11/5/15
Improving patient outcomes through knowledge translation
Simon French PhD, MPH, BAppSc(Chiro)
Associate Professor, Canadian Chiropractic Research Foundation Professorship in Rehabilitation Therapy
Faculty of Health Science, Queen’s University, Canada
[email protected]
Presentation outline
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Introduction to implementation (knowledge translation) Overview of knowledge translation research
How to develop KT interventions
How do you make a change to clinical practice?
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Australian early days…
Research must be actively pursued and developed and as fast as new knowledge is acquired it must be applied
Commonwealth Minister for Health,
William (Billy) Hughes, 1936
All breakthrough, no follow through
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For every dollar allocated to develop breakthrough treatments, one cent is allocated to ensure that patients actually receive them1
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Much of the US$240 billion/year worldwide investment in biomedical and healthcare research is wasted due to implementation failures2
1. Woolf Washington Post 2 006
2. M acleod et al Lancet 2 014
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The quality problem...
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Research consistently producing new findings
Findings won’t change patient outcomes unless they are adopted
Evidence-­‐to-­‐practice gaps
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variability between recommendations and c linical practice, across different settings and c linical c onditions
20%-­‐3 0% patients may get c are that i s not needed or c are that could be potentially harmful 1
“poverty of r esearch” to inform decisions about how to improve the delivery of health care2
1. Schuster M ilbank Q 2 005; 2 . G rol BMJ 2008
Participants received 54.9 percent (95%CI: 54.3, 55.5) of
recommended care…
The deficits we have identified in adherence to recommended
processes for basic care pose serious threats to the health of the
American public.
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Evidence-­‐to-­‐practice gaps for the management of MSK conditions
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Osteoarthritis
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Osteoporosis
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Lack of PT and other conservative care (exercise and weight loss)
Unnecessary arthroscopy
Lack of screening (DEXA scan) after minimal
trauma fracture
Vertebroplasty for vertebral fracture
Low back pain
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Unnecessary imaging
Excessive opioid prescription
Unnecessary surgery
Buchbinder et al. Nat Rev Rheumatol 2015;11:597-­‐6 05
So, change is needed…. but….
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...there is nothing more difficult to take in hand ... than to take the lead in the introduction of a new order of things...
Niccolò Machiavelli (c1505)
Solution? Knowledge translation
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Ensuring stakeholders are aware of and use research evidence to inform their health and healthcare decision-­‐making
Ensuring research is informed by current available evidence and the experiences and information needs of stakeholders
Grimshaw et al Implement Sci 2012;7:50
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Alternate terms used
to describe KT
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Knowledge Transfer
Knowledge Uptake
Research Utilisation
Implementation
Diffusion of Innovation
Quality improvement
Knowledge Management
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Dissemination & Implementation
Knowledge to Action
Knowledge Mobilisation
Research Translation
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…and many others ...
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McKibbon et al, Implement Sci 2010
CIHR knowledge translation definition
A dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products and strengthen the healthcare system
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Knowledge-­‐
to-­‐Action Cycle
Graham et al, J Eval Clin Pract 2006, 26:13-­‐2 4
Straus et al (eds), Knowledge translation in health care, 2013
What knowledge should be translated?
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Individual studies
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Rarely by themselves provide sufficient evidence
May be misleading due to bias in conduct or random variation in findings
High quality up to date synthesis of knowledge eg:
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Cochrane systematic reviews
Evidence-­‐based clinical practice guidelines
Grimshaw et al Implement Sci 2012;7:50
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Translation: continuum of research
Institute of Medicine, Clinical Research Roundtable
Sung JAMA 2003
So how can knowledge be translated?
Implementation (KT) Interventions
Complex interventions designed to change behaviour:
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Organisational
Practitioner
Patient
Decision-­‐maker/policy m aker
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So how can knowledge be translated?
100% quality
All of these approaches
(and more) but no
magic bullet
% improvemt
Educational Educational
meetings
outreach
Audit and
feedback
Guidelines Reminders
Patient
directed
Grimshaw et al 2004, Health Tech Assess
Davies et al 2010, Implement Science
Evidence for effects of KT interventions
Intervention
Number Effect s ize of s tudies (median absolute improvement in desired practice)
Interquartile Range
Educational meetings
(Forsetlund 2009)
81 RCTs
+6.0%
+2% to +16%
Computer-­‐generated paper reminders (Arditi 2012)
27 RCTs,
5 NRCTs
+11.2% +7% to +20%
Audit and feedback ( Ivers 2 012)
140 RCTs
+4.3%
+0.5% to +16%
Educational outreach ( O’Brien 2 007)
69 RCTs
+5.6%
+3% to +9%
14 RCTs, 31 NRCTs
+2.0%
0% to +11%
3 RCTs,
4 NRCTs
Insufficient evidence
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Printed educational materials
(Giguère 2012)
Financial incentives in p rimary care (Scott 2 011)
Cochrane Effective Practice and Organisation of Care (EPOC) reviews
www.thecochranelibrary.com
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Which KT intervention/s to choose?
ISLAGIATT
principle
‘It Seemed
Like A Good
Idea At The
Time’
Martin Eccles
So…
More careful planning needed…
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Changing practice: problem analysis
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Systematically identify:
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evidence-­‐practice gap
barriers and facilitators to change
Select intervention components that address barriers and facilitators
Combine techniques into a d eliverable intervention
Test feasibility and acceptability
Evaluate with a rigorous d esign
Craig et al BMJ 2008;337:a1655
Wensing et al CMAJ 2010;182:E85-88
Behavioural perspective for KT
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Knowledge translation depends on behaviour
n Community members, patients, health professionals, managers, policy makers, etc
To improve KT, need behaviour change
Theory and evidence help to understand how behaviour change occurs
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Approach to KT intervention development
Evidence
Define behaviour
Theory
Descriptive research:
interviews, survey
Understand behaviour
Evaluative research:
Design and test targeted, theoryinformed intervention in cRCT
Change behaviour
Practical considerations
Theoretical Domains Framework
Skills
Knowledge
Beliefs about
capabilities
Environmental
context and
resources
Social/Professional
role and identity
Social influences
Beliefs about
consequences
Emotion
Goals
Optimism
Reinforcement
Behavioural
regulation
Intentions
Memory, Attn &
decision
processes
Michie et al 2005, J Qual Safe Health Care
Cane, O'Connor, Michie. 2012 Implement Sci
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Designing an implementation intervention:
Which intervention components?
Barrier is . . .
Consider . . .
Lack of knowledge
Education session
Decision aids
Perception / reality mismatch
Audit and feedback
Reminders
Lack of motivation
Incentives / sanctions
Beliefs / attitudes
Peer influence
Opinion leaders
Forget
Reminders
KT research example
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KT research example: Low back pain (LBP)
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LBP is common (70% of adult population) and disabling
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World’s leading cause of disability due to non-­‐fatal health outcomes from diseases and injuries
At any time one in every five Canadians have LBP
One of the m ost common health problems in Canadian primary care
95% of LBP is non specific; serious conditions presenting as LBP are very rare
People with LBP don’t always get the best possible care
KT research example: acute LBP
“I want to run a few tests on you, just to cover my ass”
Key r ecommendations
• X-­‐rays are not required, except when fracture is suspected
• Patients with acute non-­‐specific LBP should be given advice to stay active
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Describing and u nderstanding p ractice
Intervention development phase
Definitive trial phase
Recruitment & R andomisation
Intervention delivery
Intervention fidelity
Costeffectiveness
analysis
Usual practice
Outcome m easurement
Trial analysis & interpretation
IMPLEMENT & ALIGN study designs
Designing KT interventions: 4 step process
Q1: Who n eeds to d o what, differently?
Q2: Using a theoretical
framework, which b arriers and
enablers n eed to b e addressed?
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Identify t he evidence-­‐practice gap
Specify t arget health professional group
Specify behaviour change needed
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Select t heory(ies) or frameworks likely t o inform the pathways of change
Use t heory(ies) or framework t o identify pathways of change and possible barriers and enablers
Use qualitative/quantitative methods t o identify barriers/enablers
Use chosen theory or framework t o identify •
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Q3: Which intervention components could overcome the modifiable b arriers and enhance
the enablers?
Q4: H ow can b ehaviour change be measured and u nderstood?
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potential BCTs t o overcome barriers and enhance enablers
Identify evidence t o inform selection of BCTs and modes of delivery
Identify w hich are likely t o be feasible, locally relevant and acceptable
Identify mediators of change t o investigate proposed pathways of change Select appropriate outcome measures
Determine feasibility of outcomes
French et al, Implementation Science, 2012
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Designing the KT intervention: example
Step 1 : Who n eeds to d o what d ifferently?
Step 2 : Using a theoretical
framework, which b arriers and
enablers n eed to b e addressed?
Step 3 : Which intervention components
could overcome the modifiable b arriers
and enhance the enablers?
Step 4 : H ow will we measure
behaviour change?
GPs n eed to order less x-­‐rays for
people with acute low b ack p ain
Skills & Beliefs a bout capabilities:
related to n egotiating with/
reassuring p atients that p lain
x-­‐ray is u nnecessary
Modelling;
Behavioural rehearsal;
Role p lay
Attendance a t interactive workshops;
Self-­‐report o f viewing D VD; Scores o n s elf-­‐efficacy items
TDF as a framework/toolkit for developing a knowledge translation intervention
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IMPLEMENT intervention
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Designed to address barriers & enablers to uptake of the guideline
Series of behaviour change techniques delivered via interactive facilitated workshops, e.g.:
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Information provision
Model/demonstrate the behaviour
Persuasive communication
Role play
2X workshops, 3 hours duration
Has our approach worked?
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IMPLEMENT GP study1 :
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For behavioural simulation, intervention group GPs w ere more likely to adhere to guideline recommendations about x-­‐ray ( OR 1.76, 95%CI 1.01, 3.05) and m ore likely to give advice to stay active ( OR 4.49, 95%CI 1.90 to 10.60)
Were unable to m easure change in actual behavior or clinical outcomes
ALIGN chiro/physio study2 :
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To be continued…
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1. French et al PLoS One 2013;8:e65471
McKenzie et al, Implement Sci 2010;5:86
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Broader evidence for this approach?
Conclusion:
Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines… Research is required to determine the effectiveness of tailored interventions in comparison w ith other interventions.
Where to go for more information about KT
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CIHR: Guide to Knowledge Translation Planning at CIHR: I ntegrated and End-­‐
of-­‐Grant Approaches: http://www.cihr-­‐irsc.gc.ca/
Books
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Journals
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Straus S et al. Knowledge t ranslation in health care moving from evidence t o practice,
2nd Ed. London: Wiley-­‐Blackwell, BMJ Books; 2013
Grol R et al. Improving patient care: t he implementation of change in clinical practice,
2nd Ed. London: Wiley-­‐Blackwell, BMJ Books; 2013
Implementation Science: http://www.implementationscience.com/
BMJ Quality & Safety
Many others… including general medical journals like BMJ, JAMA, NEJM
Cochrane Effective Practice & O rganisation of Care Review Group: http://epoc.cochrane.org/
KT planning template: http://www.melaniebarwick.com/
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Conclusion
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Knowledge Translation needs to be informed by implementation research
n More rigorous approach required for the development
and evaluation of KT interventions
A theory-­‐informed and evidence-­‐based approach to KT intervention development will lead to a m ore systematic and robust field
With promising benefits to human health
To m ake a change in your clinical practice…
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Adopt a rigorous approach by determining barriers/facilitators and design a tailored KT strategy to address these
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