1. Knowledge infrastructure for KT Jeremy Grimshaw MD, PhD Clinical Epidemiology Program, OHRI Department of Medicine, University of Ottawa Canada Research Chair in Health Knowledge Transfer and Uptake

2. Personal background Trained as family doctor in UK PhD in health services research Developed implementation research program in UK Moved to Canada in 2002

3. 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.

4. Outline KT K for KT KI (Infrastructure) for KT

5. KT What’s in a name……

6. KT terms encountered applied health research capacity building co-optation - cooperation - competing diffusion* dissemination* getting knowledge into practice impact Implementation* knowledge communication knowledge cycle knowledge exchange knowledge management knowledge translation knowledge mobilization knowledge transfer linkage and exchange popularization of research, research into practice research mediation research transfer research translation science communication teaching “third mission” translational research transmission utilization *cited most frequently

7. 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.

8. 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

9. Knowledge translation AudienceBasicClinicalHealth Services Population Health Researchers+++ Professionals+++ Patients+++ Administrators+++ Policy Makers+++ Industry+++ ….. Audiences for KT

10. 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 harmful Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly Grol R (2001). Med Care

11. K for KT Where’s the beef?

12. 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

13. 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

14. RCTPositive RCT Don’t believe the hype – likelihood of benefit from basic science discoveries

15. Don’t believe the hype: early highly positive results often contradicted

16. 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

17. Don’t believe the hype: early highly positive results often contradicted Ioannidis et al, Nature Genetics 2001

18. 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’

19. 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.

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

21. 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.

22. 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

23. Systematic reviews of ‘what works’ questions

24. 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

25. The Cochrane Library

27. KI for KT If you build it they will come…

28. 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

29. 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)

30. 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

31. Knowledge infrastructure for knowledge translation Potential components for regional knowledge infrastructure: Push Pull Linkage and exchange

32. 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

33. 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)

34. 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

35. 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

36. 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

37. 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 21 st century)

38. 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)

39. 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)

40. 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

41. Contacts jgrimshaw@ohri.ca Canadian Cochrane Centre cochrane@uottawa.ca http://www.ccnc.cochrane.org/en/index.html The Cochrane Collaboration http://www.cochrane.org