Advancing the science of knowledge translation

Advancing the science of knowledge translation

Jeremy Grimshaw for KT CanadaClinical Epidemiology Program, OHRI

Department of Medicine, University of OttawaCanada 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 QuarterlyGrol 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.


KT terms encounteredapplied 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


• 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.

• 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



1. Knowledge2. Skills3. Professional role and identity4. Beliefs about capabilities 5. Beliefs about consequences6. Motivation and goals7. Memory, attention and decision processes8. Environmental context and resources9. Social influences 10.Emotion11.Behavioural regulation12.Nature of the behaviour



• 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


ISLAGIATT principle

Martin P Eccles

‘It Seemed Like A Good Idea At The Time’

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


• Intervention mapping• Specify intervention objectives• Select methods and strategies• Design program

• Usability studies


• 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


Technique for behaviour change

Social/ Professional role & identity

Knowledge Skills Beliefs about capabilities

Beliefs about consequences

Motivation and goals

Memory, attention, decision processes

Environmental context and resources

Social influences

Emotion Action planning

Goal/target specified:

1 2 1 3 2 3 1 3 1 3 3 3 3 1 1 1 1 1 1 3 2 3 3

Monitoring 1 2 3 3 3 1 2 2 1 2 2 1 2 2 1 2 2 2 1 2 2 1 1 2

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

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

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

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

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

Stress management

1 1 2 1 1 1 1 1 2 1 1 2 1 1 3 3 2 1 1

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

Rehearsal of relevant skills

1 3 3 3 3 2 3 2 2 1 2 1 3 2 3 1 1

Matching behaviour change techniques to theoretical constructs

agree use; agree don’t use; disagreement; indefinite

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


• 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


• 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 Introductions

- Information provision Group introductions; Agenda and content for session

Small group work No.1: Discussion of pre-session reflective activity about x-ray

- Prompt barrier identification- Persuasive communication- Provide information on consequences- Provide opportunities for social

comparison

- Discussion in small groups (3-4) and fed back to larger group about implementing the key message about x-ray use

- Facilitator recorded barriers and enablers and revisited throughout session

Guideline recommendations

- Information provision - Persuasive communication

- Didactic presentation from facilitator with group discussion

- Introduction to acute non-specific LBP; Guideline development and stakeholders; Overview of guideline key messages

Small group No.2: Making recommendations behaviourally specific

- Prompt barrier identification - Participants reworded x-ray key message from guideline - by who, applying to who, what, where, when

Revisit small group discussions No.1 and No.2

- Persuasive communication - All group discussion. Facilitator challenged negative beliefs using persuasive communication and reinforce relevance of key message to GPs and LBP patients

Plain film x-ray for acute LBP

- Provide information on consequences- Persuasive communication

- Didactic presentation from radiologist, outlining potential 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:Red flag screening

practical

- Prompt practice (rehearsal)- Provide information on consequences- Persuasive communication

- Participants took clinical history of trained simulated patients who are demanding a x-ray

- Group discussion including feedback from simulated patients

Summary - Prompt barrier identification- Persuasive communication- Provide opportunities for social

comparison

- Group discussion - reflect on barriers on whiteboard- Questions; outstanding issues

Session 1

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


• 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.



• 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


• 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



• 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


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


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


www.implementation science.com


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 [email protected]

• EPOC [email protected]://www.epoc.uottawa.ca/index.htm

• Implementation Sciencehttp://www.implementationscience.com

Documents

Advancing the science of knowledge translation