Transcript The shoulder in pain: current concepts

Knowledge Transfer and Exchange
Denise O’Connor
Australasian Cochrane Centre
The ACC is grateful to the Australian
Department of Health and Ageing for funding
and support
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Acknowledgements
“If I have seen further, it is by standing on the shoulders of Giants”
with thanks to:
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– Isaac Newton
Sally Green
Jeremy Grimshaw
Sue Brennan
Marie Misso
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The Cochrane Collaboration
an international not-for-profit organisation which aims to help
people make well-informed decisions about healthcare by
preparing, maintaining, updating and promoting the accessibility
of systematic reviews of the effects of health care interventions
and effectiveness of diagnostic tests on The Cochrane Library
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The Australasian Cochrane Centre
 we aim to promote the
provision of effective health
care by facilitating
production of systematic
reviews and their
application to influence
service provision and clinical
practice in Australasia
 we facilitate evidence
synthesis
 we facilitate (and are
actively involved in
researching) evidence
implementation
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Outline
 What is knowledge transfer and exchange?
 Why do we need it?
 Overview of conceptual model for KTE and
need for KTE research
 Overview of reviews for KTE interventions
targeting health professionals
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What is knowledge transfer and
exchange?
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Wikipedia: knowledge transfer (no KTE defn)
 Knowledge transfer is the practical
problem of transferring knowledge from
one part of the organization to another
(or all other) parts of the organization. It
seeks to organize, create, capture or
distribute knowledge and ensure its
availability for future users.
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Knowledge transfer and exchange
 Transfer and exchange of knowledge
between relevant stakeholders that results in
action
 The processes from knowledge generation to
action are complex, and influenced by
factors including stakeholder involvement,
local context, perceived relevance, and the
knowledge itself. Knowledge needs to be
contextualized to be meaningful
World Health Organisation
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Knowledge transfer and exchange
 Stakeholders are aware of, and use,
research evidence to inform their
decision making
 Research is informed by current
available evidence and the
experiences and information needs of
stakeholders
Jeremy Grimshaw
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what’s in a name….?
Research utilisation
Knowledge-to-action (KTA)
Knowledge transfer and exchange (KTE)
Knowledge transfer
Knowledge translation
Knowledge exchange
Implementation
Dissemination
Diffusion Bridging the
research-practice
gap
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Why do we need knowledge
transfer and exchange?
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“There is a gap between
today’s scientific advances
and their application:
between what we know
and what is actually being
done. Health work teaches
us with great rigour that
action without knowledge is
wasted effort, just as
knowledge without action is
wasted resource.”
LEE Jong-wook, WHO Director General
Address to 58th World Health Assembly
2005
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“All breakthrough, no follow through”
Woolf (2006). Washington Post.
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(Limited) transfer of research findings into practice
 Variability between research findings
and clinical practice
 30-40% of patients don’t receive
treatments of proven effectiveness
 20-25% of patients receive care that is
unnecessary or potentially harmful
Grol (2001). Medical Care.
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Conceptual model for promoting
knowledge transfer and exchange
and need for KTE research
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Knowledge to Action
loop
From: Graham ID et al.
Lost in Knowledge
Translation: Time for a
Map? Journal of
Continuing Education
in the Health
Professions, 2006
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Changing practice is complex!
 Implementing knowledge (research) into practice
includes both the addition to practice of clinical
actions which are beneficial, and the removing from
practice those which are ineffective or harmful. Both
of these may involve changing clinical practice
 Ironically, most approaches to changing clinical
practice are more often based on beliefs than on
scientific evidence
Grol (1997). British Medical Journal.
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“Evidence-based medicine should
be complemented by
evidence-based implementation”
Grol (1997). British Medical Journal.
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Research in KTE
 concerned with the scientific study of
methods to promote the systematic uptake of
clinical research findings and other evidencebased practices into routine practice, and
hence, to improve the quality and
effectiveness of health care
 it includes the study of influences on health
care professional and organisational
behaviour and of interventions to enable
them to use research findings more effectively
Eccles & Mittman (2006) Implementation Science
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Need evidence
(knowledge
creation
funnels) on
how to do all
of these steps
in the KTE
cycle
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Towards evidence-based implementation
To make evidence-informed decisions about
implementation strategies we need information on:
 likely effectiveness of different interventions to
implement evidence
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direction of effect
predicted effect size of intervention
relative effectiveness of different interventions
may be better if theoretically based
 likely effect modifiers
 context
 type of targeted behaviour
 barriers to change
 resources needed to deliver interventions
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Towards evidence-based implementation
 Rigorous evaluations (mainly RCTs) provide the
best evidence of effectiveness of different
implementation interventions because:
 effects of interventions are modest and so
bias may alter results
 limited understanding of likely confounders
 substantial opportunity costs if ineffective or
inefficient implementation strategies are
used
Eccles (2003) Quality and Safety in Health Care
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Towards evidence-based implementation
 Systematic reviews of rigorous evaluations of
implementation interventions should inform
decisions because they:
 identify and summarise evidence on the
effectiveness of interventions
 include information from multiple studies
 allow the generalisability and consistency of
research findings to be assessed
 allow exploration of data inconsistencies to
be explored
Mulrow (1994) British Medical Journal
Grimshaw (2003) Quality and Safety in Health Care
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Overview of systematic reviews for KTE
interventions targeting health
professionals
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Cochrane Effective Practice and Organisation of
Care (EPOC) Group
Aims to undertake systematic
reviews of interventions to
improve health care systems
and health care delivery
including:
 Professional interventions
 Financial interventions
 Organisational interventions
 Regulatory interventions
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EPOC Australian Satellite
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Based at National Institute of Clinical Studies (NICS)
Russ Gruen (Director & Editor) and Emma Tavender (Co-ordinator)
Identify and produce EPOC reviews relevant to region
Provide training and mentoring for authors and users of EPOC reviews
in region
Foster a culture of KTE with other CC entities
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Overview of reviews of professional behaviour
change strategies
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Overview of reviews of professional behaviour
change strategies
 Previous overviews:
 Bero 1998 (18 systematic reviews)
 Grimshaw 2001 (41 systematic reviews)
 EPOC is undertaking an overview of professional,
organisational, financial and regulatory interventions – to
date identified 300-400 Cochrane and non Cochrane
reviews
 Identified over 150 systematic reviews of professional
behaviour change interventions
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Overview of reviews of professional behaviour
change strategies
Educational materials
Educational meetings
Educational outreach
Audit and feedback
Opinion leaders
Mass media
Reminders – general
Reminders – Computer
assisted drug dosage
 Tailored interventions
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Prescribing – general
Prescribing - safety
Changing roles – nursing
Changing roles – pharmacy
Financial
Regulatory
General
Multifaceted interventions
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Overview of reviews of professional behaviour
change strategies
Educational materials
Educational meetings
Educational outreach
Audit and feedback
Opinion leaders
Mass media
Reminders – general
Reminders – Computer
assisted drug dosage
 Tailored interventions
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Prescribing – general
Prescribing - safety
Changing roles – nursing
Changing roles – pharmacy
Financial
Regulatory
General
Multifaceted interventions
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Local opinion leaders
 Use of providers nominated by their
colleagues as ‘educationally influential’.
The investigators must have explicitly
stated that their colleagues identified
the opinion leaders
 Target peer group knowledge, attitudes
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Local opinion leaders
Doumit (2007) The Cochrane Library
 High quality review
 12 studies (RCT, CCT)
 Generally effective for improving appropriate
care
 Median effect across studies +10% absolute
improvement
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Summary from Overviews of reviews
 Over 150 systematic reviews of interventions to change
health professional behaviour
 Most interventions appear to be effective with average
effects between 5-10% absolute improvement in care
 However ‘No Magic Bullets’ – effects of interventions
appear to vary across targeted behaviours, professional
groups and settings
 Feasibility and resources required for interventions also
likely to vary
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Final points
 Knowledge transfer and exchange is necessary
(considering limits on health care resources) and
possible but needs to be informed by research
 The KTE evidence base is growing, but has a way
to go before it can provide practical guidance to
decision makers regarding which interventions to
use, in which contexts and how to optimise them
 Over to you: in what way will you contribute?
 Knowledge creation (generate knowledge about
what to implement or how to implement it)
 Participate in/facilitate the action cycle
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