Sharon E. Straus MD MSc FRCPCDirector, KT Program

St. Michael’sInspired CareInspiring Science

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

translation

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

Evidence-based medicine should be complemented by evidence-based implementation

Grol, BMJ 1997

Transforming health research into action Commercialisation Bench to bedside Translational research Continuing education Continuing professional development

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 definition

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…◦ McKibbon et al, Impl Sci

2010, 5:16

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

MonitorMonitorKnowledgeKnowledge

UseUse

SustainSustainKnowledgeKnowledge

UseUse

EvaluateEvaluateOutcomesOutcomes

AdaptAdaptKnowledgeKnowledge

to Local Contextto Local Context

AssessAssessBarriers/Facilitators to Barriers/Facilitators to

Knowledge UseKnowledge Use

Select, Tailor,Select, Tailor,ImplementImplement

InterventionsInterventions

Identify ProblemIdentify Problem

Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge

ProductProducts/s/

ToolsTools

SynthesSynthesisis

KnowledgKnowledge Inquirye Inquiry

Tailo

ring K

nowle

dge

KNOWLEDGE CREATIONKNOWLEDGE CREATION

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

Knowledge that is implemented should be based on best available evidence◦ For therapy/management issues this should be

systematic reviews of randomised trials or single, large randomised trials

◦ For diagnostic issues this should be systematic reviews of high quality cohort studies comparing test of interest with reference standard

Felt needs: what people say Expressed needs: expressed in actions Normative needs: defined by experts Comparative needs: group comparison Individual vs. organisational needs Subjective vs. objectively measured needs

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

Requires involvement of end-users of knowledge

Contextualise to local environment www.adapte.org

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 are the potential barriers and facilitators to

implementation of OP and falls risk assessment and management guidelines?

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 Extended to include facilitators

Patient Educ Couns 2006;63;380-90 Similar taxonomies of barriers to

implementation of research by nurses J Eval Clin Pract 2006;12:639-51

Common barrier:◦ Time

Common facilitator:◦ Need to maintain licensure and certification

8.1% dissemination of educational materials(4) 7.0% audit and feedback (5) 14.1% reminders (14) 6.0% educational outreach (13) Most interventions had modest effects on care Number of components has no impact Grimshaw JM, et al. Health Technol Assess 2004;8(6)1-72

Link the intervention to the barriers and facilitators

Use knowledge about what may work We don’t know the ‘dose’ or ‘formulation’

yet

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

RCT ITS Controlled before and after study Qualitative study

◦ Investigate the active ingredients

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

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

Requires ongoing engagement with relevant end-users

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

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;38:723-30

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, lack of knowledge of significance of OP…

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

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

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

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

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

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

FORCE study identified role for self-management

We are creating self-management tools for patients with chronic diseases

BestPrompt◦ Osteoporosis risk management tool for patients

and providers

Common sense KT◦ 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