Transcript Knowledge translation: What it is and what it isn’t

Frameworks for Knowledge
Translation
Sharon E. Straus MD MSc FRCPC
Director, KT Program
Li Ka Shing Knowledge Institute
St. Michael’s Hospital
University of Toronto
Objectives
To increase our understanding of what
knowledge translation is and isn’t
 To suggest a framework for knowledge
translation
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Care Gaps
1/3 patients do not get treatments of
proven effectiveness
 1/4 patients get care that is not needed or
potentially harmful
 Up to 3/4 of patients don’t get the
information they need for decision making
 Up to 1/2 of clinicians don’t get the
information they need for decision making
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Care gaps
Gaps between research evidence and
clinical practice leads to practice variation
 Knowledge creation, distillation and
dissemination are not sufficient to ensure
implementation
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‘Evidence based medicine should be
complemented by evidence based
implementation’
Grol (1997). British Medical Journal.
Confusion about what KT is
Transforming health research into action
 Commercialisation
 Bench to bedside
 Translational research
 Continuing education
 Continuing professional development
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Confusion about what it’s called
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Applied dissemination
Research utilisation
Implementation
Evidence uptake
Effective dissemination
Diffusion
Information dissemination and
utilisation
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Knowledge adoption
Knowledge synthesis, transfer
and exchange
Knowledge linkage and
exchange
Research into action/practice
Translating research into
practice
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McKibbon et al, Impl Sci (in
press)
It is in the CIHR mandate:
…
What is knowledge translation?
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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
Science of Knowledge Translation
 Practice of Knowledge Translation
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Two broad types of KT at CIHR
End of grant KT
Integrated KT
 The researcher develops and implements a plan
for making knowledge users aware of the
knowledge generated through a research project
 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
End-of-grant KT
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Typical dissemination and communication
activities undertaken by most researchers:
 KT
to peers such as conference presentations and
publications in peer-reviewed journals.
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End of grant KT can involve
 more
intensive dissemination activities that tailor the
message and medium to a specific audience, such as
briefs to stakeholders;
 more interactive approaches such as educational
sessions with patients, practitioners and/or policy
makers; media engagement or the use of knowledge
brokers.
Framework for more interactive
dissemination:
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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?
Integrated KT
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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
Also known by such terms as collaborative
research, action-oriented research, and coproduction of knowledge
Should produce research findings that are more
likely relevant to and used by the end users.
Monitor
Knowledge
Use
Select, Tailor,
Implement
Interventions
Assess
Barriers/Facilitators to
Knowledge Use
KNOWLEDGE CREATION
Knowledge
Inquiry
Synthesis
Adapt
Knowledge
to Local Context
Evaluate
Outcomes
Products/
Tools
Identify Problem
Identify, Review,
Select Knowledge
Sustain
Knowledge
Use
An example
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Your local public health agency has been
working with the home care agency and a
patient advocacy group because they have
noticed a problem with admissions to hospital in
older adults with falls and fractures.
They did a local study showing that less than
40% of these people get assessed for
osteoporosis or falls risk
 What
strategies could you implement to address this?
Measuring the gap: Needs
assessment
Standardised assessment exercises
 Knowledge questions
 Chart audits, chart stimulated recall
 Interviews
 Focus groups
 Observation: Direct, video, use of SPs
 Administrative Data, Clinical data
 Reflection on practice
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Adapting knowledge to local
context
Requires involvement of end-users of
knowledge
 Contextualise to local environment
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Barriers and strategies to
overcome the gap
An example

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Your local public health agency has been
working with the home care agency and a
patient advocacy group because they have
noticed a problem with admissions to hospital in
older adults with falls and fractures.
They did a local study showing that less than
40% of these people get assessed for
osteoporosis or falls risk
 What
strategies could you implement to address this?
Barriers and Facilitators to KTA
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Systematic review of barriers to implementation
of guidelines by physicians
 Identified
>250 barriers including awareness of
existing guidelines, absence of external barriers to
implementation, time
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Extended to include facilitators
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JAMA 1999;282:1458-65
Patient Educ Couns 2006;63;380-90
Similar taxonomies of barriers to implementation
of research by nurses
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J Eval Clin Pract 2006;12:639-51
KTA Strategies
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8.1% dissemination of educational materials (4)
7.0% audit and feedback (5)
14.1% reminders (14)
6.0% educational outreach (13)
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Most interventions had modest effects on care
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Number of components has no impact
Grimshaw JM, et al. (2004) Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol
Assess 8(6)1-72.
MRC framework for assessing
complex interventions
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Phase 1: Defining the intervention
 Theoretical
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basis for the intervention, components
Phase 2: Exploratory Phase
 Acceptability
and feasibility of delivering the
intervention
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Phase 3: Explanatory Phase
 Rigorous
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evaluation
Phase 4: Pragmatic Phase
 Post-implementation
surveillance
Selecting the KTA strategy
Link the intervention to the barriers and
facilitators
 Use knowledge about what may work
 We don’t know the ‘dose’ or ‘formulation’
yet
 CME:
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 Large
group vs. small group
 Didactic vs. interactive
 Multiple components/methods vs. single
Measuring impact of knowledge
use
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Type of knowledge use:
 Instrumental/concrete
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e.g. prescribing of warfarin in patients with atrial
fibrillation
 Conceptual
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e.g. provider attitudes about evidence
 Symbolic
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e.g. given your knowledge of the evidence around
inappropriate use of restraints on older medical
inpatients, you convince the nurse manager to
develop a ward-based protocol on restraint use
Evaluating the impact of knowledge
use
RCT
 ITS
 Controlled before and after study
 Qualitative study
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 Investigate
the active ingredients
Sustaining knowledge use
Post-implementation surveillance of the
intervention, outcomes and the health care
system
 May require modification of the
intervention
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 And
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assessment of barriers/facilitators
Requires ongoing engagement with
relevant end-users
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
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 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
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 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
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Force Study
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Patients were eligible for inclusion in the
study if they were:
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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
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Outcomes
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Primary outcome:
 Appropriate
use of osteoporosis
 Falls risk management at 6 months
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Secondary outcomes:
 Appropriate
 Falls
 Fractures
use of management at 12 months
Results
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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
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Number of falls in IP group was greater at
12 months
 (RR
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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
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 Osteoporosis
risk management tool for
patients and providers
Development of the intervention
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MRC Framework:
 Systematic
review of computerised disease
management tools in osteoporosis
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JGIM 2008;23(12):2095-105
 Iterative
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process of design, test and revise
JAMIA (in press)
 Evaluation
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underway
of the intervention
Some KT Resources
KT Seminar Series
 KT Clearinghouse
http://ktclearinghouse.ca
 KT Consultation Service
 KT Basics Course
 Knowledge Translation in Health Care.
Eds Straus, Tetroe, Graham. Wiley, 2009
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