Using an ambassador program to improve the management of chronic pain
Paul Taenzer, PhD, Calgary Health Region Chronic Pain Centre
Christa Harstall, MHSA, Alberta Heritage Foundation for Medical Research
Saifee Rashiq, MD, University of Alberta Hospital
Pamela Barton, MD, Calgary Health Region Chronic Pain Centre
Don Schopflocher, PhD, Alberta Health and Wellness
An ambassador program focusing on improving the quality of pain management was introduced in Alberta. In a partnership between researchers, senior clinicians and government officials, research and clinical leaders presented evidence on chronic pain interventions to local clinicians through community workshops. Participants reported an increase in knowledge, knowledge sharing and practice changes as a result. The ambassador program holds promise as a knowledge translation (KT) approach, but would best serve the needs of clinicians as an ongoing professional education service.
As early as the 1970s, leading pain management researchers remarked that if we used currently available knowledge to guide clinical practice, more than 90% of uncontrolled pain would be managed successfully. Thirty years later, surveys of patients hospitalized for surgery, cancer patients, and those with chronic pain continue to indicate that we are far from achieving that goal.
The slow progress in improving the quality of pain management contrasts sharply with the explosion of relevant research and the publication of practice guidelines for numerous clinical pain dilemmas. Challenges remain in the consistent and comprehensive assessment of pain; the use of validated treatments; the availability of adequately trained health care professionals; and budget provisions for space, equipment, personnel, medications, and pain treatment facilities.
Our KT strategy was inspired by the work of the Swedish Council on Technology Assessment in Health Care (SBU). SBU conducts scientific assessments in health care to identify the interventions that offer the greatest benefit for patients and the most efficient utilization of resources. In the mid-1990s, SBU developed an ambassador program, where senior clinicians were hired to be liaisons between SBU and the decision makers and clinicians in each health district. The senior clinicians conducted workshops, clinical rounds, and conferences, and met with clinicians and policy makers to inform them of the latest results from SBU health technology assessments (HTAs). The ambassadors also informed SBU of local priorities that could be considered for future HTAs.
We adapted the Swedish ambassador program to the Alberta context with an initial focus on management of chronic, non-cancer pain.
The KT initiative
Our project built on established relationships among researchers from the Health Technology Assessment Unit of the Alberta Heritage Foundation for Medical Research (AHFMR), senior clinicians from the University of Calgary and University of Alberta and senior government officials from Alberta Health and Wellness. As a group, we have been involved in developing priorities for HTAs related to chronic pain for the past several years.
The primary objectives of the project were to develop and test an ambassador model that would serve as a successful prototype for KT, increase clinician knowledge about best evidence in chronic pain management, and encourage clinicians to incorporate research evidence into the management of chronic pain patients. In order to develop, implement and test the model, an advisory committee was established with representatives from all of the relevant stakeholder groups in the province, including the authors, the Alberta College of Physicians and Surgeons, the Alberta Medical Association and a representative from one of the rural Alberta health regions. Consultants with expertise in dissemination of clinical practice guidelines, continuing medical education and adult learning complemented the advisory committee.
We developed a workshop format for the program to present research evidence on specific chronic pain interventions to local clinicians. A team that included a clinical ambassador who was a well-recognized provincial leader in continuing education related to pain management, and a research ambassador who was available to explain how the evidence presented was derived from the research literature, conducted each workshop. For each intervention, a comprehensive search and selection process for the best research evidence was undertaken. Systematic reviews and HTA reports were rated by the HTA researchers, and one-page, "evidence-in-brief" summaries of the research evidence were generated. The clinical ambassadors also produced one-paragraph statements of how the research evidence could be incorporated into clinical practice.
We focused on making participation at the workshops appealing, convenient and not too time-consuming. Workshops were held in local communities, at a convenient time of day, with participants (family physicians and pharmacists) able to claim continuing education credits. Strategies for enhancing learning included minimizing didactic material, using a case-based interactive format for KT, inviting a multidisciplinary group of participants and keeping the workshop format flexible so that participants could direct the content to their areas of need. The session was wrapped up by having participants focus on what they learned, on how they might apply it in their practices, and on changes they would like to see in their health region's policies and practices.
Results of the KT experience
Eleven workshops were conducted in eight of the nine Alberta health regions in the fall of 2004. The evidence presented at the workshops covered 18 specific interventions, most of which were related to chronic low back pain. One hundred and thirty health care providers participated, including nurses (27%), physicians (21%), physical and occupational therapists (18%), administrators (17%), pharmacists (9%), and psychologists, mental health, or social workers (7%).
An independent evaluation of the program six weeks after each workshop indicated that the workshop participants found the ambassadors highly credible, appreciated the evidence-in-brief summaries, found the workshop format effective and reported a significant increase in their knowledge of key treatments for chronic pain management. They had begun sharing the evidence and evidence-in-brief summaries with colleagues and with patients. One third of the participants indicated they had made changes to their practice based on what they learned at the workshop.
The case-based, flexible, interactive workshop format engaged multidisciplinary participants who frequently had not previously worked together. Participant post-interviews and anecdotal observations suggested that, in a number of cases, the multidisciplinary group assembled for the workshops continued to communicate and in some cases meet, in order to facilitate the management of patients with chronic pain in their region.
The participants also suggested a variety of topics in pain management and other areas in which they thought the ambassador program could be a good mechanism for KT. These include domains where there is great variability in clinical practice which reflects either a lack of generally recognized effective management plans, or a lack of wide adoption of recent scientific advances.
A project such as the ambassador program would best serve the needs of practising clinicians if it were an ongoing professional education service.
As a research team, one of the more important lessons we learned from this project arose from the challenge we encountered to our fundamental approach to our professional work. The research ambassadors thrive on precision and are wary of generalizations that "go beyond the data." The clinical ambassadors, however, are sensitive to the needs of clinicians in busy practices who are seeking simple solutions for what they should do in a given case. The tension between the drive for precision and the need for operational simplicity led to active debates on how to present the evidence-in-brief summaries. It also highlighted the need for all team members to appreciate and honour the professional foundations of their colleagues and to recognize the importance of judicious compromise.
After the workshops were completed, participants continued to download the evidence-in-brief summaries from the project website and made periodic requests for additional workshops and other services from the project team. Clearly a project such as the ambassador program would best serve the needs of practising clinicians if it were an ongoing professional education service. A strategy for sustainability is a clear requirement.
The workshops conducted through the ambassador program have provided support for efforts to create a regional, multidisciplinary chronic pain management program.
A related issue is the "shelf life" of research evidence. Since launching the project, the HTA researchers have updated the literature reviews at four-month intervals. Not surprisingly, at each of these junctures, new systematic reviews were identified which required several of the evidence-in-brief summaries to be substantially updated. This clearly indicates the need for ongoing infrastructure to ensure the latest research evidence is being considered.
Conclusions and implications
We are aware of several examples of how the learnings and experiences from the ambassador program have been incorporated into regional action. The Calgary Health Region, which has an ongoing process for developing care pathways and supports for the care of patients with chronic diseases, has incorporated our evidence-in-brief summaries into the low back pain clinical pathway. In another health region, the workshops conducted through the ambassador program have provided support for efforts to create a regional, multidisciplinary chronic pain management program. In a third health region, the clinicians who were initially brought together for the ambassador workshop are continuing to meet on a regular basis to further their professional education and to develop more integrated clinical services.
While the ambassador program appears to hold significant promise as a KT approach, a number of questions remain unanswered. Chief among these are hard data on whether the participants permanently changed their clinical practices, and, if so, the impacts of these practice changes on tangible patient outcomes. Another question relates to the generalizability of the approach. It could be argued that our team was ideal to conduct such a project since we had both the required breadth of skills and a long history of colleagueship. If the ambassador model is to be adopted in other jurisdictions and to other clinical foci, other teams of researchers and senior clinicians will be needed. These teams will face the challenges of resolving scientific and clinical gaps to develop consensus on how best to communicate practice-relevant research evidence and adopt a successful interactive, flexible teaching style. A longer-term commitment will also be required in order to maintain ongoing educational and support services to community-based clinicians.
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