JG rimshaw by 0D23zh

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									               Advancing the science of
                knowledge translation
             Jeremy Grimshaw for KT Canada
            Clinical Epidemiology Program, OHRI
        Department of Medicine, University of Ottawa
Canada Research Chair in Health Knowledge Transfer and Uptake
                Background

  ‘All breakthrough, no follow through’
                               Woolf (2006) Washington Post op ed


• Much of the US $100 billion/year worldwide
  investment in biomedical and health research is
  wasted because of dissemination and
  implementation failures
              Background




Institute of Medicine; Clinical Research Roundtable,
             Sung et al. JAMA 289:1278,2003
                   Background
• Consistent evidence of failure to translate research
  findings into clinical practice
    • 30-40% patients do not get treatments of proven
       effectiveness
    • 20–25% patients get care that is not needed or
       potentially harmful

• This has led to increased policy and research interest
  into efforts to bridge the evidence-practice gap to
  improve quality of care
                    Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly
                                                        Grol R (2001). Med Care
                                                           Seddon (2001) QHC
           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.
Knowledge translation
              KT terms encountered
applied health research           knowledge mobilization
capacity building                 knowledge transfer
co-optation - cooperation -       linkage and exchange
    competing                     popularization of research,
diffusion*                        research into practice
dissemination*                    research mediation
getting knowledge into practice   research transfer
impact                            research translation
Implementation*                   science communication
knowledge communication           teaching
knowledge cycle                   “third mission”
knowledge exchange                translational research
knowledge management              transmission
knowledge translation             utilization
                                  *cited most frequently
         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)
      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
      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
   • Behavioural and organisational
   • Design and engineering
   • Methodologists
• Broad range of forms of enquiry needed
       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.
       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.
        Developing methods to assess
         barriers and facilitators 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)
        Developing methods to assess
         barriers and facilitators to KT
• Formal assessment of context, likely barriers to KT
• Mixed methods
  • Literature review
  • Informal consultation
  • Focus groups
  • Surveys
• Needs interdisciplinary perspective
Developing methods to assess
 barriers and facilitators to KT
        Developing methods to assess
         barriers and facilitators to KT
1. Knowledge
2. Skills
3. Professional role and identity
4. Beliefs about capabilities
5. Beliefs about consequences
6. Motivation and goals
7. Memory, attention and decision processes
8. Environmental context and resources
9. Social influences
10. Emotion
11. Behavioural regulation
12. Nature of the behaviour
Developing methods to assess
 barriers and facilitators to KT
        Developing methods to assess
         barriers and facilitators to KT
• Focus groups, theoretical approach
• Ongoing cluster RCT to develop and evaluate
  intervention to improve GP management of low
  back pain ( diagnostic imaging,  exercise)
• Conducted focus group with 42 general
  practitioners
• Focus group analysis based upon the BPS
  domains
   Developing methods to assess
    barriers and facilitators to KT



                        ‘It Seemed
ISLAGIATT               Like A Good
  principle             Idea At The
                        Time’


         Martin P Eccles
            Developing methods for
            optimizing KT strategies
• 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
            Developing methods for
            optimizing KT strategies
• Intervention mapping
   • Specify intervention objectives
   • Select methods and strategies
   • Design program




• Usability studies
           Developing methods for
           optimizing KT strategies

• We have found it useful to distinguish:
  • What we are trying to change
  • Why are we trying to change it? (constructs:
    barriers and enablers)
  • How are we going to change it, including
     • Behaviour change technique
     • Context: the mode of delivery (eg group
       meeting, DVD)
     • Content: how the technique will be
       operationalised
Developing methods for
optimizing KT strategies
                     Matching behaviour change techniques to theoretical constructs

                     Social/        Knowledge   Skills    Beliefs        Beliefs about   Motivati   Memory,      Environme   Social
 Technique for
                     Professional                         about          consequences    on and     attention,   ntal        influen
behaviour
                     role &                               capabilities                   goals      decision     context
change
                     identity                                                                       processes    and
                                                                                                                 resources
Goal/target          1              2 1         3 2 3     1              3 1             3 3 3 3    1 1          1           1

specified:
Monitoring           1              2           3 3 3     1 2 2          1 2 2           1 2 2      1 2 2        2           1 2


Self-monitoring                                 2 3 3     3 3 2 3        3 2 2 2         1 3 2 1    2 23



Contract             2 1                        1         1              1 1             2 3 1 2    2                        3 2



Rewards;             1 2 1          1           3 3 3     2 1            2 1 2           2 3 3 3    1 1 2        1           1 2


Graded task,         1              1           3 3 2     2 2 3          2               2 3 2 2    1 2          1           1


Increasing skills:   1 2                        3 3 3 3   2 2 3 2        1               2 3 2      1 2                      1



Stress               1                          1 2       1 1 1          1               1 2 1      1 2 1                    1

management
Coping skills        1                          2/3 3 1   2 2 2          1               1          1 1                      1 1



Rehearsal of         1                          3 3 3 3   2 3 2                          2 1        2 1

relevant skills




                             agree use; agree don’t use; disagreement;
Developing methods for optimizing KT
  strategies – IMPLEMENT example
• What we are trying to change?
   • Knowledge of what red flags are and skills in how to
     identify them and diagnose acute low back pain
• Why are we trying to change it?
   • Construct: Knowledge (GP)
• How are we going to change it?
   • Technique: Information provision
   • Context: educational meeting; advertising campaign;
     DVD
   • Content: Behavioural task with feedback; eg in pairs
     run through the process; quiz?; practise use of an
     algorithm
Developing methods for optimizing KT
  strategies – IMPLEMENT example
• What we are trying to change?
   • Skills and beliefs about capabilities related to giving advice to
     stay active (inc what advice to give)
• Why are we trying to change it?
   • Construct: Skills, Knowledge (GP), Beliefs about capabilities
• How are we going to change it?
   • Technique: behavioural rehearsal; role play; scripting
   • Context: educational meeting; advertising campaign; DVD
   • Content: Participants write down wording of their last or usual
     message to stay active and then discuss in groups of 2-4 and
     create a script they feel comfortable with. Then role play with
     feedback. Educators model if necessary. Idea is that GPs
     should feel comfortable with wording of their own script,
     compared with a generic script, so that it is in their own language
     and consistent with the way they speak, behave, etc
Developing methods for optimizing KT
  strategies – IMPLEMENT example
•   Two small group educational meetings
•   Homework
•   DVD, educational materials
•   Patient leaflets
            Session One. Confidence in Diagnosis

            Section Title                Behaviour change techniques delivered   Content

            Welcome and                  - Information provision                 Group introductions; Agenda and content for session
                 Introductions

            Small group work No.1:       - Prompt barrier identification         - Discussion in small groups (3-4) and fed back to larger
Session 1         Discussion of pre-
                  session reflective
                                         - Persuasive communication
                                         - Provide information on consequences
                                                                                         group about implementing the key message about
                                                                                         x-ray use
                  activity about x-      - Provide opportunities for social      - Facilitator recorded barriers and enablers and revisited
                  ray                           comparison                               throughout session

            Guideline                    - Information provision                 - Didactic presentation from facilitator with group
                  recommendations        - Persuasive communication                      discussion
                                                                                 - Introduction to acute non-specific LBP; Guideline
                                                                                         development and stakeholders; Overview of
                                                                                         guideline key messages

            Small group No.2:            - Prompt barrier identification         - Participants reworded x-ray key message from guideline -
                  Making                                                                 by who, applying to who, what, where, when
                  recommendations
                  behaviourally
                  specific

            Revisit small group          - Persuasive communication              - All group discussion. Facilitator challenged negative
                   discussions No.1                                                      beliefs using persuasive communication and
                   and No.2                                                              reinforce relevance of key message to GPs and
                                                                                         LBP patients

            Plain film x-ray for acute   - Provide information on consequences   - Didactic presentation from radiologist, outlining potential
                    LBP                  - Persuasive communication                     harms and non-utility of x-ray for LBP

            Red flag screening           - Model/demonstrate the behaviour       - Peer expert took clinical history of simulated patient
                                                                                        demonstrating red flag screening and resisting
                                                                                        pressure from patient to order an x-ray

            Small group No.3:            - Prompt practice (rehearsal)           - Participants took clinical history of trained simulated
            Red flag screening           - Provide information on consequences           patients who are demanding a x-ray
                   practical             - Persuasive communication              - Group discussion including feedback from simulated
                                                                                         patients

            Summary                      - Prompt barrier identification         - Group discussion - reflect on barriers on whiteboard
                                         - Persuasive communication              - Questions; outstanding issues
                                         - Provide opportunities for social
                                                comparison
Developing methods for optimizing KT
    strategies – Usability studies
• Develop prototype intervention
• Test prototype in 5 to 8 subjects to review content and
  format using ‘think aloud’ methodology. These sessions
  will be audio recorded and the results transcribed and
  analysed.
• In general a modest number of subjects are required for
  usability testing (e.g. 8-9 subjects), and often 4 to 5 are
  necessary to identify 80% of the usability problems.
• Cycles of design, development and testing will be
  completed until no further major revisions are needed.
          Evaluating the effectiveness
         and efficiency of KT strategies
• 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
            Evaluating the effectiveness
           and efficiency of KT strategies
• 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.
 Evaluating the effectiveness
and efficiency of KT strategies
          Evaluating the effectiveness
         and efficiency of KT strategies
• Pragmatic 2 x 2 factorial design of two forms of
  educational materials – replicated for three behaviours
  (aggressive cardiovascular risk management in diabetes,
  diabetic eye screening and use of thiazides for first line
  hypertension management)
• Largest implementation trial to date – approx 6,500
  family practices in Ontario
• No statistically significant differences
         Evaluating the effectiveness
        and efficiency of KT strategies

• Other forms of enquiry needed to determine
  causal explanation
   • Intervention fidelity studies
   • Process evaluations (qualitative case studies)
   • Theory based process evaluations (mediating
     pathways)
   • Secondary analyses (moderator analyses)
   • Temporal analyses
• Embedded economic evaluations
 Evaluating the effectiveness
and efficiency of KT strategies
          Evaluating the effectiveness
         and efficiency of KT strategies
• Conducted a theory based process evaluation alongside
  OPEM trial
• Hypothesised that OPEM interventions would likely be
  mediated through changes in intentions, attitudes and
  social norms
• Administered TPB survey before and after intervention
  for two replications (thiazides, diabetic screening)
• Before data demonstrated very positive intentions,
  attitudes and social norms – possibly suggesting
  ‘psychological ceiling effect’, family doctors able to
  identify lots of post intention barriers to behaviours
• Theory based process evaluation aided interpretation of
  the study results
          Evaluating the effectiveness
         and efficiency of KT strategies
Need to build a cumulative science
• O’Brien (2007) SR of 66 RCTs of Academic detailing -
  Median effect across 16 RCTs of prescribing behaviour
  4.8% absolute improvement, interquartile range 3.0% to
  6.5%
• WE DO NOT NEED FURTHER TWO ARM TRIALS OF
  ACADEMIC DETAILING VS CONTROL AS THEY WILL
  LIKELY PROVIDE LITTLE NEW INFORMATION
• Need for increased use of multi arm trials/factorial trials
  to increase informativeness of trials
        Evaluating the effectiveness
       and efficiency of KT strategies
Need to build a cumulative science
              Developing KT theory

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
Developing KT theory
            Developing KT methods

• Substantial methodological differences between cluster
  randomized trials and conventional randomized trials
  pose serious challenges to the current conceptual
  framework for research ethics
    Developing the field of 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
• Move towards research programs and laboratories
Developing the field of KT research




www.implementation science.com
    Developing the field of KT research

Challenges
• Advocating for ongoing research support
• Incremental development of generalisable knowledge
  (requires greater standardisation of concepts,
  terminology, methods and reporting)
• Facilitating interdisciplinarity
• Capacity development
• Career progression
• ?Establish a formal field
• Translating Knowledge translation research
               Contact details

• Jeremy Grimshaw
  jgrimshaw@ohri.ca
• EPOC
  epoc@uottawa.ca
  http://www.epoc.uottawa.ca/index.htm
• Implementation Science
  http://www.implementationscience.com

								
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