Knowledge Translation Overview of some Canadian Activities

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Knowledge TranslationOverview of some Canadian
Activities

• Claire Bombardier
• Jeremy Grimshaw
• Linda Li
• Jessie McGowan
• Nancy Santesso
• Peter Tugwell

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CARE IV

• Thank you for the invitation to my first CARE
  experience !
• I found yesterday most interesting.
• As a Rheumatologist- Clinical Epidemiologist I
  like the 3 areas you have identified
• Implementation of Effective Research
• Knowledge Translation and Exchange
• Measuring Outcomes using Patient Centered
  Approach.

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CARE IV

• Am delighted to learn of the interest in
  Knowledge Translation
• This is a niche where you can really make a
  difference !
• i.e. there is is no international association of
  Knowledge Translation in Musculoskeletal Diseases
  might CARE be a forum for international
  research into KT in MSK/Chronic Disease?

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Summary

• Knowledge Translation Definition and Importance
  
• Knowledge Translation Models
• Knowledge Translation Activities in Canadian
  Arthritis Network.

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Summary

• Knowledge Translation Definition and Importance
  

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Knowledge translation

• Canadian Institutes of Health Research
  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 the challenge

• 30-40 patients do not get treatments of proven
  effectiveness
• 2025 patients get care that is not needed or
  potentially harmful
• The transfer of research conclusions into
  practice is an unpredictable and haphazard
  process (Agency for Health Research and Quality,
  2001)

Schuster, McGlynn, Brook (1998). Milbank Memorial
Quarterly Grol (1997) BMJ Sung et al (2003).
JAMA Grol R (2001). Med Care
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Framework for an evidence base for practie and
policy on interventions in the health care and
public health systems?
1 BURDEN OF ILLNESS and AETIOLOGY
5 MONITORING OF PROGRAM
2 COMMUNITY EFFECTIVENESS
2006 Version

• Equity Effectiveness Iterative Measurement Loop
• Always insist on considering BOTH
• Mean results
• Distribution by Socio-economic position

4 KNOWLEDGE TRANSLATION IMPLEMENTATION
3 ECONOMIC EVALUATION
Tugwell, Robinson, Desavigny, Hawker BMJ
2006332358-361
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Towards evidence implementation

• We placed high value on developing the basic
  science of medicine.
• We have not emphasised the process by which the
  science is translated into practice.
• Grol (1997). British Medical Journal.

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We havenot emphasised the process by which the
science is translated into practice.

• How do we ensure that ....
• stakeholders are aware of and use research
  evidence to inform their decision making?
• The KT Approach depends upon the different
  stakeholders the 6 Ps

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The Approach depends upon the different
stakeholders the 6 Ps

• Patients
• Practitioners
• Public
• Policy makers
• Private sector
• Press

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Summary

• Knowledge Translation Definition and Importance
  
• Knowledge Translation Models

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Everyone likes a framework to provide direction
to plan Knowledge Translation !

• Popular ones in addition to the frameworks
  presented yesterday
• Evidence Generation and Implementation
  (Bombardier)
• Knowledge Transfer Strategy (Lavis et al. 2003)
  CHSRF Developing a Dissemination Plan
  (http//www.chsrf.ca/knowledge_transfer/pdf/dissem
  ination_plan_e.pdf)
• Ottawa Model of Research Use (OMRU)

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Additional Frameworks to provide direction to
plan knowledge translation...

• Evidence Generation and Implementation
  (Bombardier)

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Evidence-based Practice
Evidence generation
Evidence implementation
1.Define the clinical condition
7. Improve quality of care
2.Generate evidence
6. Assess quality of care
3.Summarize existing evidence
5. Translate Guidelines/ messages
4. Create guidelines/ messages
Claire Bombardier, 2003
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There are frameworks to provide direction to plan
knowledge translation...

• Evidence Generation and Implementation
  (Bombardier)
• Knowledge Transfer Strategy (Lavis et al. 2003)
  CHSRF Developing a Dissemination Plan
  (http//www.chsrf.ca/knowledge_transfer/pdf/dissem
  ination_plan_e.pdf)
• )

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Concept of Push vs Pull
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Lavis Knowledge Translation Framework
Source Lavis JN et al. Bull WHO 2006 84
620-628.
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Everyone likes a framework to provide direction
to plan Knowledge Translation!

• Popular ones in addition to the frameworks
  presented yesterday
• Evidence Generation and Implementation
  (Bombardier)
• Knowledge Transfer Strategy (Lavis et al. 2003)
  CHSRF Developing a Dissemination Plan
  (http//www.chsrf.ca/knowledge_transfer/pdf/dissem
  ination_plan_e.pdf)
• Ottawa Model of Research Use (OMRU)
• Graham and Logan 2004

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Ottawa Model of Research Use
Assess Monitor
Evaluate Barriers and supports interventions
and degree of use outcomes

• 1. Environment
• patients
• culture/social
• structural
• economic
• uncontrolled events

• 2. Potential adopters
• awareness
• attitudes
• knowledge/skills
• concerns
• current practice

• 4. Implementation intervention strategies
• barrier management
• transfer
• follow-up

• 6. Outcomes
• patient
• practitioner
• system

• 5. Adoption
• intention
• use
• sustain

• 3. Evidence-based innovations
• development process
• innovation attributes

(Graham and Logan, 2004)
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Summary

• Knowledge Translation Definition and Importance
  
• Knowledge Translation Models
• Knowledge Translation Activities in Canadian
  Arthritis Network CAN.

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Canadian Arthritis Network CAN KT Unit

• Working with selected CAN researchers on the
  development of the KTE template
• Working with selected CAN researchers and
  stakeholders on the friendly front end or EBAM
  Evidence Based Actionable messages
• Create a communication network for all CAN
  researchers based on the CHAIN model.

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Summary

• Knowledge Translation Definition and Importance
  
• Knowledge Translation Models
• Knowledge Translation Activities in Canadian
  Arthritis Network.
• The Canadian KT group would love to work with
  others in CARE !
• Might CARE be an international forum for KT in
  MSK/Chronic Disease?

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2ND PART
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KTEffective Consumer

• Peter Brooks
• Rachelle Buchbinder
• Betsy Kristjansson
• Annette OConnor
• Cindy Gallois
• Nancy Santesso
• Peter Tugwell
• Andrew Wilson

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Knowledge Translation for Consumers

• Environment today
• patient centred care, patient as leader of their
  care, shift to consumer participation
• Potential Adopters The New Effective Consumer
• some patients want to actively participate in
  their care
• patients increasingly recognised as expert of
  their own disease
• patients want information and to make decisions
  about their care
• patients want to manage their own disease and use
  health care resources effectively

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Education Programmes do they work?

• Lancet Review
• Overall, roughly 40 of self-management
  interventions for arthritis showed some
  improvement in self-reported symptoms, as did a
  similar proportion for measures of disabilitya
  greater effect on pain was identified for
  osteoarthritis, with four of five studies
  reporting some benefit.
• (Newman, 2004)

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Knowledge Translation for Consumers

• Based on taxonomy of interventions by the
• Cochrane Consumers and Communication Review Group
• Strategies can include
• Interventions to and from the consumer (e.g self
  management programmes)
• Interventions for communication between providers
  and consumers (e.g Decision aids)
• Interventions for communication between consumers
  (e.g Peer support)
• Interventions for communication to the healthcare
  provider from another source (e.g. Patient
  centred approaches)
• Service delivery interventions (e.g. Interactive
  Health Communication Applications)

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Ottawa Model of Research Use
Assess Monitor
Evaluate Barriers and supports interventions
and degree of use outcomes

• 1. Environment
• patients
• culture/social
• structural
• economic
• uncontrolled events

• 2. Potential adopters
• awareness
• attitudes
• knowledge/skills
• concerns
• current practice

• 4. Implementation intervention strategies
• barrier management
• transfer
• follow-up

• 6. Outcomes
• patient
• practitioner
• system

• 5. Adoption
• intention
• use
• sustain

• 3. Evidence-based innovations
• development process
• innovation attributes

(Graham and Logan, 2004)
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What are the barriers and supports to consumers
participating their care?

• We asked patients with arthritis in Australia
  and Canada to
• describe a personal experience that you thought
  was especially effective or ineffective in
  handling your health situation - please explain
  what was good or bad about it what could have
  been different

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Ottawa Model of Research Use
Assess Monitor
Evaluate Barriers and supports interventions
and degree of use outcomes

• 1. Environment
• patients
• culture/social
• structural
• economic
• uncontrolled events

• 4. Implementation intervention strategies
• barrier management
• transfer
• follow-up

• 2. Potential adopters
• awareness
• attitudes
• knowledge/skills
• concerns
• current practice

• 6. Outcomes
• patient
• practitioner
• system

• 5. Adoption
• intention
• use
• sustain

• 3. Evidence-based innovations
• development process
• innovation attributes

(Graham and Logan, 2004)
33
What are the barriers and supports to consumers
participating their care?

• We learnt about their environment
• internet is an important source of health
  information
• physicians are most often the gate keeper to
  health and health care
• communication with physician is key
• increasing acceptance for patients to manage and
  take control of their disease

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Ottawa Model of Research Use
Assess Monitor
Evaluate Barriers and supports interventions
and degree of use outcomes

• 1. Environment
• patients
• culture/social
• structural
• economic
• uncontrolled events

• 2. Potential adopters
• awareness
• attitudes
• knowledge/skills
• concerns
• current practice

• 4. Implementation intervention strategies
• barrier management
• transfer
• follow-up

• 6. Outcomes
• patient
• practitioner
• system

• 5. Adoption
• intention
• use
• sustain

• 3. Evidence-based innovations
• development process
• innovation attributes

(Graham and Logan, 2004)
35
Effective Consumer

• We learnt about the adopters - effective
  patients, they.
• seek and judge the quality of information
• adapt information to their own situation and know
  what is important to them in their own lives
• develop good relationships with their health care
  providers and communicate well
• want to be and are involved in decisions
• implement their decisions and navigate the health
  care system

36
Ottawa Model of Research Use
Assess Monitor
Evaluate Barriers and supports interventions
and degree of use outcomes

• 1. Environment
• patients
• culture/social
• structural
• economic
• uncontrolled events

• 2. Potential adopters
• awareness
• attitudes
• knowledge/skills
• concerns
• current practice

• 4. Implementation intervention strategies
• barrier management
• transfer
• follow-up

• 6. Outcomes
• patient
• practitioner
• system

• 5. Adoption
• intention
• use
• sustain

• 3. Evidence-based innovations
• development process
• innovation attributes

(Graham and Logan, 2004)
37
Evidence based innovation - What have we
developed to support patients to become effective
consumers?

• Cochrane Musculoskeletal Group
• 1 of 51 groups in the Cochrane Collaboration
• the Cochrane Collaboration produces systematic
  reviews of the effects of health care
  interventions for many diseases and conditions
  and makes them assessible on the Cochrane Library
  (www.thecochranelibrary.com)

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What have we developed to support patients to
become effective consumers?

• Cochrane Musculoskeletal Group produces Cochrane
  Reviews for
• Range of MSK conditions
• Back pain
• Rheumatoid arthritis
• Osteoarthritis
• Ankylosing spondylitis
• Soft tissue (shoulder and elbow)
• Range of treatments
• Drugs
• Physiotherapy
• Acupuncture
• Thermotherapy
• Non-medicinal and Herbal supplements

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Evidence Based Innovation User friendly
Cochrane Reviews

• Cochrane Reviews are generally not user friendly
• Large word counts, scientific format, medical
  jargon and statistics
• Need short evidence based summaries or messages
  of the results that are transferable to patients
  and consumers
• So friendly front ends of Cochrane Reviews
  developed with consumers and available on the
  Internet, guidelines for patient information
  followed, information based on rigorous evidence

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We go from
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Evidence based/informed decision making

• evidence expertise values

Up-to-date and user friendly information for
diagnosis, prognosis, benefits and harms of
treatments needed for patient to make informed
decisions
Past experience and disease specific knowledge is
unique to each patient
Importance of benefits and harms are based on the
patients values
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Patient Decision Aids

• Audience Patients and clinicians
• Meant to encourage and guide dialogue and
  decision making between patients and providers
  should be used in doctors consultation or before
  consultation

• Uses multiple methods to present information
  and pulls in other factors such as expertise and
  values

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Decision Aids are a response to changing
patient-physician relationships

• Example Joans medication for osteoarthritis in
  her knee doesnt seem to be working well to stop
  the pain. She asks the doctor about
  physiotherapy and tai chi
• OLD-STYLE
• Physician sole responsibility
• knowledgeable about benefits and harms
• Decided what was right for patient
• doctor knows best
• Patient listens and complies obeys
• NEW-STYLE
• Physician and Patient work through decision
  together
• Physician can use decision aid to work through
  the decision

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• Presents info about
• disease, condition, decision
• benefits and harms of treatment or no treatment

• Asks about
• personal values that can be a factor when making
  a decision
• role person wants to play in decision making
• comprehension of the evidence and if more
  information is needed

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DO DECISION AIDS WORK?

• Cochrane systematic overview of randomised trials
  comparing patient decision aids and traditional
  methods of involving/informing patients
• compared with usual care, decision aids
• improved knowledge of the options and outcomes
• resulted in more realistic expectations
• decreased decisional conflict
• enhanced participation in decision making
• decreased the proportion of people remaining
  undecided, and improved agreement between values
  and choice
• did not affect anxiety
• O'Connor AM et al. Decision aids for people
  facing health treatment or screening decisions.
  Cochrane Database Syst Rev. 2003.

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Decisional Conflict Mismatch between your
recommendation and patients values

• Unresolved uncertainty / decisional conflict
• leads to
• poor decision quality (uninformed, not congruent
  with values)
• Non-compliance/discontinuance
• dissatisfaction / regret
• overuse of health services
• (MDM 1995, 2003 Cochrane review 2003
  Wennberg 2002)

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Creating Decision Aids

• Many of our decision aids are available at
• http//www.blackwellpublishing.com/medicine/bmj/rh
  eumatology/decaids.asp
• OR
• http//decisionaid.ohri.ca/decaids.html
• Challenges to encourage patients and/or
  physicians to use
• Evaluation pending

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Ottawa Model of Research Use
Assess Monitor
Evaluate Barriers and supports interventions
and degree of use outcomes

• 1. Environment
• patients
• culture/social
• structural
• economic
• uncontrolled events

• 2. Potential adopters
• awareness
• attitudes
• knowledge/skills
• concerns
• current practice

• 4. Implementation intervention strategies
• barrier management
• transfer
• follow-up

• 6. Outcomes
• patient
• practitioner
• system

• 5. Adoption
• intention
• use
• sustain

• 3. Evidence-based innovations
• development process
• innovation attributes

(Graham and Logan, 2004)
51
Self Management Education Programmes

• Aim to enable patients to become more involved in
  the management of their disease (especially day
  to day)
• Provide information and skills for behavioural
  change
• Focus is less on drug treatments
• Content, duration, delivery (peer vs health care
  professional), theoretical approach varies

Newman.S Lancet 2004
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The Chronic Disease Self-Management Program
Lorig

• Subjects covered include
• 1) techniques to deal with problems such as
  frustration, fatigue, pain and isolation,
• 2) appropriate exercise for maintaining and
  improving strength, flexibility, and endurance,
• 3) appropriate use of medications,
• 4) communicating effectively with family,
  friends, and health professionals,
• 5) nutrition,
• 6) how to evaluate new treatments.

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Ottawa Model of Research Use
Assess Monitor
Evaluate Barriers and supports interventions
and degree of use outcomes

• 1. Environment
• patients
• culture/social
• structural
• economic
• uncontrolled events

• 2. Potential adopters
• awareness
• attitudes
• knowledge/skills
• concerns
• current practice

• 4. Implementation intervention strategies
• barrier management
• transfer
• follow-up

• 6. Outcomes
• patient
• practitioner
• system

• 5. Adoption
• intention
• use
• sustain

• 3. Evidence-based innovations
• development process
• innovation attributes

(Graham and Logan, 2004)
54
Education Programmes do they work?

• Lancet Review
• Overall, roughly 40 of self-management
  interventions for arthritis showed some
  improvement in self-reported symptoms, as did a
  similar proportion for measures of disabilitya
  greater effect on pain was identified for
  osteoarthritis, with four of five studies
  reporting some benefit.
• (Newman, 2004)

55
Education Programmes do they work?

• Limitations in all reviews due to heterogeneity
  between trials
• Content, duration, intensity, mode of delivery,
  manner of delivery, self selection to participate
  therefore, difficult to tell what makes the
  programme successful
• Research design, sample size, follow-up and
  dropout rates, unreported data
• Outcomes therefore difficult to compare

Newman.S Lancet 2004
56
At least 32 outcomes were identified in education
programme studies and not all are validated!
(Newman, 2003)

• Physical function Pain
• Psychological Status Joint Counts
• Disease Activity Coping
• Self-efficacy Social Function
• Knowledge Grip Strength
• Morning Stiffness Physical and Relaxation
  Exercise
• Joint Protection Arthritis Helplessness
• Patient Global Walking Time
• Joint Mobility/ROM Negative Social Interaction
• Loneliness Energy conservation
• Diet Communication with doctor
• Medication adherence Daily hassles/stress
• Life satisfaction Work disability
• Interference with daily life Number of reported
  problems
• Fatigue Sleep
• Stair climbing, lifting, rising Visits to doctor

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Challenges to evaluate self management programmes
as a successful KT strategy

• What components of education and self management
  programmes are successful
• What outcomes should be measured
• How to measure those outcomes
• 1 Approach is the Effective Consumer Outcome
  Scale

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EFFECTIVE CONSUMER 17 OUTCOME SCALE
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EC 17 (Effective Consumer 17)

• We have worked within the OMERACT process to
  develop a scale to measure effective consumers
  people who can manage their disease and
  participate in their health care
• People who.
• seek and judge the quality of information
• adapt information to their own situation and know
  what is important to them in their own lives
• develop good relationships with their health care
  providers and communicate well
• want to be and are involved in decisions
• implement their decisions and navigate the health
  care system

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What weve done to develop the scale

• Search the literature for definitions, scales and
  indicators of an effective consumer
• Conduct in-depth interviews with patients,
  doctors, family members for their views of an
  effective consumer
• Develop a list of characteristics of an effective
  consumer and review with patients OMERACT 7
• Test the scale with about 400 patients across
  Canada and Australia
• Perform psychometric analysis of results and
  obtained feedback at OMERACT 8
• Reduced scale to 17 items

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Still to do

• Evaluate the scale in self management programmes
• Self Management Programmes (Lorig) are starting
  for the first time in many years in Dublin,
  Ireland by Arthritis Ireland
• Over 190 people will complete the programme from
  September to December 2006
• The EC 17 will be compared to standard outcome
  measures used in the Self Management Programmes

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Knowledge Translation for ConsumersSummary

• Initial experience described with potential
  strategies to support patients to become
  effective consumers
• disseminate health information
• support decision making and communication
• provide self management programmes
• Need more experience with methods and different
  frameworks to evaluate whether these knowledge
  translation strategies are effective

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• CARE is ideal forum for research into KT for
  consumers!

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Summary

• The Canadian KT group would love to work with
  others in CARE !
• Might CARE be an international forum for KT in
  MSK/Chronic Disease?