L

1
Létat des connaisances sur la recherche en
transfert des connaissances

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

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Knowledge translation

• CIHR definition
• Knowledge translation is a dynamic and iterative
  process that includes the synthesis,
  dissemination, exchange and ethically-sound
  application of knowledge to improve the health of
  Canadians, provide more effective health services
  and products and strengthen the healthcare
  system.
• This process takes place within a complex system
  of interactions between researchers and knowledge
  users which may vary in intensity, complexity and
  level of engagement depending on the nature of
  the research results and on the needs of the
  particular knowledge user.

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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
• End point of knowledge translation to health care
  professionals should be evidence based behaviours

4
Approaches to knowledge translation
Knowledge to action Graham et al (2006). Lost
in Knowledge Translation. Time for a Map? Journal
of Continuing Education for Health Professionals
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Assessing barriers to KT

• Structural (e.g. financial disincentives)
• Organisational (e.g. inappropriate skill mix,
  lack of facilities or equipment)
• Peer group (e.g. local standards of care not in
  line with desired practice)
• Individual (e.g. knowledge, attitudes, skills)
• Professional - patient interaction (e.g. problems
  with information processing)

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Selecting knowledge translation interventions

• Choice of dissemination and implementation
  should be based upon
• Diagnostic assessment of barriers
• Understanding of mechanism of action of
  interventions
• Empirical evidence about effects of interventions
• Available resources
• Practicalities, logistics etc

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Cochrane Effective Practice and Organisation of
Care (EPOC) Group

• EPOC aims to undertake systematic reviews of
  professional, organisation, financial and
  regulatory interventions to improve health care
  systems and health care delivery
• Register of 6000 primary studies
• 50 reviews, 41 protocols

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http//www.cadth.ca/index.php/en/compus/optimal-th
er-resources/interventions
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Overview of reviews of professional behaviour
change strategies

• Educational materials
• Educational meetings
• Educational outreach
• Local opinion leaders
• Audit and feedback
• Reminders and prompts
• Tailored interventions
• Multifaceted interventions

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Educational outreach

• Educational outreach - Use of a trained person
  who met with providers in their practice settings
  to give information with the intent of changing
  the providers practice. The information given
  may have included feedback on the performance of
  the provider(s).

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Educational outreach

• Derives from social marketing approach
• Use social persuasion methods to target
  individuals knowledge and attitudes
• Typically aim to get maximum of 3 messages across
  in 10-15 minutes using approach tailored to
  individual health care provider
• Typically use additional strategies to reinforce
  approach
• Typically focus on relatively simple behaviours
  in control of individual physician eg choice of
  drugs to prescribe

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Educational outreach

• OBrien (2007) Cochrane Library
• High quality review
• 69 studies (RCT, CCT)
• Multifaceted educational outreach visits were
  generally effective for improving appropriate
  care
• Prescribing behaviours - median effect across 17
  comparisons 4.8 absolute improvement,
  interquartile range 3.0 to 6.5
• Other behaviours median effect across 17
  comparisons 6.0 absolute improvement,
  interquartile range 3.6 to 16.0

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Overview of reviews summary

• Summary
• Variety of interventions to change health
  professional behaviour effects tend to be
  modest but important from population perspective
• However No Magic Bullets effects of
  interventions appears to vary across targeted
  behaviours, professionals and settings
• Feasibility and resources required for
  interventions also likely to vary

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Knowledge translation research

• Knowledge translation is a human enterprise that
  can be studied to understand and improve
  knowledge translation approaches
• Knowledge translation research is the scientific
  study of the determinants, processes and outcomes
  of knowledge translation.
• Goal is to develop a generalisable empirical and
  theoretical basis to optimise KT activities

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Knowledge translation research

• Knowledge translation research relatively new
  field in health research
• Inherently interdisciplinary
• Wide range of disciplines need to be engaged
• Clinical
• Health services research
• Educational, behavioural and organisational
• Design and engineering
• Methodologists
• Broad range of forms of enquiry needed

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Knowledge translation research

• Knowledge synthesis (to identify the knowledge
  for KT)
• Research into the evolution of and critical
  discourse around research evidence
• Research into knowledge retrieval, evaluation and
  knowledge management infrastructure
• Identification of knowledge to action gaps
• Development of methods to assess barriers and
  facilitators to KT
• Development of the methods for optimizing KT
  strategies
• Evaluations of the effectiveness and efficiency
  of KT strategies
• Development of KT theory and
• Development of KT research methods.

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Knowledge translation research

• Knowledge synthesis (to identify the knowledge
  for KT)
• Research into the evolution of and critical
  discourse around research evidence
• Research into knowledge retrieval, evaluation and
  knowledge management infrastructure
• Identification of knowledge to action gaps
• Development of methods to assess barriers and
  facilitators to KT
• Development of the methods for optimizing KT
  strategies
• Evaluations of the effectiveness and efficiency
  of KT strategies
• Development of KT theory and
• Development of KT research methods.

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UK MRC Framework for Evaluating Complex
Interventions
Continuum of increasing evidence
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UK MRC Framework for Evaluating Complex
Interventions Diagnostic Phase

• Formal assessment of context, likely barriers to
  KT
• Consideration of potential theories (behavioural,
  organisational) that might be helpful
• Mixed methods
• Literature review
• Informal consultation
• Focus groups
• Surveys
• Needs interdisciplinary perspective

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UK MRC Framework for Evaluating Complex
Interventions Diagnostic Phase

• Ferlie and Shortell suggest four levels of
  interventions to improve the quality of health
  care
• the individual health professional
• health care groups or teams
• organisations providing health care
• the larger health care system or environment in
  which individual organizations are embedded.
• Different types of theory will be relevant to
  interventions at different levels
• Ferlie, Shortell (2001). Milbank Quarterly

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UK MRC Framework for Evaluating Complex
Interventions Diagnostic Phase

• Given that clinical practice is a form of human
  behaviour, we are currently exploring the
  applicability of predictive theories of human
  behaviour from other similar settings.
• Focus has been on theories that
• (Have standard approaches to measurement)
• Have been empirically tested.
• Explain behavior in terms of factors that are
  amenable to change.
• Include non volitional factors.

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UK MRC Framework for Evaluating Complex
Interventions Diagnostic Phase
Walker (2001) Br J Hlth Psych
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UK MRC Framework for Evaluating Complex
Interventions Diagnostic Phase
Available from http//www.rebeqi.org/
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UK MRC Framework for Evaluating Complex
Interventions Diagnostic Phase

• More theory, less theories needed
• Multiple theories and frameworks of individual
  and organizational behavior change.
• Most professional behavior change frameworks are
  descriptive and normative rather than predictive.
• Few have been operationalised in detail
• Many have not been prospectively evaluated.
• Few head-to-head comparisons of different
  theories
• Need for predictive theories that incrementally
  improve likelihood of successful implementation.
• Need for rigorous evaluation of candidate
  theories

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UK MRC Framework for Evaluating Complex
Interventions Modelling Phase

• Phase 1 Modelling
• Intervention mapping
• Specify intervention objectives
• Select methods and strategies
• Design program
• Usability testing

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UK MRC Framework for Evaluating Complex
Interventions Modelling Phase
Intervention mapping
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UK MRC Framework for Evaluating Complex
Interventions Exploratory Phase

• Phase 2 Exploratory studies
• Small scale studies to demonstrate that
  unit/patient recruitment is likely achievable,
  intervention is deliverable in study settings,
  data collection is feasible
• Randomised or non randomised

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UK MRC Framework for Evaluating Complex
Interventions definitive phase

• Causal description did our KT strategy lead to
  improve knowledge use
• Causal explanation why did our KT strategy
  work/not work (understanding of mediating
  pathways)
• Economic evaluation
• Understanding of potential effect modifiers
  (context, targeted group, targeted behaviour,
  variations in intervention)
• Many current KT evaluations fail to address some
  or all of these issues

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UK MRC Framework for Evaluating Complex
Interventions definitive phase

• Rigorous evaluations (mainly randomised
  controlled trials) provide the best evidence of
  causal description of different interventions
  because
• Effects of interventions are modest
• Limited understanding of likely confounders
• Substantial opportunity costs if ineffective or
  inefficient dissemination and implementation
  strategies used

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UK MRC Framework for Evaluating Complex
Interventions definitive phase

• Pragmatic largely cluster randomised trials are
  optimal design for establishing causal
  description.
• Design aspects can be used to enhance
  informativeness of RCTs
• Multiple arm trials, factorial designs
• Policy friendly designs
• Step wedge designs, balanced incomplete block
  designs
• However for logistical, pragmatic and ethical
  reasons, quasi experimental designs may be
  needed.

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UK MRC Framework for Evaluating Complex
Interventions definitive phase

• Evaluated effects of short educational messages
  on test ordering reports and audit and feedback
  on subsquent test ordering behaviour

NEXUS
DRAM
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UK MRC Framework for Evaluating Complex
Interventions definitive phase
60
60
50
50
40
40
Requests for knee x-rays
30
30
20
20
Number of practices
Number of practices
Std. Dev 16.93
10
Your practice
Std. Dev 16.93
10
Your practice
Mean 15.8
Mean 15.8
N 247.00
0
N 247.00
0
5.0
0.0
85.0
80.0
75.0
70.0
65.0
60.0
55.0
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
85.0
80.0
75.0
70.0
65.0
60.0
55.0
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
Requests per 1000 patients
Requests per 1000 patients
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UK MRC Framework for Evaluating Complex
Interventions definitive phase
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UK MRC Framework for Evaluating Complex
Interventions definitive phase

• NEXUS and DRAM short educational messages led to
  15-30 reduction in subsequent test ordering
• NEXUS feedback no effect
• DRAM feedback 10-15 reduction in subsequent
  test ordering
• Take home messages
• Simple (and cheap) interventions may lead to
  improved professional behaviour
• Minor changes in audit and feedback design may
  lead to different results
• Importance of replicating studies

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UK MRC Framework for Evaluating Complex
Interventions definitive phase

• Other forms of enquiry needed to determine causal
  explanation
• Process evaluations (qualitative case studies)
• Theory based process evaluations (mediating
  pathways)
• Secondary analyses (moderator analyses)
• Temporal analyses
• Embedded economic evaluations

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Summary - KT

• Knowledge translation is about ensuring that
  stakeholders are aware of and use research
  evidence to inform their decision making
• Knowledge to action loop provides framework for
  thinking about knowledge translation
• Different approaches likely to be needed
  depending on innovation, barriers to adoption,
  targeted stakeholders and health care system
• Evidence base about how to do KT is incomplete
  especially for policy makers
• Nevertheless opportunities for researchers to be
  more thoughtful about KT throughout research
  process

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Summary KT research

• KT is a relatively new field - few health
  researchers have been engaged in the field for
  more than 10 years
• Substantive level of research activity
• Cochrane Effective Practice and Organisation of
  Care (EPOC) group register includes over 6,000
  RCTs and quasi experiments of interventions to
  improve health care delivery and health care
  services
• Increasing funding and reporting opportunities
  for knowledge translation research
• Substantial challenges to establishing KT
  research as a distinct field

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Contact details

• Jeremy Grimshaw
• jgrimshaw_at_ohri.ca
• EPOC
• epoc_at_uottawa.ca
• http//www.epoc.uottawa.ca/index.htm
• Implementation Science
• http//www.implementationscience.com