Knowledge for Knowledge Translation

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Knowledge for Knowledge Translation

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

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Outline

• Session 1
• Definitions
• K for KT
• Session 2
• Effects of KT strategies
• KT for policy makers
• KT for clinicians
• KT for patients
• What can/should researchers do to promote KT?
• Putting it together

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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

• 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
  basic science 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 publication and outcome
bias

• Consistent evidence of publication bias
  positive studies more likely to be published and
  more likely to be published earlier.
• Growing evidence of outcome bias in randomised
  trials changes in primary outcome in
  randomised trials (if primary outcome shows no or
  modest effect) to outcome showing positive
  changes.

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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

• Problems of information management
• 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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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

• Clinical practice guidelines
• Systematically developed statements to assist
  practitioner and patient decisions about
  appropriate health care for specific clinical
  circumstances.
• Institute of Medicine (1992). Guidelines for
  clinical practice from development to use.

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K for KT

• Factors influencing validity of CPGs
• Composition of guideline development group
• Multidisciplinary group
• Methods of identifying and synthesising evidence
• Sytematic review
• Methods of developing guidelines
• Explicit method linking recommendations to
  strength of evidence
• Grimshaw, Russell (1993). Quality in Health Care.

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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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K for KT buyer beware

• Quality of systematic reviews and CPGs highly
  variable. Need to appraise prior to use
• Systematic reviews Oxman and Guyatt
• Guideline appraisal AGREE instrument

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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 based on mature K base.

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Contact details

• Jeremy Grimshaw - jgrimshaw_at_ohri.ca
• EPOC epoc_at_uottawa.ca