Sharon Straus TEACH 2010-1

Sharon E. Straus MD MSc FRCPC Director, KT Program

St. Michael’s Inspired Care Inspiring Science

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To describe what KT is and isn’t To provide a framework for knowledge translation

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1/3 patients do not get treatments of proven effectiveness

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1/4 patients get care that is not needed or potentially harmful

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Up to 3/4 of patients don’t get the information they need for decision making

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Up to 1/2 of clinicians don’t get the information they need for decision making

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Evidence-based medicine should be complemented by evidence-based implementation ď‚– Grol, BMJ 1997

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Transforming health research into action

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Commercialisation

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Bench to bedside

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Translational research

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Continuing education

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Continuing professional development

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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 â—Ś CIHR definition

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Applied dissemination

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Research utilisation

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Implementation

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Evidence uptake

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Effective dissemination

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Diffusion

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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… ◦ McKibbon et al, Impl Sci 2010, 5:16

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Describes a way of doing research with researchers and research users working together to shape the research process

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Starts with collaboration on setting the research question through to completion of the study and dissemination of its results

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Should produce research findings that are more likely relevant to and used by the end users

Monitor Knowledge Use

ge led

Synthesi s Adapt Knowledge to Local Context

Evaluate Outcomes

Kno w

Knowledge Inquiry

Tai lor

Assess Barriers/Facilitators to Knowledge Use

KNOWLEDGE CREATION

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Select, Tailor, Implement Interventions

Product s/ Tools

Identify Problem Identify, Review, Select Knowledge

Sustain Knowledge Use

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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

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Knowledge that is implemented should be based on best available evidence â—Ś For therapy/management issues this should be systematic reviews of randomised trials or single, large randomised trials â—Ś For diagnostic issues this should be systematic reviews of high quality cohort studies comparing test of interest with reference standard

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Felt needs: what people say

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Expressed needs: expressed in actions

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Normative needs: defined by experts

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Comparative needs: group comparison

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Individual vs. organisational needs

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Subjective vs. objectively measured needs

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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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Requires involvement of end-users of knowledge

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Contextualise to local environment

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www.adapte.org

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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.

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They did a local study showing that less than 40% of these people get assessed for osteoporosis or falls risk â—Ś What are the potential barriers and facilitators to implementation of OP and falls risk assessment and management guidelines?

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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  JAMA 1999;282:1458-65

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Extended to include facilitators  Patient Educ Couns 2006;63;380-90

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Similar taxonomies of barriers to implementation of research by nurses  J Eval Clin Pract 2006;12:639-51

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Common barrier: ◦ Time

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Common facilitator: ◦ Need to maintain licensure and certification

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8.1% dissemination of educational materials(4)

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7.0% audit and feedback (5)

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14.1% reminders (14)

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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

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Grimshaw JM, et al. Health Technol Assess 2004;8(6)1-72

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Link the intervention to the barriers and facilitators

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Use knowledge about what may work

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We don’t know the ‘dose’ or ‘formulation’ yet

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Type of knowledge use: ◦ Instrumental/concrete

 e.g. prescribing of warfarin in patients with atrial fibrillation

◦ Conceptual

 e.g. provider attitudes about evidence

◦ Symbolic

 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

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RCT

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ITS

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Controlled before and after study

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Qualitative study ◦ Investigate the active ingredients

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Post-implementation surveillance of the intervention, outcomes and the health care system

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May require modification of the intervention ◦ And assessment of barriers/facilitators

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Requires ongoing engagement with relevant end-users

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Consider: ◦ Who are the stakeholders ◦ What are the threats to sustainability:  Human resources  Process  Organisational

◦ How can we engage all the relevant stakeholders to facilitate sustainability

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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.

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Existing evidence for management of osteoporosis available ◦ Age and Ageing 2009;38:723-30

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They engaged primary care clinicians, general internists, pharmacists and rehabilitation therapists

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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, lack of knowledge of significance of OP…

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Randomised trial of a multi-component educational intervention aimed at enhancing implementation of falls and osteoporosis management strategies for high-risk patients

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Randomised 201 patients to immediate intervention or delayed intervention

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Patients in the delayed intervention group were offered the intervention at 6 months

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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

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Nurse completed the Berg Balance Scale, InterRai Screener, medication review and checked for orthostatic hypotension

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BMD ordered and results sent to PCP with relevant prescribing information based on Osteoporosis Society of Canada guidelines

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Similar information given to patient

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Primary outcome: ◦ Appropriate use of osteoporosis ◦ Falls risk management at 6 months

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Secondary outcomes: ◦ Appropriate use of management at 12 months ◦ Falls ◦ Fractures

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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 2.07 [95% CI 1.07 to 4.02])

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Quality of life enhanced in intervention group

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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

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Common sense KT â—Ś Not every piece of research needs an elaborate, multicomponent KT strategy

◦ KT Seminar Series ◦ KT Consultation Service ◦ KT Basics Course and End of Grant KT Course ◦ http://ktclearinghouse.ca ◦ Knowledge Translation in Health Care. Eds Straus, Tetroe, Graham. Wiley 2009