Knowledge Into Action Dave Murday Center for Health Services

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Knowledge Into ActionDave MurdayCenter for
Health Services Policy Research

• Translating Research into
• Policy Practice

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Health Disparities

• Racial and ethnic minorities continue to carry an
  unequal share of disease burden and deaths for
  various health conditions in South Carolina
• Death rates among minorities for both cancer and
  heart disease are nearly 1.5 times that of
  whites.
• Racial and ethnic minorities are more than 3
  times more likely to die of diabetes and are 2
  times more likely to die of stroke than whites.
• DHEC Healthy People Living in Healthy
  Communities (2008)

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RAND/McGlynn 2003 Study
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RAND/McGlynn 2003 Study
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RAND/McGlynn 2003 Study
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RAND/McGlynn 2003 Study

• Overall, participants received about half of the
  recommended processes involved in care.
• Deficits in processes involved in primary and
  secondary preventive care are also associated
  with preventable deaths.
• The gap between what we know works and what is
  actually done is substantial enough to warrant
  attention.

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Knowledge Into Action

• Quality health care that is effective,
  efficient, up-to-date, and timely.
• Providing the right care, at the right time, for
  the right person, in the right way.
• Up to two decades may pass before research
  findings become part of routine clinical
  practice, if ever.

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Institute of Medicine (2003)

• Unequal Treatment Confronting Racial and Ethnic
  Disparities in Health Care
• Racial and ethnic minorities tend to receive a
  lower quality of healthcare than non-minorities,
  even when access-related factors, such as
  patients insurance status and income, are
  controlled.

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Institute of Medicine (2003)

• As in the case of studies of cardiovascular
  disease, evidence suggests that disparities in
  cancer care are associated with higher death
  rates among minorities.

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Klonoff (2009)

• Despite almost 30 years of recognition that there
  exist real differences in the treatment being
  provided to patients based on their ethnicity or
  racial group, there is still little understanding
  of the factors that underlie these differences.

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Klonoff (2009)

• While some evidence suggests that the gaps are
  narrowing, other data suggest that differences
  still exist for very serious procedures and
  treatments, and that these differences could
  contribute to differential mortality and
  morbidity.

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Knowledge Into Action

• Three stories
• Clemson Extension
• Popular Mechanics Article
• Flossing teeth

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American Heart Association
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Knowledge Into Action

• Three Initiatives
• AHRQ Translating Research Into Practice (TRIP)
• NIH Roadmap Centers for Clinical Translational
  Research
• Canadian Institute of Health Research Knowledge
  Translation (KT)

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AHRQ Framework
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AHRQ TRIP Barriers

• Competing priorities
• Lack of buy-in
• Dont believe change is necessary
• Dont believe intervention is effective
• Lack skills, resources needed to implement
• Aspects of intervention were unacceptable locally

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Other Barriers

• Physician level not knowing guidelines exist,
  disagreeing with content, blame patient
• Patient level beliefs, time, trust, financial
  limitations
• System level patient volume, resource
  constraints, not having right information at
  right place and time
• Clinical inertia

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Strategies

• Performance gap assessment
• Continuing education
• Academic detailing/educational outreach
• Audit and feedback
• Decision support/alerts/reminders
• Opinion leaders/change champions
• Continuous quality improvement

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AHRQ TRIP

• Knowledge into action is linear
• Scientific discovery
• Synthesis
• Dissemination
• Develop guidelines/best practices/treatment
  protocols
• Implementation of performance indicators
• Quality improvement

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Clinical and Translational Science Award (CTSA)
Consortium

• Led by the National Center for Research Resources
  (NIH/NCRR), this national network of medical
  research institutions is working together to
  accelerate the process of turning laboratory
  discoveries into treatments for patients, to
  engage communities in clinical research efforts,
  and to train the next generation of clinical and
  translational researchers.

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NIH CTSAs

• 39 CTSA centers so far, 60 by 2012, MUSC likely
  this year
• Accelerate the movement of scientific findings
  into practice via translational research
• Two types of translational research
• T1 (bench to bedside)
• T2 (bedside to community)
• Linear model

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NIH CTSAs

• T1 translational research (ID new treatment)
• Basic science (bench science, animal studies)
• Pilot studies
• Efficacy trials (traditional clinical trials)
• T2 translational research
• Effectiveness trials (real world
  patients/settings)
• Dissemination research (conditions that support
  or impede adoption of new interventions)

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Institute of Medicine

• T1 - The transfer of new understandings of
  disease mechanisms gained in the laboratory into
  the development of new methods for diagnosis,
  therapy, and prevention and their first testing
  in humans.
• T2 - The translation of results from clinical
  studies into everyday clinical practice and
  health decision making.

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NIH CTSAs

• CTSAs are more skewed toward T1
• Biomedical funding is more skewed toward T1
• Grant mechanisms, academic incentives and
  training all geared toward T1 research
• T2 struggles more with human behavior and
  organizational inertia, resource constraints, and
  the messiness of proving the effectiveness under
  conditions that investigators cannot fully
  control.

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CIHR Knowledge Translation

• KT goes beyond dissemination and diffusion, is an
  ongoing and iterative process that requires the
  active participation of both researchers and
  research users (policy, practice)
• Bringing decision makers who can use the results
  of a particular piece of research into its
  formulation and conduct is the best predictor for
  seeing the findings applied

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CIHR Knowledge Translation

• Research can have an impact on
• Agenda-setting,
• Policy formulation
• Implementation
• Evaluation
• Research findings must be translated into
  information that is meaningful to practitioners.

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CIHR Knowledge Translation

• Push, to signify that researchers need to do a
  better job of communicating their results to the
  world of practice
• Pull, to signify that practice organizations need
  to become more evidence-based in their policy
  making and
• Exchange, to signify that, from the beginning,
  research is designed to be attentive to the needs
  of practice

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CIHR Knowledge Translation

• KT involves an active exchange of information
  between the researchers who create new knowledge
  and those who use it.
• KT strategies and activities vary according to
  the type of research to be translated (e.g.,
  biomedical, clinical, health services and policy
  or population and public health) and the intended
  audience (e.g., other researchers, front-line
  practitioners, health system managers,
  policy-makers or the general public).
• Bringing users and creators of knowledge together
  during all stages of the research cycle is
  fundamental to successful KT.

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Canadian KT Model
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Two Stage Knowledge to Action

• Knowledge Creation Cycle
• Knowledge comes from many sources and includes
  clinical and personal experience as well as
  research.
• Knowledge is sifted through filters, becoming
  more distilled and more useful to stakeholders.
• It moves from inquiry (asking the right
  questions), through synthesis (pulling together
  research and information from other sources), to
  products (delivering the right information in the
  right format).
• In the final phase, guidelines and decision aids
  are designed and distributed to influence the
  behavior of stakeholders.

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Two Stage Knowledge to Action

• Action Cycle
• Identify a problem that needs addressing
• Identify, review, and select knowledge relevant
  to the problem
• Adapt this knowledge to the local context
• Assess the barriers to using the knowledge
• Design transfer strategies to promote use of
  knowledge
• Monitor knowledge diffusion throughout the user
  group
• Evaluate the impact of the users application of
  the knowledge and
• Sustain the ongoing use of knowledge by users.

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Obama Science of Change

• Time Magazine, April 2, 2009
• Consortium of Behavioral Scientists
• "A Record Turnout Is Expected."
• The most powerful motivator for hotel guests to
  reuse towels, national-park visitors to stay on
  marked trails and citizens to vote is the
  suggestion that everyone is doing it.

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Obama Science of Change

• "People want to do what they think others will
  do, the Obama campaign really got that.
• "It was amazing to have these bullet points
  telling us what to do and the science behind it.
• Obama is betting his presidency on our ability to
  change our behavior. His top priorities the
  economy, health care and energy all depend on
  it.

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Obama Science of Change

• Basically, we need to make better choices about
  mortgages and credit cards, insurance and
  retirement plans so we won't need bailouts down
  the road.
• The problem, as anyone with a sweet tooth, an
  alcoholic relative or a maxed-out Visa card
  knows, is that old habits die hard.

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Obama Science of Change

• We've got plenty of gurus, talk-show hosts and
  celebrity spokespeople badgering us to save
  energy, lose weight and live within our means,
  but we're still addicted to oil, junk food and
  debt.
• It's fair to ask whether we're even capable of
  changing.