Knowledge infrastructure for KT Jeremy Grimshaw MD, PhD Clinical Epidemiology Program, OHRI Department of Medicine, University of Ottawa Canada Research.

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

Personal background

• Trained as family doctor in UK• PhD in health services research• Developed implementation research program

in UK• Moved to Canada in 2002

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.

Outline

• KT

• K for KT

• KI (Infrastructure) for KT

KT

What’s in a name……

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

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.


• 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


Audience Basic Clinical Health Services

Population Health

Researchers +++ +++ +++ +++

Professionals +++ +++

Patients +++ +++

Administrators +++ +++

Policy Makers +++ +++ +++

Industry +++ +++

…..

Audiences for KT


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

K for KT

Where’s the beef?

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

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

Years after index basic science publication

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Years after index basic science publication

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RCT Positive RCT

Don’t believe the hype – likelihood of benefit from basic science discoveries

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

Total genetic information (subjects or alleles)

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DISEASE/GENE

Nephropathy/ACE

Alcoholism/DRD2

HTN/Angiotensinogen

Parkinson/CYP2D6

Lung cancer/GSTM1

Schizophrenia/DRD3

Down dementia/APOE

Lung cancer/CYP2D6


Ioannidis et al, Nature Genetics 2001

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’

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.

K for KT

• Systematic reviews are a generic methodology used to synthesise evidence from a broad range of research methods addressing different questions.

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.

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

Systematic reviews of ‘what works’ questions

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

The Cochrane Library

The Cochrane Library

KI for KT

If you build it they will come…

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


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)


• 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


• Potential components for regional knowledge infrastructure:• Push• Pull• Linkage and exchange


• 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


• 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)


• 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


• 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


• Skill sets needed for regional knowledge infrastructure:• Information science skills• Clinical and policy skills• Basic research skills• Adult education skills• Quality improvement skills• Informatics


• 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)


• 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)

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)

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

Contacts

• [email protected]• Canadian Cochrane Centre

[email protected]

http://www.ccnc.cochrane.org/en/index.html• The Cochrane Collaboration

http://www.cochrane.org

Knowledge infrastructure for KT Jeremy Grimshaw MD, PhD Clinical Epidemiology Program, OHRI Department of Medicine, University of Ottawa Canada Research.

Documents

kt slide

hype slide

contradicted slide

research evidence

uptake slide

med care slide

knowledge infrastructure

knowledge users