Translating Research into Practice: A United States Perspective

1
Translating Research into Practice A United
States Perspective

• Marita G. Titler, PhD, RN, FAAN
• Director of Research, Quality and Outcomes
  Management
• Department of Nursing Services and Patient
• University of Iowa Hospitals and Clinics
• and
• Clinical Professor
• University of Iowa College of Nursing
• Iowa City, IA

2
Focus of this Paper

• Overview the state of the science of translation
  research in the United States
• Stimulate a discussion about translation science
  from various world perspectives
• Stimulate discussions of possible international
  collaborative research

3
Definition of Translation Research

• Testing the effect of interventions aimed at
  promoting the rate and extent of adoption of
  evidence-based practices by nurses, physicians,
  and other healthcare providers (Titler Everett,
  2001)
• Describing organizational, unit, and individual
  variables that effect the use of evidence in
  clinical and operational decision-making

4
Healthcare System in the U.S.

• Private not-for-profit
• Private for profit
• Public
• Third party reimbursement (private, governmental)
• Uninsured
• Veteran Healthcare
• CMS (Medicare reimbursement)

5

• Between the healthcare we have and the care we
  could have lies not just a gap but a chasm.

6
The Dilemma and Challenge

• The stark reality is that we invest billions
  in research to find appropriate treatments, we
  spend more than 1 trillion on healthcare
  annually, we have extraordinary capacity to
  deliver the best care in the world, but we
  repeatedly fail to translate that knowledge and
  capacity into clinical practice

(IOM, 2003 Priority Areas for National Action
Berg et al, 1997 Dickersin Manheimer, 1998
Kamerow, 1997)
7
Examples

• Fewer than half of adults gt50 years of age
  received recommended screening tests for
  colorectal cancer.
• Inadequate care after a heart attack results in
  18,000 unnecessary deaths per year.
• 17 million people were informed by their
  pharmacist that the drugs that were prescribed
  could cause an interaction

IOM, 2003
8
The Harkin Question

• There is a reason its the National Institutes
  of Health and not the National Institutes of
  Science. We expect the NIH to be actively
  involved in translational research. Yes, you get
  the basic science done, but we want to know, how
  does that help us lead healthier lives?

(Brainard J., The Chronicle of Higher Education,
Feb. 6, 2004)
9
NIH Roadmap

• These initiatives are integrated to accelerate
  our knowledge into effective prevention and
  treatment strategies, and in many ways transform
  the way we conduct research and the way we
  accelerate the translation of that research to
  the bedside and eventually to clinical practice.

(Zerhouni quotation in The Scientist, October 1,
2003).
10
Big Message Its Important

• Translation of research findings is critical in
  the NIH agenda/roadmap.
• AHRQ - translating research into practice (TRIP I
  and II studies Partnership Studies)
• Magnet Designation
• JCAHO Accreditation Criteria
• CMS
• Specialty Nursing Organizations (e.g. ONS,
  AWHONN, AACN)

11
Funding Agencies in the U.S.- Translation Science

• Agency for Healthcare Research and Quality
• Veterans Health Administration is the largest
  healthcare delivery system in the U.S.
• CMS
• RWJ
• NIH (fairly new area)

12
Design/Methods

• Electronic search strategies
• Manual search strategies
• Federal agency web-sites
• Limited to research and U.S.
• Major search terms

13
Purpose of Studies

• Describe barriers and facilitators of
  evidence-based practice/research use (Baessler et
  al, 1994 Barta, 1995 Carroll et al, 1997
  Charles , 2000 Funk et al, 1991, 1995 Katz,
  1999 Pettemgill et al, 1994)
• Assess research use/levels of adoption of certain
  evidence-based practices (e.g. pressure ulcer
  prevention) (Brett et al, 1987 Coyle Sokop,
  1990 Morin et al, 1999 Omery Williams, 1999
  Rutledge et al, 1995 Wells Baggs, 1994)

14
Purpose of Studies

• Demonstration projects (1970s-90s) to implement
  evidence-based practices.
• Multiple case reports of evidence-based practice
  projects to improve patient care
• Describe factors that influence adoption of
  evidence in practices.
• Testing the effect of interventions designed to
  translate research into practice.
• Improve quality of care based on evidence in
  multiple sites (e.g. CalNoc project on falls).

15
Methods Used

• Descriptive cross-sectional designs
• Qualitative methods
• Randomized designs
• Case reports
• Partnership models

16
Findings Across Studies

• Most focused on clinical topics
• Most nonexperimental/paucity of randomized
  clinical trials
• Most acute care focused, primary care, and then
  long-term care
• A variety of single and multifaceted TRIP
  interventions were investigated

17
Selected U.S. Studies

• Dufault et al
• Sales et al
• Donaldson et al
• Jones et al
• Watson et al

• Titler et al
• Feldman et al
• Fifield
• Kovner
• Resnick

18
Methodological Challenges

• Single and multifaceted strategies
• Metric of TRIP intervention
• Selection/measurement of dependent measures
• Multi-site studies
• Level of engagement (individuals and
  organization)
• Statistical analysis (clustering/nesting)

19
Sustainability

• Where is the boundary between the downstream
  effect of the TRIP intervention as compared to
  evidence that the improvement is being sustained
  over time.
• What type and dose of TRIP interventions are
  needed to keep/sustain the adherence to the EBPs?
  Are sustainability interventions necessary?

20
Sustainability
21
Summary

• More experimental studies to test the effect of
  TRIP interventions
• Address measurement issues
• Multi-site and international studies
• Take advantage of the natural experiments by
  studying what works and what does not work (e.g.
  Magnet status VA AHRQ Partnership grants)

22
Closing Thoughts

• American healthcare could benefit greatly from
  the establishment by the federal government of a
  Health Care Extension Service modeled on the
  Agricultural Extension Service (Berwick, 2003)
• To create a future different from its past,
  healthcare needs leaders and scientists who
  understand innovation and how it spreads, who
  respect the diversity of change itself, and who
  will design and conduct research to hasten the
  transfer of knowledge into care delivery.