Knowledge infrastructure for KT

1
Knowledge infrastructure for KT

• Jeremy Grimshaw MD, PhD
• Clinical Epidemiology Program, OHRI
• Department of Medicine, University of Ottawa
• Canada Research Chair in Health Knowledge
  Transfer and Uptake

2
Personal background

• Trained as family doctor in UK
• PhD in health services research
• Developed implementation research program in UK
• Moved to Canada in 2002

3
Personal perspective

• Focus has been on
• professional and organizational behavior change.
• improving technical aspects of care ie how do we
  ensure patients get the right (evidence based)
  treatments at the right time.
• populations of physicians and health care
  organizations.

4
Outline

• KT
• K for KT
• KI (Infrastructure) for KT

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• KT
• Whats in a name

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KT terms encountered

• applied health research
• capacity building
• co-optation - cooperation - competing
• diffusion
• dissemination
• getting knowledge into practice
• impact
• Implementation
• knowledge communication
• knowledge cycle
• knowledge exchange
• knowledge management
• knowledge translation

• knowledge mobilization
• knowledge transfer
• linkage and exchange
• popularization of research,
• research into practice
• research mediation
• research transfer
• research translation
• science communication
• teaching
• third mission
• translational research
• transmission
• utilization
• cited most frequently

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Knowledge translation

• CIHR definition
• Knowledge translation is the exchange, synthesis
  and ethically-sound application of researcher
  findings within a complex system of relationships
  among researchers and knowledge users.

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Knowledge translation

• Knowledge translation is about ensuring that
• 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

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Knowledge translation
Audiences for KT
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Knowledge translation

• Why do we need to think about knowledge
  translation?
• Traditional KT approaches have emphasised
  publication in peer reviewed journals
• Consistent evidence of failure to translate
  research findings into clinical practice
• 30-40 patients do not get treatments of proven
  effectiveness
• 2025 patients get care that is not needed or
  potentially harmful
• Schuster, McGlynn, Brook (1998). Milbank Memorial
  Quarterly
• Grol R (2001). Med Care

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• K for KT
• Wheres the beef?

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K for KT

• Individual studies rarely by themselves provide
  sufficient evidence for policy or practice
  changes
• Individual studies are often misleading
• An additional issue is dealing with the hype from
  scientific discoveries

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Dont believe the hype likelihood of benefit
from basic science discoveries
25, 190 articles (published in 1979-1983 in
Nature, Science, Cell, JEM, JCI, JBC)
562 articles (retrieved key word search)
153 potentially eligible articles (full text)
101 original articles that made clear promises
for immediate clinical translation
Contopoulos-Ioannidis et al. Am J Med 2003 and
Ioannidis JP. J Translational Med 2004
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Dont believe the hype likelihood of benefit
from basic science discoveries
RCT
Positive RCT
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Dont believe the hype early highly positive
results often contradicted
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Dont believe the hype early highly positive
results often contradicted

• Analyzed 115 articles published in 1990-2003 in
  the 3 major general medical journals (NEJM, JAMA,
  Lancet) and specialty journals that had received
  over 1000 citations each by August 2004
• 49 reported evaluations of health care
  interventions 45 claimed that the interventions
  were effective.
• By 2004 5/6 non randomised studies and 9/39
  randomised trials were already contradicted or
  found to be exaggerated
• Ioannidis JP. JAMA 2005

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Dont believe the hype early highly positive
results often contradicted
Ioannidis et al, Nature Genetics 2001
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K for KT

• The results of individual studies need to be
  interpreted alongside the totality of evidence
  (ie systematic reviews)
• Emphasis on KT of individual studies may distract
  the stakeholder group (increasing the noise to
  signal)
• Dont believe the hype
• Dont generate the hype

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K for KT

• Users Guides to the Medical Literature
• We now recommend that resolving a clinical
  problem begins with a search for a valid
  systematic review or practice guideline as the
  most efficient method of deciding on the best
  patient care.
• Guyatt GH, Rennie D (1994). JAMA.

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K for KT

• Systematic reviews are a generic methodology used
  to synthesise evidence from a broad range of
  research methods addressing different questions.

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K for KT

• The steps involved in undertaking a systematic
  review include
• stating the objectives of the research
• defining eligibility criteria for studies to be
  included
• identifying (all) potentially eligible studies
• applying eligibility criteria
• assembling the most complete dataset feasible
• analysing this dataset, using statistical
  synthesis and sensitivity analyses, if
  appropriate and possible
• preparing a structured report of the research.

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K for KT

• Systematic reviews are a generic methodology used
  to synthesise evidence from a broad range of
  research methods addressing different questions.
• Effectiveness of health care interventions
• Diagnostic and screening tests
• Determinants of health
• Aetiological epidemiological studies
• Genetic epidemiological studies
• Health system issues (eg quality of discharge
  coding)
• Qualitative methods consumers experiences of
  health care

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Systematic reviews of what works questions
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K for KT

• Increasing availability of high quality
  guidelines and systematic reviews available to
  support practice
• Cochrane Collaboration
• AHRQ evidence based practice reports
• HUGENet
• Multiple guideline development agencies

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The Cochrane Library
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The Cochrane Library
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• KI for KT
• If you build it they will come

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Knowledge infrastructure for knowledge
translation

• Canadian health care systems have largely failed
  to invest in knowledge infrastructure
• As a result, they abrogate responsibility for
  knowledge management to consumers, health care
  professionals, managers and policy makers

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Knowledge infrastructure for knowledge
translation

• Reality check
• Over 20,000 medical journals published per year
• Published research of variable quality and
  relevance
• Users often poorly trained in critical appraisal
  skills
• Users often have limited time (average time
  professionals have available to read lt1
  hour/week)

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Knowledge infrastructure for knowledge
translation

• Canadian health care systems have largely failed
  to invest in knowledge infrastructure
• As a result, they abrogate responsibility for
  knowledge management to consumers, health care
  professionals, managers and policy makers
• Health care systems need to invest in knowledge
  infrastructure
• Knowledge infrastructure should be considered as
  important as the sewers for a knowledge based
  health care system

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Knowledge infrastructure for knowledge
translation

• Potential components for regional knowledge
  infrastructure
• Push
• Pull
• Linkage and exchange

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Knowledge infrastructure for knowledge
translation

• Potential components for regional knowledge
  infrastructure
• Push
• Knowledge management
• Rapid response services
• eg. Aggressive Research Information Service
  (West Midlands, UK)
• Knowledge intelligence services
• Clearing houses for evidence based tools
• eg decision aids, clinical practice guidelines,
  health technology assessments

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Knowledge infrastructure for knowledge
translation

• Potential components for regional knowledge
  infrastructure
• Push
• Knowledge packaging and communications
• Friendly front ends
• eg actionable messages for policy makers and
  managers
• Targeted push of summarised information
• eg Contacts, Help, Advice and Information
  Networks (CHAIN)

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Knowledge infrastructure for knowledge
translation

• Potential components for regional knowledge
  infrastructure
• Pull
• Capacity building for potential research users
• EXTRA (senior managers)
• SEARCH (front line managers)
• Cochrane Consumer training
• Requiring explicit documentation of how evidence
  was considered within decision making

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Knowledge infrastructure for knowledge
translation

• Potential components for regional knowledge
  infrastructure
• Linkage and exchange
• Local RD function that can undertake small scale
  projects eg to identify priorities for KT and
  service delivery, to assess applicability of
  research evidence to local settings, to support
  local quality improvement efforts

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Knowledge infrastructure for knowledge
translation

• Skill sets needed for regional knowledge
  infrastructure
• Information science skills
• Clinical and policy skills
• Basic research skills
• Adult education skills
• Quality improvement skills
• Informatics

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Knowledge infrastructure for knowledge
translation

• Skill sets needed for regional knowledge
  infrastructure
• Information science skills (oh did I mention that
  already? Senior moment, forgive me but youre
  really important you know for health care systems
  in the 21st century)

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Knowledge infrastructure for knowledge
translation

• Budget needed for regional knowledge
  infrastructure
• Unclear. What would be reasonable to support
  knowledge management for a population of 1
  million citizens?
• More pressing is how do we articulate the value
  argument for a regional knowledge infrastructure.
  I suspect that everyone would accept the
  argument for better evidence however no-one
  appears to want to pay for this (unlike
  electronic health records etc)

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KI necessary but not sufficient

• Knowledge infrastructure is necessary but not
  sufficient to ensure knowledge translation
• The new tower of Babel?
• Hibble, Kanka, Pencheon, Pooles. BMJ (1998)

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Summary

• Knowledge translation is about ensuring that
  stakeholders are aware of and use research
  evidence to inform their decision making
• KT should be seen as a shared responsibility
  between the research community, the health care
  system and the society in which they work.
• Investment in knowledge infrastructure is
  essential to the development of a knowledge based
  infrastructure

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Contacts

• jgrimshaw_at_ohri.ca
• Canadian Cochrane Centre
• cochrane_at_uottawa.ca
• http//www.ccnc.cochrane.org/en/index.html
• The Cochrane Collaboration
• http//www.cochrane.org