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Knowledge infrastructure for KT
Jeremy Grimshaw MD, PhDClinical Epidemiology Program, OHRI
Department of Medicine, University of Ottawa
Canada Research Chair in Health Knowledge Transfer and Uptake
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Personal background
• Trained as family doctor in UK• PhD in health services research• Developed implementation research program
in UK• Moved to Canada in 2002
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Personal perspective
• Focus has been on:• professional and organizational behavior
change.• improving technical aspects of care ie how
do we ensure patients get the right (evidence based) treatments at the right time.
• populations of physicians and health care organizations.
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Outline
• KT
• K for KT
• KI (Infrastructure) for KT
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KT
What’s in a name……
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KT terms encountered
applied health researchcapacity buildingco-optation - cooperation -
competingdiffusion*dissemination* getting knowledge into practiceimpactImplementation* knowledge communicationknowledge cycleknowledge exchange knowledge managementknowledge translation
knowledge mobilization knowledge transfer linkage and exchangepopularization of research, research into practiceresearch mediationresearch transferresearch translation science communication teaching“third mission” translational research transmission utilization
*cited most frequently
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Knowledge translation
CIHR 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
• 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
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Knowledge translation
Audience Basic Clinical Health Services
Population Health
Researchers +++ +++ +++ +++
Professionals +++ +++
Patients +++ +++
Administrators +++ +++
Policy Makers +++ +++ +++
Industry +++ +++
…..
Audiences for KT
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Knowledge translation
Why do we need to think about knowledge translation? • Traditional KT approaches have emphasised
publication in peer reviewed journals• 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 harmfulSchuster, McGlynn, Brook (1998). Milbank Memorial Quarterly
Grol R (2001). Med Care
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K for KT
Where’s the beef?
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K for KT
• Individual studies rarely by themselves provide sufficient evidence for policy or practice changes
• Individual studies are often misleading• An additional issue is dealing with the hype
from scientific discoveries
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Don’t believe the hype – likelihood of benefit from basic science discoveries
25, 190 articles (published in 1979-1983 in Nature, Science, Cell, JEM, JCI, JBC)
562 articles (retrieved key word search)
153 potentially eligible articles (full text)
101 original articles that made clear promises for immediate clinical translation
Contopoulos-Ioannidis et al. Am J Med 2003 and Ioannidis JP. J Translational Med 2004
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Years after index basic science publication
242220181614121086420
Prop
ortio
n w
ith ra
ndom
ized
clin
ical
tria
l
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
0.0
Years after index basic science publication
242220181614121086420
Prop
ortio
n w
ith "p
ositi
ve" r
ando
miz
ed tr
ial
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
0.0
RCT Positive RCT
Don’t believe the hype – likelihood of benefit from basic science discoveries
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Don’t believe the hype: early highly positive results often contradicted
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Don’t believe the hype: early highly positive results often contradicted
• Analyzed 115 articles published in 1990-2003 in the 3 major general medical journals (NEJM, JAMA, Lancet) and specialty journals that had received over 1000 citations each by August 2004
• 49 reported evaluations of health care interventions; 45 claimed that the interventions were effective.
• By 2004 5/6 non randomised studies and 9/39 randomised trials were already contradicted or found to be exaggerated
Ioannidis JP. JAMA 2005
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Total genetic information (subjects or alleles)
100005000
40003000
20001000
500400
300200
10050
40
Cu
mu
lative o
dds r
atio
543
2
1
,5,4,3
,2
,1
,05,04,03,02
DISEASE/GENE
Nephropathy/ACE
Alcoholism/DRD2
HTN/Angiotensinogen
Parkinson/CYP2D6
Lung cancer/GSTM1
Schizophrenia/DRD3
Down dementia/APOE
Lung cancer/CYP2D6
Don’t believe the hype: early highly positive results often contradicted
Ioannidis et al, Nature Genetics 2001
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K for KT
• The results of individual studies need to be interpreted alongside the totality of evidence (ie systematic reviews)
• Emphasis on KT of individual studies may distract the stakeholder group (increasing the noise to signal)• ‘Don’t believe the hype’• ‘Don’t generate the hype’
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K for KT
Users’ Guides to the Medical Literature
‘We now recommend that resolving a clinical problem begins with a search for a valid systematic review or practice guideline as the most efficient method of deciding on the best patient care.’
Guyatt GH, Rennie D (1994). JAMA.
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K for KT
• Systematic reviews are a generic methodology used to synthesise evidence from a broad range of research methods addressing different questions.
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K for KT
• The steps involved in undertaking a systematic review include • stating the objectives of the research • defining eligibility criteria for studies to be
included • identifying (all) potentially eligible studies • applying eligibility criteria • assembling the most complete dataset feasible • analysing this dataset, using statistical synthesis
and sensitivity analyses, if appropriate and possible
• preparing a structured report of the research.
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K for KT
• Systematic reviews are a generic methodology used to synthesise evidence from a broad range of research methods addressing different questions. • Effectiveness of health care interventions• Diagnostic and screening tests• Determinants of health• Aetiological epidemiological studies• Genetic epidemiological studies• Health system issues (eg quality of discharge
coding)• Qualitative methods – consumers’ experiences of
health care
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Systematic reviews of ‘what works’ questions
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K for KT
• Increasing availability of high quality guidelines and systematic reviews available to support practice:• Cochrane Collaboration• AHRQ evidence based practice reports• HUGENet• Multiple guideline development agencies
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The Cochrane Library
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The Cochrane Library
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KI for KT
If you build it they will come…
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Knowledge infrastructure for knowledge translation
• Canadian health care systems have largely failed to invest in knowledge infrastructure
• As a result, they abrogate responsibility for knowledge management to consumers, health care professionals, managers and policy makers
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Knowledge infrastructure for knowledge translation
Reality check• Over 20,000 medical journals published per
year• Published research of variable quality and
relevance• Users often poorly trained in critical
appraisal skills• Users often have limited time (average time
professionals have available to read = <1 hour/week)
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Knowledge infrastructure for knowledge translation
• Canadian health care systems have largely failed to invest in knowledge infrastructure
• As a result, they abrogate responsibility for knowledge management to consumers, health care professionals, managers and policy makers
• Health care systems need to invest in knowledge infrastructure
• Knowledge infrastructure should be considered as important as the sewers for a knowledge based health care system
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Knowledge infrastructure for knowledge translation
• Potential components for regional knowledge infrastructure:• Push• Pull• Linkage and exchange
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Knowledge infrastructure for knowledge translation
• Potential components for regional knowledge infrastructure:• Push
Knowledge management• Rapid response services
eg. Aggressive Research Information Service (West Midlands, UK)
• Knowledge intelligence services• Clearing houses for evidence based tools
eg decision aids, clinical practice guidelines, health technology assessments
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Knowledge infrastructure for knowledge translation
• Potential components for regional knowledge infrastructure:• Push
Knowledge packaging and communications• Friendly front ends
eg actionable messages for policy makers and managers
• Targeted push of summarised information
eg Contacts, Help, Advice and Information Networks (CHAIN)
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Knowledge infrastructure for knowledge translation
• Potential components for regional knowledge infrastructure:• Pull
• Capacity building for potential research users• EXTRA (senior managers)• SEARCH (front line managers)• Cochrane Consumer training
• Requiring explicit documentation of how evidence was considered within decision making
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Knowledge infrastructure for knowledge translation
• Potential components for regional knowledge infrastructure:• Linkage and exchange
• Local R&D function that can undertake small scale projects eg to identify priorities for KT and service delivery, to assess applicability of research evidence to local settings, to support local quality improvement efforts
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Knowledge infrastructure for knowledge translation
• Skill sets needed for regional knowledge infrastructure:• Information science skills• Clinical and policy skills• Basic research skills• Adult education skills• Quality improvement skills• Informatics
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Knowledge infrastructure for knowledge translation
• Skill sets needed for regional knowledge infrastructure:• Information science skills (oh did I mention that
already? Senior moment, forgive me but you’re really important you know for health care systems in the 21st century)
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Knowledge infrastructure for knowledge translation
• Budget needed for regional knowledge infrastructure:• Unclear. What would be reasonable to support
knowledge management for a population of 1 million citizens?
• More pressing is how do we articulate the value argument for a regional knowledge infrastructure. I suspect that everyone would accept the argument for better evidence however no-one appears to want to pay for this (unlike electronic health records etc)
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KI necessary but not sufficient
Knowledge infrastructure is necessary but not sufficient to ensure knowledge translation
The new tower of Babel?Hibble, Kanka, Pencheon, Pooles. BMJ (1998)
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Summary
• Knowledge translation is about ensuring that stakeholders are aware of and use research evidence to inform their decision making
• KT should be seen as a shared responsibility between the research community, the health care system and the society in which they work.
• Investment in knowledge infrastructure is essential to the development of a knowledge based infrastructure
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Contacts
• [email protected]• Canadian Cochrane Centre
http://www.ccnc.cochrane.org/en/index.html• The Cochrane Collaboration
http://www.cochrane.org