Surgical implementation gap: an interrupted time series analysis with interviews examining the impact of surgical trials on surgical practice in England

Abstract

ObjectivesLandmark studies published near the turn of the 21st century found an implementation gap concerning the effect of evidenced-based findings on clinical practice. The current study examines the uptake of six trials that produced actionable findings to describe the effects of evidence on practice and the reasons for those effects.DesignA sequential, explanatory mixed methods study was conducted. First, a quantitative study assessed whether actionable findings from large, publicly funded elective surgical trials influenced practice. Subsequently, qualitative interviews were conducted to explain the quantitative findings.SettingChanges in NHS-funded practice were tracked across hospitals in England. Interviews were conducted online.Data and participantsThe six surgical trials were funded and published by England’s National Institute for Health Research’s Health Technology Assessment programme between 2006 and 2015. Quantitative time series analyses used data about the frequencies or proportions of relevant surgical procedures conducted in England between 2001 and 2020. Subsequently, qualitative interviews were conducted with 25 participants including study authors, surgeons and other healthcare staff in the supply chain. Transcripts were coded to identify major temporal events and Consolidated Framework for Implementation Research (CFIR) domains/constructs that could influence implementation. Findings were synthesised by clinical area.ResultsThe quantitative analyses reveal that practice changed in accordance with findings for three trials. In one trial (percutaneous vs nasogastric tube feed after stroke), the change took a decade to occur. In another (patella resurfacing), change anticipated the trial findings. In the third (abdominal aortic aneurysm repair), changes tracked the evolving evidence base. In the remaining trials (two about varicose veins and one about gastric reflux), practice did not change in line with findings. For varicose veins, the results were superseded by a further trial. For gastric reflux, surgical referrals declined as medical treatment increased. The exploratory qualitative analysis informed by CFIR found that evidence from sources apart from the trial in question was mentioned as a reason for non-adoption in the three trials where evidence did not affect practice and in the trial where uptake was delayed. There were no other consistent patterns in the qualitative data.ConclusionWhile practice does not always change in the direction indicated by clinical trials, our results suggest that individuals, official committees and professional societies do assimilate trial evidence. Decision-makers seem to respond to the totality of evidence such that there are often plausible reasons for not adopting the evidence of any one trial in isolation.

Uncertainties and opportunities in delivering environmentally sustainable surgery: the surgeons' view

“…Surgeons are invested in their training and behaviours in theatre, and often worry about the collateral impact of practices on patient safety. Studies suggest that it may take 17 years for practice to change following evidence, with only half of actionable trial findings having an influence on practice, although recent evidence suggests the implementation gap is closing [22]. Implementation considerations need to be built into behaviour change interventions in surgery, with a high‐quality evaluation of safety and patient outcomes to ensure that changes are sustainable and adopted widely [11].…”

Making it happen: engaging the power of many in translating research into practice

“…While there are leaks all along the research-to-practice pipeline, in this issue of the journal, Schmidtke and colleagues have focused on the post-trial implementation of research findings and of factors contributing to the uptake or lack thereof of those findings. 2 Schmidtke and colleagues conducted a sequential, explanatory mixed methods study of six large, publicly funded RCTs in England. 2 They noted that despite these trials being of high quality and adequately powered, only half had their results implemented into practice over a range of 6-14 years.…”

“…2 Schmidtke and colleagues conducted a sequential, explanatory mixed methods study of six large, publicly funded RCTs in England. 2 They noted that despite these trials being of high quality and adequately powered, only half had their results implemented into practice over a range of 6-14 years. Not surprisingly, whether or not the evidence was adopted depended on more than just the research trial methodology.…”

“…Not only does the uptake of evidence take a long time, but even when it does occur, it often does not happen completely. While there are leaks all along the research-to-practice pipeline, in this issue of the journal, Schmidtke and colleagues have focused on the post-trial implementation of research findings and of factors contributing to the uptake or lack thereof of those findings 2…”

“…Based on the authors’ research and on experience, the answer may be to leverage the power of large organisations (outer setting) to create standards and to ensure adherence to those standards. Schmidtke and colleagues noted specifically the importance of official committees and professional societies such as the National Institute for Health and Care Excellence in the UK in assimilating trial evidence and in using evidence-based guidelines to support uptake of research into clinical practice 2. In the USA, the American College of Surgeons (ACS) has a similar role in incentivising individuals and organisations to ‘make things happen’, not just through guideline creation but also through formal clinical accreditation programmes on a broad scale.…”