systematic reviews of the evidence related to elder abuse:

　

　For the first two reviews, criteria were developed to determine the quality of the studies retrieved.

The numbers in brackets represent scores given to each assessed article.

　Criteria were also developed to assess the quality of evidence related to screening tools (in this case for abuse).

　For the third review, the effectiveness of interventions related to elder abuse, the quality of the studies found was very limited and we were not able to apply quality criteria. There are, however, a number of sets of criteria that can be used to assess quality of studies that examine the effectiveness of interventions. One simple method is the ABC Method:

　

　

　In the review of effectiveness of elder abuse interventions, all of the studies found were descriptive in design, the lowest level of quality of evidence listed in this set of criteria. Criteria also exist for the assessment of the quality of qualitative research.

　

　Example: Effectiveness of Home Visiting (Omit if time is short and move to Anticipatory care, p. 54)

　

　A systematic review was conducted to assess the evidence of effectiveness for home visiting as a program delivery strategy for prenatal and postnatal clients.

　

What's the Evidence?

One hundred and eighty articles were potentially relevant but only 20 were relevant when we read them. Of these only 12 studies had adequate methodological rigour. These studies were randomized trials except one moderate quality study which was a cohort design. Two studies targeted prenatal clients, six were for postnatal clients, and four included interventions for both the pre and postnatal period.

The most effective interventions:

　In summarizing the literature, there are no negative effects of home visiting, that is, home visits have not been shown to do any harm. Moreover, the studies have demonstrated a positive impact of home visiting on physical health, mental health and development, social health, health habits, knowledge and service utilization.

Some of the articles report no effect or selective effects, but the effects seems to be mediated by the number and length of visit and by the preexisting level of health and social status of the clients. Greater treatment differences are associated with higher intensity. Effectiveness can be marred by inadequate intensity or poor timing of home visits 20-22 . Interventions have more impact on people of higher risk (eg. Unmarried, low income, teen mothers) than those of moderate or low risk. If the only outcome of interest is reduction in low birth weight, home visiting alone does not achieve that. However, many studies lack a strong theoretical framework linking the intervention to the expected outcome The weakness of theoretical causal link between social support and low birth weight may account for limited impact. Similar theoretical weaknesses are found in many of the studies.

Home visiting can definitely increase the effectiveness of other medical, social, and educational services.

　

　Example : Anticipatory Care

　Seniors are major consumers of health care resources in Canada. A significant proportion of seniors are at risk for falls, functional decline, institutionalization, and death.

　Anticipatory care is defined as proactive, provider initiated care which is above and beyond the demand-led usual care. It is provided in an ambulatory primary care setting and linked to the usual care system.

　The goal is to identify the unrecognized problems in people at increased risk and to link these people to the appropriate health care providers. The intervention usually involves a home visit by a public health nurse or a family practice nurse who works in collaboration with the older person's family physician. Components of the intervention usually include assessment, health education, and referral to health and social services.

That older people are at increased risk for falls, institutionalization, and death. Effective interventions are needed to prevent these outcomes, and to enable older persons to continue to live in their own homes.

A meta-analysis of published studies was completed to determine whether anticipatory care is effective in (a) reducing mortality, acute care hospitalization, admission to long-team care, and falls; and (b) increasing the percentage of older people living in the community.

Fifteen randomized controlled trials that evaluated anticipatory care with community-dwelling elderly persons were found. A total of 13,386 people participated in the trials.

　

　Anticipatory care was associated with an 18% reduction of mortality.

　

　Anticipatory care was associated with fewer admission to long-term care.

　

　Anticipatory care was associated with an increased likelihood of living in the community.

　

　To our surprise, anticipatory care was not associated with fewer admissions to acute care, reduced falls, or increased use of home help or Meals on Wheels.

　

　Only one study was conducted in Canada, a concern for our application. There has not been a well designed study evaluating the impact of anticipatory care on quality of life and costs and use of services.

　

　Six studies are methodologically stronger (rating 3 out of 5) than the others.

　

　We perceive a serious need for evaluation of the impact of anticipatory care interventions on mortality, institutionalization, quality of life, costs and health care utilization among older persons in Ontario.

　We are being more systematic in planning our nursing interventions. We are particularly concerned that we make evidence-based decisions for care in the community. We think about literature evidence, patient and caregiver beliefs and constraints of policy, time, and money. We use systematic planning models which include determining goals, assessing need, specifying objectives. Based on the literature combined with needs assessment we design alternative actions, selecting a course of action. Then we implement and begin evaluating.

　

　Of course the very big challenge has been to find the research evidence and assure ourselves that the evidence is good enough to use for our own program planning. Sometimes the evidence is not good enough and we become motivated to encourage funders to sponsor the research and we do a new study. We have found that using systematic reviews of the literature is a very sound solution to determining what evidence we use.

If you have any questions, I would be pleased to answer them.