Transcript Lost in knowledge translation: Finding a way to write ‘the

Lost in knowledge
translation: Finding a
way forward
Sharon E. Straus MD MSc FRCPC
St. Michael’s Hospital
University of Toronto
Objectives
To outline end-of-grant KT versus
integrated KT
 To provide a framework for knowledge
translation
 To describe KT Canada

Confusion about what KT is
Transforming health research into action
 Commercialisation
 Bench to bedside
 Translational research
 Continuing education
 Continuing professional development

What is knowledge translation?

Knowledge translation is a dynamic and
iterative process that includes synthesis,
dissemination, exchange and ethically
sound application of knowledge to improve
the health of Canadians, provide more
effective health services and products and
strengthen the health care system
 CIHR
 Adopted
by WHO
Knowledge to action
Confusion about what it’s called







Applied dissemination
Research utilisation
Implementation
Evidence uptake
Effective
dissemination
Diffusion
Information
dissemination and
utilisation





Knowledge adoption
Knowledge synthesis,
transfer and
exchange
Knowledge linkage
and exchange
Research into
action/practice
Translating research
into practice
It is in the CIHR mandate:
…
Two broad types
of KT at CIHR
End of grant KT
 The researcher develops and implements a plan
for making knowledge users aware of the
knowledge generated through a research project
Integrated KT
 Research approaches that engage potential
knowledge users as partners in the research
process
 Requires a collaborative or participatory
approach to research that is action oriented and
is solutions and impact focused
 For example, the knowledge user partner helps
to define the research question and is involved
in interpreting and applying the findings
End-of-grant KT

Typical dissemination and communication
activities undertaken by most researchers:
 KT
to peers such as conference presentations
and publications in peer-reviewed journals

End of grant KT can involve
 more
intensive dissemination activities that
tailor the message and medium to a specific
audience
 more interactive approaches such as
educational sessions with patients,
practitioners and/or policy makers
Framework for more interactive
dissemination:





Who are the end users of the research and who
will be interested in knowing the results?
What are the key messages?
Who are the principal target audiences for each
of these messages?
Who is the most credible messenger for these
messages and how do we engage them in
communicating these messages?
What KT strategy will we use?
An example

Project to explore impact of mentorship for
clinician scientists
 Completed
systematic reviews of mentorship
interventions and of factors influencing academic
career choice, and a qualitative study of mentorship

Who would be interested in these results?
 Funders,
Department Chairs, University Admin,
Researchers, Trainees

JCEHP 2008;28(3):117-22; Acad Med 2009;84(1):135-9
What are the key messages?



We brought together a stakeholder group to
discuss the results of the research and develop
key messages
1.5 day workshop with funders, university
administrators, clinician scientists at various
stages of their career, experts in mentorship
Discussion groups focused on contextualising
the evidence and discussing barriers to use in
the local setting
Key messages

Mentorship strategies




Educational interventions


Academic institutions need to establish a format to find a mentor
Department Chairs should support the creation of mentorship
facilitators/champions
Team mentorship (including mentorship at a distance) should be
considered
For mentors and mentees to be implemented by facilitators
Role of AHFMR


Should enhance accountability of ‘mentorship’ component of the
career awards
Should include mentorship in all career awards
Who are the principal target
audiences for each message?
Administrators at Universities, VP
Research
 Department Chairs
 Researchers (mentors and mentees)
 Chairs of Research Institutes
 AHFMR

Who is the most credible
messenger for each message?

University administrators – we had a Vice Dean
in our group who tackled this
2


of us also met regularly with the VP Research
Department chairs – we identified local
champions for mentorship amongst department
chairs
AHFMR assisted with this process and worked
to engage administrators
Examples of our strategies
Target Audience
Barriers
KT Strategy
Administrators (VPs of
Research)
Lack of time
Written summary of key
messages; academic
detailing conducted
in person by
researchers
Department Chairs
Lack of capacity
Identify local
champions/opinion
leaders; academic
detailing
Researchers
(mentors/mentees)
Lack of time
Lack of capacity
Lack of tools
Mass media: use of
existing university
newsletters,
electronic magazines,
websites; Creation of
workshops
Integrated KT
Describes a way of doing research with
researchers and research users working
together to shape the research process
 Starts with collaboration on setting the
research question through to completion of
the study and dissemination of its results
 Should produce research findings that are
more likely relevant to and used by the
end users

An Example




The mentorship project was launched because
of discussions between researchers and funders
The qualitative study was done in response to a
need identified by the funder
This was an example of integrated KT with end
of grant KT
It has also led to a larger, multicentre study of
mentorship
2 Frameworks inform the science
and practice of KT
Knowledge to Action cycle
 MRC Framework for evaluating complex
interventions

Knowledge-to-Action Cycle
Monitor
Knowledge
Use
Select, Tailor,
Implement
Interventions
Assess
Barriers to
Knowledge Use
KNOWLEDGE CREATION
Knowledge
Inquiry
Synthesis
Adapt
Knowledge
to Local Context
Evaluate
Outcomes
Products/
Tools
Sustain
Knowledge
Use
Identify Problem
Identify, Review,
Select Knowledge
Graham et al., 2006
MRC framework for assessing
complex interventions

Phase 1: Defining the intervention
 Theoretical
basis for the intervention,
components

Phase 2: Exploratory Phase
 Acceptability
and feasibility of delivering the
intervention

Phase 3: Explanatory Phase
 Rigorous

evaluation
Phase 4: Pragmatic Phase
 Post-implementation
surveillance
EPOCare
EPOCare: The challenges
We need information
 We don’t get what we need from the
resources that we use
 We have different information needs


90% of searches
were successful
 52%
confirmed
management
 23% led to changes in
management
 25% led to additional
decisions

But cart was too big!

JAMA 1998;280:1336-8
The Next Step: Phase 1
Needs assessment of general internists,
family physicians and housestaff
through surveys and focus groups
 42% of staff physicians and 70% of
housestaff have a PDA
 Clinicians primarily use PDAs for
scheduling and storing
addresses/telephone numbers

Phase 2: Our approach and challenges
PalmPilot Xybernaut
Blackberry
iPAQ


Wireless server
Formatter

XML Server
Clinical
Evidence
Acute
Medicine
Gov’t
Guidelines
What kinds of info are
most useful to clinicians?
What is the most
effective way of querying
evidence-based
resources?
How do we format
answers?

Adapted knowledge to local context
 Completed
studies to determine how
clinicians wanted evidence presented
 Completed in rural and urban settings
Human Factors in Telecommunication 2006;S42-6
 Human Factors and Ergonomics Proceedings, 2003

The 2 second, 2 minute or 2
hour answer
Which search style would you use?
Barriers and Facilitators

Completed usability testing and direct
observation of target groups of clinicians
to understand workflow

BMC Med Inf Dec Mak 2007;7:22
Results: Form Factors
Family physicians wanted larger screen
size and were less concerned with
portability
 General internists wanted portability
 Medical residents wanted portability and
larger screen size

Phase 3: Evaluation



Pilot study of the use of mobile computers to
determine their impact on patient care
Completed on an inpatient GIM service at the
University Health Network
Assessed:
 use
of resources
 impact of evidence on decisionmaking
 usability of PDAs on a busy internal medicine service
Results: Use of evidence
Resources most commonly used between
5pm and 8am (80% of visits)
 59% of queries resulted in changes to the
way they thought about the issue or in
changes to their management plan

Results: Form factors
Tables and bullet points were the
preferred format for presentation of
information
 Wanted more wireless access points
 Worst thing about the devices – their size

Next Steps
Assessing Blackberrys which will provide
access to evidence resources, decision
support and the electronic health records
 On GIM inpatient units – randomisation of
teams
 Impact on response time, team
communication, access to evidence

FORCE Study
Local public health agency has been
working with the home care agency and a
patient advocacy group because they
noticed a problem with admissions to
hospital in older adults with falls and
fractures.
 Existing evidence for management of
osteoporosis available

 Age
and Ageing 2009;1-7
They engaged primary care clinicians,
general internists, pharmacists and
rehabilitation therapists
 They did a local study showing that less
than 40% of these people get assessed for
osteoporosis or falls risk
 Identified barriers and facilitators to
adaptation of the evidence

 Lack
of primary care clinicians; lack of referral
to specialists…
FORCE Study
Randomised trial of a multi-component
educational intervention aimed at
enhancing implementation of falls and
osteoporosis management strategies for
high-risk patients
 Randomised 201 patients to immediate
intervention or delayed intervention
 Patients in the delayed intervention group
were offered the intervention at 6 months

Force Study

Patients were eligible for inclusion in the
study if they were:

community-dwelling,
 aged 55 years or older,
 able to give informed consent, and
 were identified to be at high risk for
osteoporosis or falls
Intervention
Nurse completed the Berg Balance Scale,
InterRai Screener, medication review and
checked for orthostatic hypotension
 BMD ordered and results sent to PCP with
relevant prescribing information based on
Osteoporosis Society of Canada
guidelines
 Similar information given to patient

Outcomes

Primary outcome:
 Appropriate
use of osteoporosis
 Falls risk management at 6 months

Secondary outcomes:
 Appropriate
 Falls
 Fractures
use of management at 12 months
Results

Appropriate OP therapy
 56%
of IP group vs. 27% of DP group at 6
months (RR 2.09 [95% CI 1.29 to 3.40])
 At 12 months, there was no difference
between the 2 groups

Number of falls in IP group was greater at
12 months
 (RR

2.07 [95% CI 1.07 to 4.02])
Quality of life enhanced in intervention
group
Fracture Prevention – Monika Kastner
FORCE study identified role for selfmanagement
 We are creating self-management tools for
patients with chronic diseases
 BestPrompt

 Osteoporosis
risk management tool for
patients and providers
Development of the intervention

MRC Framework:
 Systematic
review of computerised disease
management tools in osteoporosis

JGIM 2008;23(12):2095-105
 Iterative

process of design, test and revise
JAMIA (in press)
 Evaluation

underway
of the intervention
KT Canada




Creating new knowledge about how best to
achieve KT across different decision maker
groups;
Advancing the theory and methods of KT;
Developing, testing, and commercialising tools
and services aimed at sustaining KT; and
Working with partners across the continuum of
care to effect KT.
KT Canada

4 interlinked research programs that are
directly aligned with the knowledge-to-action
loop
 Knowledge
distillation
 Determinants of knowledge use
 Selecting, tailoring and evaluating effectiveness and
efficiency of KT interventions, and
 Sustaining KT

Targeting 3 key stakeholder groups
Training Initiative



Provide outstanding, innovative training centres
and laboratories for trainees from various
research disciplines to develop skills in KT and
KT research;
Link trainees and mentors to collaboratively
advance the science and practice of KT; and,
Partner with other national and international
research groups to promote KT research and
training
Training Initiative



Stream 1. graduate (MSc and PhD) and
advanced (post-doctoral) training in the science
of KT research;
Stream 2. training in the basic principles of KT
and KT research for researchers from other
areas; and,
Stream 3. basic training in KT for any knowledge
users interested in enhancing their knowledge
and skills for practising KT.

Join Us
 KT
Seminar Series
 http://ktclearinghouse.ca
 Knowledge Translation in Health Care. Eds
Straus, Tetroe, Graham. Wiley 2009