Lost in knowledge translation: time for a map?

Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: a cluster randomised controlled trial of knowledge transfer

Background

Hyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke.

Methods and design

Metropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control.

Discussion

This is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services.

Trial Registration

Australia New Zealand Clinical Trial Registry (ANZCTR) No: ACTRN12608000563369

EXACKTE(2): exploiting the clinical consultation as a knowledge transfer and exchange environment: a study protocol

Background

While the evidence suggests that the way physicians provide information to patients is crucial in helping patients decide upon a course of action, the field of knowledge translation and exchange (KTE) is silent about how the physician and the patient influence each other during clinical interactions and decision-making. Consequently, based on a novel relationship-centered model, EXACKTE² (EXploiting the clinicAl Consultation as a Knowledge Transfer and Exchange Environment), this study proposes to assess how patients and physicians influence each other in consultations.

Methods

We will employ a cross-sectional study design involving 300 pairs of patients and family physicians from two primary care practice-based research networks. The consultation between patient and physician will be audio-taped and transcribed. Following the consultation, patients and physicians will complete a set of questionnaires based on the EXACKTE² model. All questionnaires will be similar for patients and physicians. These questionnaires will assess the key concepts of our proposed model based on the essential elements of shared decision-making (SDM): definition and explanation of problem; presentation of options; discussion of pros and cons; clarification of patient values and preferences; discussion of patient ability and self-efficacy; presentation of doctor knowledge and recommendation; and checking and clarifying understanding. Patients will be contacted by phone two weeks later and asked to complete questionnaires on decisional regret and quality of life. The analysis will be conducted to compare the key concepts in the EXACKTE² model between patients and physicians. It will also allow the assessment of how patients and physicians influence each other in consultations.

Discussion

Our proposed model, EXACKTE², is aimed at advancing the science of KTE based on a relationship process when decision-making has to take place. It fosters a new KTE paradigm by putting forward a relationship-centered perspective and has the potential to reveal unknown mechanisms that underline effective KTE in clinical contexts. This will result in better understanding of the mechanisms that may promote a new generation of knowledge transfer strategies.

Physiotherapists and use of low back pain guidelines: a qualitative study of the barriers and facilitators

INTRODUCTION

A new set of clinical practice guidelines (CPGs) for the management of low back pain (LBP) and prevention of persistent disability entitled "Clinic on Low back pain in Interdisciplinary Practice" (CLIP) was developed in the province of Quebec, Canada. The literature shows that simply disseminating CPGs does not necessarily lead to their adoption by clinicians. To improve adherence to CPGs among healthcare professionals, the literature suggests that there is a need to identify and address the factors impeding or facilitating their use. The aim of this study was therefore to identify the barriers to and facilitators of CLIP CPG use, as perceived by physiotherapists (PTs).

METHODS

A descriptive study using a qualitative method was conducted with a sample of 16 PTs from a variety of professional backgrounds. Each participant used the CPGs over a 6-week period with two patients suffering from LBP, and then participated in a semi-structured interview in which he or she was asked to identify the barriers and facilitators experienced.

RESULTS

The participating PTs identified many barriers and facilitators pertaining to the guidelines themselves, the users and the environment. Four key nodes emerged from these barriers and facilitators during data analysis. It appears that the clinicians' understanding of the CPGs, the level of compatibility between their practices and the CLIP CPG recommendations, the level of CPG relevance as perceived by the clinicians, and their level of agreement with the CPGs, all affected their use of the guidelines.

CONCLUSIONS

In order to increase CLIP CPG use, the implementation strategy to be developed should take into account the barriers and facilitators that were identified in this study.

Knowledge Translation in Disability and Rehabilitation Research

Knowledge translation (KT) has emerged recently in the health science community as a means to address perceived gaps in the application of the best research to treatment of disease. Specifically, in the area of disability and rehabilitation research, the National Institute on Disability and Rehabilitation Research (NIDRR) has identified KT as one of the three areas for critical outcome achievement. This article analyzes some of the issues raised by the notion of KT. First, the article puts KT in the broader context of the study of knowledge flow problems. Second, it introduces the knowledge value mapping (KVM) framework as an avenue for addressing some of the fundamental issues that KT raises in the context of disability and rehabilitation research. Third, it illustrates the application of the framework with a KVM case study of accessible currency. Finally, it discusses the implications of the case study in the broader context of health research agencies such as NIDRR.

Policy-contribution assessment and field-building analysis of the Robert Wood Johnson Foundation's Active Living Research Program

BACKGROUND

The Robert Wood Johnson Foundation requested this utilization-focused evaluation of its Active Living Research (ALR) program. This evaluation reports on the trajectory of influence of past and future ALR outcomes on field-building and policy contributions as well as on possible users of completed and disseminated ALR products.

METHODS

In 2006 and 2007, key-informant interviews were conducted with 136 representatives of first-line potential users of ALR research products, including state physical activity and nutrition program coordinators, policymakers, scientists, and funders. Literature reviews, bibliometric analyses, and document reviews served to describe the context for ALR's work and the ways it could enhance its utility for field building and policymaking.

RESULTS

The contributions of ALR to the emerging transdisciplinary field included leadership in the development of measurement tools, epidemiologic studies, implementation research, the translation of research to practice, and the communication of learned lessons to diverse audiences. ALR's contributions to policy discussions were found across a spectrum of policy-development phases that included describing the problem, raising awareness of alternative strategies for increasing physical activity, convening nontraditional partners, and evaluating policy implementation.

CONCLUSIONS

Policy-relevant research can make contributions to policymakers' thinking but almost never causes a change by itself. Five years after the original authorization of ALR, there is ample evidence of its recognition as a resource by key players, its field-building influence, and its contributions to policy discussions. All these bear promise for a broader contribution to obesity prevention. Recommendations for increasing ALR's impact on policy and practice are offered.

Knowledge brokering: exploring the process of transferring knowledge into action

Background

There are many theories about knowledge transfer but there are few clear descriptions of knowledge transfer interventions or the processes they involve. This failure to characterise structure and process in proposed KT interventions is a major barrier to the design and implementation of evaluations of particular KT strategies. This study is designed to provide a detailed description of the processes involved in a knowledge transfer intervention and to develop and refine a useful model of the knowledge transfer process.

Methods and design

This research is taking a sociological approach to investigating the process of knowledge transfer. The approach is designed to articulate the broad components of the knowledge transfer process and to test these against evidence from case study sites. The research falls into three phases. First, we have carried out a literature review to produce a theoretical framework of the knowledge transfer process. This involved summarising, thematically analysing and synthesising evidence from the literature. Second, we are carrying out fieldwork in a mental health setting based on the application of a knowledge brokering intervention. The intervention involves helping participants identify, refine and reframe their key issues, finding, synthesising and feeding back research and other evidence, facilitating interactions between participants and relevant experts and transferring information searching skills to participants. Finally, we are using the observations of the knowledge broker and interviews with participants to produce narratives of the brokering process. The narratives will be compared in order to identify evidence which will confirm, refute or revise each of the broad components of the knowledge transfer process. This comparison will enable us to generate a refined framework of knowledge transfer which could be used as a basis for planning and evaluating knowledge transfer interventions.

Discussion

This study will provide an opportunity for a detailed description of a knowledge transfer intervention and the processes which are involved. Our approach is also designed to enable us to develop and refine a useful model of the knowledge transfer process. We believe that it will significantly enhance the growing body of knowledge about knowledge transfer.

Mapping new theoretical and methodological terrain for knowledge translation: contributions from critical realism and the arts

Background

Clinical practice guidelines have been a popular tool for the improvement of health care through the implementation of evidence from systematic research. Yet, it is increasingly clear that knowledge alone is insufficient to change practice. The social, cultural, and material contexts within which practice occurs may invite or reject innovation, complement or inhibit the activities required for success, and sustain or alter adherence to entrenched practices. However, knowledge translation (KT) models are limited in providing insight about how and why contextual contingencies interact, the causal mechanisms linking structural aspects of context and individual agency, and how these mechanisms influence KT. Another limitation of KT models is the neglect of methods to engage potential adopters of the innovation in critical reflection about aspects of context that influence practice, the relevance and meaning of innovation in the context of practice, and the identification of strategies for bringing about meaningful change.

Discussion

This paper presents a KT model, the Critical Realism and the Arts Research Utilization Model (CRARUM), that combines critical realism and arts-based methodologies. Critical realism facilitates understanding of clinical settings by providing insight into the interrelationship between its structures and potentials, and individual action. The arts nurture empathy, and can foster reflection on the ways in which contextual factors influence and shape clinical practice, and how they may facilitate or impede change. The combination of critical realism and the arts within the CRARUM model promotes the successful embedding of interventions, and greater impact and sustainability.

Conclusion

CRARUM has the potential to strengthen the science of implementation research by addressing the complexities of practice settings, and engaging potential adopters to critically reflect on existing and proposed practices and strategies for sustaining change.

Evaluation of a partnership approach to translating research on breast cancer and the environment

BACKGROUND

The growing literature on community-based participatory research (CBPR) suggests that a participatory approach benefits science in important ways. However there have been few formal evaluations of a CBPR approach itself, and few standards developed to assist in such efforts.

OBJECTIVES

This evaluation used CBPR guidelines developed by Green and colleagues to evaluate the participatory approach of the Community Outreach and Translation Core (COTC) of the Bay Area Breast Cancer and the Environment Research Center (BABCERC) in translating scientific findings from two key projects to the public.

METHOD

To assess key stakeholders' perceptions of alignment between the projects and the guidelines, four COTC members, four researchers, and four community members rated the projects on each of the 26 guidelines. These data were triangulated with transcripts from interviews with the same participants and a focus group with a subset of the participants.

RESULTS

The participatory approach by the COTC resulted in many important benefits including improved relationships among diverse stakeholders, knowledge generation, increased sensitivity and propriety of the research, and increased community support of research. However, several atypical features of this collaboration-for example, the basic and etiological nature of the science being undertaken, and the multiple communities (lay and activist/advocate) involved-resulted in different levels and qualities of participation among stakeholders.

CONCLUSIONS

Further research should focus on the adaptation of participatory research principles for different kinds of community partners and on the development and refinement of standards and tools to assist in evaluating the process and outcome of participatory research.

German ambulatory care physicians' perspectives on continuing medical education - a national survey

INTRODUCTION

This survey aimed to investigate German ambulatory physicians' opinions about mandatory continuing medical education (CME) and CME resources shortly before the introduction of mandatory CME in 2004.

METHODS

A structured national telephone survey of general practitioners and specialists was conducted. Main outcome measures were opinions about mandatory CME, preferred CME media, and financial aspects of CME. Data analysis applied Pearson's correlation coefficient for explorative analysis of correlations, analysis of variance for group comparison, and chi(2)-test for investigation of distribution of 2 or more categorical variables.

RESULTS

Of the 511 participants, 73% felt that CME supported them in keeping up to date with new medical knowledge, yet only half believed in its ability to minimize medical errors or increase quality of patient care. Traditional ways of learning were preferred. Significant differences in CME behavior were found between primary-care physicians and specialists, the latter using more communicative media. Also, a small group of very skeptical physicians who do not agree with the need for CME in general was identified. Average expenditure for CME was estimated between 500 and 1000 Euros per year. A majority of physicians called for other parties, eg, health insurances or government, to share the financial responsibility for CME.

DISCUSSION

Mandatory CME was accepted as a necessity already before the new legislation took effect, with prevailing skepticism at the same time. Future research is needed on how to motivate physicians and especially certain subgroups of physicians to use CME methods shown to be effective in changing clinical behavior.

From consultation-liaison psychiatry to integrated care for multiple and complex needs

The aim of the present study was to review the ways in which contemporary medicine addresses physical/psychiatric multimorbidity, to review the underlying concepts and methodologies used, and to propose a novel approach that may help consultation-liaison psychiatry (CLP) position itself better in the health-care field. A Medline search of the terms 'consultation-liaison psychiatry', 'integrated care', 'quality assurance' and 'qualitative methodology', was complemented by study of the literature on complexity theory and by discussions with colleagues in both the health science and sociology fields. There is a growing realization that presentation with multimorbidity of both physical and psychiatric disorders is the norm. Other health-care disciplines have responded quickly to meeting the multiple and complex needs of such patients, attracting funding to an extent that CLP has been unable to achieve. Uncritical application, however, of integrated care technology based on evidence from randomized controlled trials has produced disappointing results. There is a growing realization that such quantitative methods need to be complemented by in-depth exploration using non-traditional methods including qualitative ones, and drawing on complexity theory. The Cochrane Collaboration is exploring this. As CLP and other medical and health-care disciplines face the challenge of patients with multimorbidity, they need to find acceptable answers to the question of what works for whom in what context for patients with multiple and complex needs. CLP can contribute its rich experience in the qualitative approaches that will be needed in research addressing this question, but needs help from other disciplines to refine its techniques so that its contributions are considered valid. The context for implementing effective interventions derived from such studies will in future be that of transdisciplinary teams whose mode of working is empirically based and transparent. CLP is well placed by dint of its psychodynamic and systems theory roots to provide leadership in this transformation in health-care delivery.

Decision technologies as normative instruments: exposing the values within

OBJECTIVE

Describe some of the implicit normative and value judgments made in decision technologies development and use.

METHODS

Using conceptual analysis of published models, we first outline some of the background assumptions of the knowledge translation/evidence-based medicine view of decision technologies. We then describe how normative judgments are embedded in decision technology development and use, drawing from empirical normative analysis of qualitative interviews with clinical practice guidelines developers (n=18) and users (n=17) in Canada and the UK.

RESULTS

Normative judgments are made in at least three stages of decision technologies' "life cycle": (1) in the identification of contexts where decisions are seen as requiring support; (2) in determining what type of information and options should be part of the content of decision technologies; (3) in the negotiation between different actors regarding how effectiveness of decision technologies should be judged. These findings contrast with the knowledge translation/evidence-based medicine picture of decision technologies as neutral carriers of facts, or 'pure' synthesis of research evidence.

CONCLUSION

Normative judgments are at play throughout the life cycle of decision technology development and use. References to scientific notions of truth and validity in the knowledge translation/evidence-based medicine model tend to overlook the socio-political dimension of decision technology development and implementation, as well as the contested nature of what "good decision" these technologies aim to support.

PRACTICE IMPLICATIONS

Empirical normative analysis is an important research tool to better understand the values, interests and power relationships embedded in decision technologies. Such lines of inquiry could foster a more open debate among stakeholders - including patients and members of the public - regarding the norms promoted by practice guidelines and patient decision aids. It also offers new insights in understanding the problem of implementing decision technologies in clinical practice.

The need for systems change: reflections on knowledge translation and organizational change

BACKGROUND

Despite over 40 years' work on general systems theory, informed by critical social science, there is a mismatch between the theories used to explain and influence clinical practice in nursing and the way in which transferring new knowledge into practice is articulated.

DATA SOURCES

The analysis and emerging propositions were based on a critique of seminal texts published in English up to 2008 covering critical social science, action science, diffusion of innovations, practice development and the management of innovations.

DISCUSSION

There is an implicit adherence to the world view that healthcare systems operate like machines, and much of the science generated around knowledge translation research tends to be logico-deductive. This is in direct contrast to the prevailing arguments of general systems theorists, who view the system more as an organism. Five propositions are posited: knowledge translation is a necessary but not sufficient mechanism to transform systems; the 'system-as-machine' metaphor is profoundly unhelpful to knowledge translation; the healthcare system is best viewed as a complex entity; successful innovation is a function of the level of local autonomy experienced by individuals, teams and the unit involved; innovation is most effective when it involves key stakeholders.

CONCLUSION

The purposeful integration of systems theory with knowledge translation theories and models may enable the application of research and new knowledge to practice to be speeded up.

The need for knowledge translation in chronic pain

One in five Canadians suffers from some form of persistent or chronic pain. The impact on individual lives, families and friends, the health services sector and the economy is huge. Reliable evidence is available that the burden of persistent pain can be markedly reduced when available knowledge is applied. Bridging the quality chasm between chronic pain and the care process will require a unique confluence of opinion from all stakeholders committed within a focused community of practice to address the impact of pain. Various levels of success in this regard have been demonstrated when there is exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users. It is now critical to accelerate the capture of the benefits of research for Canadians through improved health, more effective and responsive services and products, and a strengthened health care system to bring about health reform and health care reform across Canada as it pertains to the one in five Canadians living with chronic, disabling pain. The overarching outcome of such an initiative needs to be promoted to sustain a balanced portfolio of curiosity- and needs-based research, which along with existing knowledge, can be mobilized and applied for the benefit of Canadians, the health care system and the economy.

Active for life: final results from the translation of two physical activity programs

BACKGROUND

Most evidence-based programs are never translated into community settings and thus never make a public health impact.

DESIGN

Active for Life (AFL) was a 4-year translational initiative using a pre-post, quasi-experimental design. Data were collected from 2003 to 2007. Analyses were conducted in 2005 and 2008.

SETTING/PARTICIPANTS

Nine lead organizations at 12 sites participated. Active Choices participants (n=2503) averaged 65.8 years (80% women, 41% non-Hispanic white). Active Living Every Day (ALED) participants (n=3388) averaged 70.6 years (83% women, 64% non-Hispanic white).

INTERVENTION

In AFL, Active Choices was a 6-month telephone-based and ALED a 20-week group-based lifestyle behavior change program designed to increase physical activity, and both were grounded in social cognitive theory and the transtheoretical model. The interventions were evaluated in Years 1, 3, and 4. An adapted shortened ALED program was evaluated in Year 4.

MAIN OUTCOME MEASURE

Moderate- to vigorous-intensity physical activity, assessed with the CHAMPS self-reported measure.

RESULTS

Posttest survey response rates were 61% for Active Choices and 70% for ALED. Significant increases in moderate- to vigorous-intensity physical activity, total physical activity, and satisfaction with body appearance and function, and decreases in BMI were seen for both programs. Depressive symptoms and perceived stress, both low at pretest, also decreased over time in ALED. Results were generally consistent across years and sites.

CONCLUSIONS

Active Choices and ALED were successfully translated across a range of real-world settings. Study samples were substantially larger, more ethnically and economically diverse, and more representative of older adult's health conditions than in efficacy studies, yet the magnitude of effect sizes were comparable.

Can the democratic ideal of participatory research be achieved? An inside look at an academic-indigenous community partnership

Democratic or equal participation in decision making is an ideal that community and academic stakeholders engaged in participatory research strive to achieve. This ideal, however, may compete with indigenous peoples' right to self-determination. Study objectives were to assess the perceived influence of multiple community (indigenous) and academic stakeholders engaged in the Kahnawake Schools Diabetes Prevention Project (KSDPP) across six domains of project decision making and to test the hypothesis that KSDPP would be directed by community stakeholders. Self-report surveys were completed by 51 stakeholders comprising the KSDPP Community Advisory Board (CAB), KSDPP staff, academic researchers and supervisory board members. KSDPP staff were perceived to share similar levels of influence with (i) CAB on maintaining partnership ethics and CAB activities and (ii) academic researchers on research and dissemination activities. KSDPP staff were perceived to carry significantly more influence than other stakeholders on decisions related to annual activities, program operations and intervention activities. CAB and staff were the perceived owners of KSDPP. The strong community leadership aligns KSDPP with a model of community-directed research and suggests that equitable participation-distinct from democratic or equal participation-is reflected by indigenous community partners exerting greater influence than academic partners in decision making.

Promoting the social value of research in Kenya: examining the practical aspects of collaborative partnerships using an ethical framework

The ethics of research continue to attract considerable debate, particularly when that research is sponsored by partners from the North and carried out in the South. Ethical research should contribute to social value in the country where research is being carried out, but there is significant debate around how this might be achieved and who is responsible. The literature suggests that researchers might employ two inter-related strategies to maximise social value: collaborative partnerships with policy makers and communities from the outset of research, and dissemination of research results to participants, policy makers and implementers once the research is over. These areas have received relatively little empirical attention. In this study, we carried out 40 in-depth interviews to explore the role of collaborative partnerships in health research priority setting, and the way in which research findings are disseminated to aid policy making and implementation in Kenya. Interviewees included policy makers, researchers, policy implementers and representatives of organisations funding health reforms in Kenya. Two policy issues were drawn upon as tracers wherever possible: (1) the introduction of Artemesinin-based Combination Therapies (ACTs), an anti-malarial treatment policy; and (2) Haemophilus influenzae (Hib) vaccine for the prevention of pneumococcal diseases among children. The findings point to significant gaps in the 'research to policy to practice' pathway, particularly for national research institutions with a focus on clinical/biomedical research. These gaps reflect poorly effective partnerships among stakeholders and limit the potential social value of much research. While more investment is needed to establish strong structures for promoting and directing collaboration and partnership, how to target this investment is not entirely clear, especially in the context of the considerable power of the global health agenda and the research financing tied to it.

Connecting with clinicians: opportunities to strengthen rehabilitation research

PURPOSE

This article examines the distinctive opportunities and challenges involved in connecting with clinicians to strengthen rehabilitation research.

METHOD

The relevant literature on various factors that link researchers and clinicians is summarized and discussed.

RESULTS

Links between researchers and clinicians are demonstrated by evidence-based practice, common conceptual background and the development of research capacity. Sustainable partnerships can evolve throughout the research process by using various enduring strategies such as experts' committee as well as novel approaches like communities of practice.

CONCLUSION

This paper reflects the conviction that reducing the gap between research and clinical practice will be facilitated by implementing partnerships originating from both researchers and clinicians.

Knowledge integration: conceptualizing communications in cancer control systems

OBJECTIVE

This paper was prepared by the National Cancer Institute of Canada (NCIC) Working Group on Translational Research and Knowledge Transfer. The goal was to nurture common ground upon which to build a platform for translating what we know about cancer into what we do in practice and policy.

METHODS

Methods included expert panels, literature review, and concept mapping, to develop a framework that built on earlier cancer control conceptualizations of communications that have guided researchers and end users.

RESULTS

The concept of 'knowledge integration' is used to describe the resulting refinement and the nature of evidence necessary for decision-making to at the systems level. Current evidence for knowledge integration in cancer control is presented across the levels of individual, organizational and systems level interventions and across basic, clinical and population science knowledge bases.

CONCLUSION

A systems-oriented approach to integrating evidence into action assists organizations to conduct research and policy and practice.

PRACTICE IMPLICATIONS

Practitioners can use this framework to understand the challenges of implementing and evaluating cancer control strategies.

Health research funding agencies' support and promotion of knowledge translation: an international study

CONTEXT

The process of knowledge translation (KT) in health research depends on the activities of a wide range of actors, including health professionals, researchers, the public, policymakers, and research funders. Little is known, however, about health research funding agencies' support and promotion of KT. Our team asked thirty-three agencies from Australia, Canada, France, the Netherlands, Scandinavia, the United Kingdom, and the United States about their role in promoting the results of the research they fund.

METHODS

Semistructured interviews were conducted with a sample of key informants from applied health funding agencies identified by the investigators. The interviews were supplemented with information from the agencies' websites. The final coding was derived from an iterative thematic analysis.

FINDINGS

There was a lack of clarity between agencies as to what is meant by KT and how it is operationalized. Agencies also varied in their degree of engagement in this process. The agencies' abilities to create a pull for research findings; to engage in linkage and exchange between agencies, researchers, and decision makers; and to push results to various audiences differed as well. Finally, the evaluation of the effectiveness of KT strategies remains a methodological challenge.

CONCLUSIONS

Funding agencies need to think about both their conceptual framework and their operational definition of KT, so that it is clear what is and what is not considered to be KT, and adjust their funding opportunities and activities accordingly. While we have cataloged the range of knowledge translation activities conducted across these agencies, little is known about their effectiveness and so a greater emphasis on evaluation is needed. It would appear that "best practice" for funding agencies is an elusive concept depending on the particular agency's size, context, mandate, financial considerations, and governance structure.

Pursuing common agendas: a collaborative model for knowledge translation between research and practice in clinical settings

There is an emerging discourse of knowledge translation that advocates a shift away from unidirectional research utilization and evidence-based practice models toward more interactive models of knowledge transfer. In this paper, we describe how our participatory approach to knowledge translation developed during an ongoing program of research concerning equitable care for diverse populations. At the core of our approach is a collaborative relationship between researchers and practitioners, which underpins the knowledge translation cycle, and occurs simultaneously with data collection/analysis/synthesis. We discuss lessons learned including: the complexities of translating knowledge within the political landscape of healthcare delivery, the need to negotiate the agendas of researchers and practitioners in a collaborative approach, and the kinds of resources needed to support this process.

An integrated strategy of knowledge application for optimal e-health implementation: a multi-method study protocol

BACKGROUND

E-health is increasingly valued for supporting: 1) access to quality health care services for all citizens; 2) information flow and exchange; 3) integrated health care services and 4) interprofessional collaboration. Nevertheless, several questions remain on the factors allowing an optimal integration of e-health in health care policies, organisations and practices. An evidence-based integrated strategy would maximise the efficacy and efficiency of e-health implementation. However, decisions regarding e-health applications are usually not evidence-based, which can lead to a sub-optimal use of these technologies. This study aims at understanding factors influencing the application of scientific knowledge for an optimal implementation of e-health in the health care system.

METHODS

A three-year multi-method study is being conducted in the Province of Quebec (Canada). Decision-making at each decisional level (political, organisational and clinical) are analysed based on specific approaches. At the political level, critical incidents analysis is being used. This method will identify how decisions regarding the implementation of e-health could be influenced or not by scientific knowledge. Then, interviews with key-decision-makers will look at how knowledge was actually used to support their decisions, and what factors influenced its use. At the organisational level, e-health projects are being analysed as case studies in order to explore the use of scientific knowledge to support decision-making during the implementation of the technology. Interviews with promoters, managers and clinicians will be carried out in order to identify factors influencing the production and application of scientific knowledge. At the clinical level, questionnaires are being distributed to clinicians involved in e-health projects in order to analyse factors influencing knowledge application in their decision-making. Finally, a triangulation of the results will be done using mixed methodologies to allow a transversal analysis of the results at each of the decisional levels.

RESULTS

This study will identify factors influencing the use of scientific evidence and other types of knowledge by decision-makers involved in planning, financing, implementing and evaluating e-health projects.

CONCLUSION

These results will be highly relevant to inform decision-makers who wish to optimise the implementation of e-health in the Quebec health care system. This study is extremely relevant given the context of major transformations in the health care system where e-health becomes a must.

An interdisciplinary clinical practice model for the management of low-back pain in primary care: the CLIP project

BACKGROUND

Low-back pain is responsible for significant disability and costs in industrialized countries. Only a minority of subjects suffering from low-back pain will develop persistent disability. However, this minority is responsible for the majority of costs and has the poorest health outcomes. The objective of the Clinic on Low-back pain in Interdisciplinary Practice (CLIP) project was to develop a primary care interdisciplinary practice model for the clinical management of low-back pain and the prevention of persistent disability.

METHODS

Using previously published guidelines, systematic reviews and meta-analyses, a clinical management model for low-back pain was developed by the project team. A structured process facilitating discussions on this model among researchers, stakeholders and clinicians was created. The model was revised following these exchanges, without deviating from the evidence.

RESULTS

A model consisting of nine elements on clinical management of low-back pain and prevention of persistent disability was developed. The model's two core elements for the prevention of persistent disability are the following: 1) the evaluation of the prognosis at the fourth week of disability, and of key modifiable barriers to return to usual activities if the prognosis is unfavourable; 2) the evaluation of the patient's perceived disability every four weeks, with the evaluation and management of barriers to return to usual activities if perceived disability has not sufficiently improved.

CONCLUSION

A primary care interdisciplinary model aimed at improving quality and continuity of care for patients with low-back pain was developed. The effectiveness, efficiency and applicability of the CLIP model in preventing persistent disability in patients suffering from low-back pain should be assessed.

Live a legacy or live a lie: a choice

This article is about the result of a choice to Live a Legacy or Live a Lie. The choice led to the development and implementation of a clinical practice model (CPM) designed to create a healthy, healing integrated practice culture. The focus is on the foundation of the model that is a unique ongoing process called the Core Belief Review. The purpose of the review is to uncover those things that matter most for both those who give and receive care. The ongoing open communication process provides insights and truths about reality and a sense of direction related to the nature of the work necessary to create and sustain the best places to give and receive care. The results of the review feedback from 2500 providers and recipients of care are correlated to the actions taken to address the complexities of the point-of-care reality and the clinical outcomes reached as a result of collaboration and lessons learned within an International Consortium.

The relevance of qualitative research for clinical programs in psychiatry

It is time to move beyond education about qualitative research theory and methods to using them to understand and improve psychiatric practice. There is a good fit between this agenda and current thinking about research use that broadens definitions of evidence beyond the results of experiments. This paper describes a qualitative program evaluation to illustrate what kind of useful knowledge is generated and how it can be created through a clinician-researcher partnership. The linkage and exchange model of effective knowledge translation described involves interaction between clinicians and researchers throughout the research process and results in mutual learning through the planning, disseminating, and application of existing or new qualitative research in decision making.

Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series

Background

Continuing challenges to timely adoption of evidence-based clinical practices in healthcare have generated intense interest in the development and application of new implementation methods and frameworks. These challenges led the United States (U.S.) Department of Veterans Affairs (VA) to create the Quality Enhancement Research Initiative (QUERI) in the late 1990s. QUERI's purpose was to harness VA's health services research expertise and resources in an ongoing system-wide effort to improve the performance of the VA healthcare system and, thus, quality of care for veterans. QUERI in turn created a systematic means of involving VA researchers both in enhancing VA healthcare quality, by implementing evidence-based practices, and in contributing to the continuing development of implementation science.

The efforts of VA researchers to improve healthcare delivery practices through QUERI and related initiatives are documented in a growing body of literature. The scientific frameworks and methodological approaches developed and employed by QUERI are less well described. A QUERI Series of articles in Implementation Science will illustrate many of these QUERI tools. This Overview article introduces both QUERI and the Series.

Methods

The Overview briefly explains the purpose and context of the QUERI Program. It then describes the following: the key operational structure of QUERI Centers, guiding frameworks designed to enhance implementation and related research, QUERI's progress and promise to date, and the Series' general content. QUERI's frameworks include a core set of steps for diagnosing and closing quality gaps and, simultaneously, advancing implementation science. Throughout the paper, the envisioned involvement and activities of VA researchers within QUERI Centers also are highlighted. The Series is then described, illustrating the use of QUERI frameworks and other tools designed to respond to implementation challenges.

Conclusion

QUERI's simultaneous pursuit of improvement and research goals within a large healthcare system may be unique. However, descriptions of this still-evolving effort, including its conceptual frameworks, methodological approaches, and enabling processes, should have applicability to implementation researchers in a range of health care settings. Thus, the Series is offered as a resource for other implementation research programs and researchers pursuing common goals in improving care and developing the field of implementation science.

Colorectal cancer care knowledge mapping: identifying priorities for knowledge translation research

OBJECTIVE

We do not know the extent and nature of knowledge translation (KT) in oncology. This study examined colorectal cancer (CRC) health services research, and engaged researchers and decision makers in prioritizing KT research gaps.

METHODS

MEDLINE was searched from 1996 to 2006 for CRC health services research in Canada, Australia, the United Kingdom, and United States. Studies were tabulated by indicator, type of research and country to reveal gaps. Researchers and decision makers prioritized gaps via questionnaire, then generated research questions for top-ranked gaps at a one-day workshop.

RESULTS

A total of 132 articles were categorized and 29 individuals attended the workshop. We lack knowledge about factors influencing rates of many indicators. Researchers and decision makers prioritized KT research on factors that could either influence the utilization of screening or enhance the quality of surgical outcomes. They acknowledged lack of research capacity and policy support as barriers, and confusion about the concept of KT.

CONCLUSIONS

Several opportunities were revealed for improving the quality of CRC screening and surgery. Greater coordination of, and support for KT research is required to address these gaps. Further research should evaluate different methods of achieving KT between researchers and decision makers for research planning.

Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges

BACKGROUND

The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified.

DISCUSSION

This being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model - important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation. Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place. In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally.

SUMMARY

The paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches. We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives.

Development of a mentorship strategy: a knowledge translation case study

INTRODUCTION

There are many theories and frameworks for achieving knowledge translation, and the assortment can be confusing to those responsible for planning, evaluation, or policymaking in knowledge translation. A conceptual framework developed by Graham and colleagues provides an approach that builds on the commonalities found in an assessment of planned-action theories. This article describes the application of this knowledge to action framework to a mentorship initiative in academic medicine. Mentorship influences career success but is threatened in academia by increased clinical, research, and administrative demands.

METHODS

A case study review was undertaken of the role of mentors, the experiences of mentors and mentees, and mentorship initiatives in developing and retaining clinician scientists at two universities in Alberta, Canada. This project involved relevant stakeholders including researchers, university administrators, and research funders.

RESULTS

The knowledge to action framework was used to develop a strategy for mentorship for clinician researchers. The framework highlights the need to identify and engage stakeholders in the process of knowledge implementation. A series of initiatives were selected and tailored to barriers and facilitators to implementation of the mentorship initiative; strategies for evaluating the knowledge use and its impact on outcomes were developed.

DISCUSSION

The knowledge to action framework can be used to develop a mentorship initiative for clinician researchers. Future work to evaluate the impact of this intervention on recruitment and retention is planned.

Stakeholder engagement opportunities in systematic reviews: knowledge transfer for policy and practice

Knowledge transfer and exchange is the process of increasing the awareness and use of research evidence in policy or practice decision making by nonresearch audiences or stakeholders. One way to accomplish this end is through ongoing interaction between researchers and interested nonresearch audiences, which provides an opportunity for the two groups to learn more about one another. The purpose of this article is to describe and discuss various stakeholder engagement opportunities that we employ throughout the stages of conducting a systematic review, to increase knowledge utilization within these audiences. Systematic reviews of the literature on a particular topic can provide an unbiased overview of the state of the literature. The engagement opportunities we have identified are topic consultation, feedback meetings during the review, member of review team, and involvement in dissemination. The potential benefits of including stakeholders in the process of a systematic review include increased relevance, clarity, and awareness of systematic review findings. A further benefit is the potential for increased dissemination of the findings. Challenges that researchers face are that stakeholder interactions can be time- and resource-intensive, it can be difficult balancing stakeholder desires with scientific rigor, and stakeholders may have difficulties accepting findings with which they do not agree. Despite these challenges we have included stakeholder involvement as a permanent step in the procedure of conducting a systematic review.

Knowledge translation for research utilization: design of a knowledge translation model at Tehran University of Medical Sciences

INTRODUCTION

The present study aimed to generate a model that would provide a conceptual framework for linking disparate components of knowledge translation. A theoretical model of such would enable the organization and evaluation of attempts to analyze current conditions and to design interventions on the transfer and utilization of research knowledge.

METHODS

This research, performed in 2006-2007 at the Tehran University of Medical Sciences (TUMS), utilized two distinct methodologies: a narrative review to identify existing knowledge transfer models and frameworks and focus group discussions to determine the views and opinions of researchers and decision makers regarding barriers to knowledge translation within the health system.

RESULTS

A knowledge translation cycle is described, with five domains: knowledge creation, knowledge transfer, research utilization, question transfer, and the context of organization.

DISCUSSION

The knowledge translation cycle offers a theoretical basis for identifying basic requirements and linking mechanisms in the translation of knowledge for research utilization.

Public health decision-makers' informational needs and preferences for receiving research evidence

OBJECTIVES

The purpose of this study was to identify decision-makers' preferences for the transfer and exchange of research knowledge. This article is focused on how the participants define evidence-based decision-making and their preferences for receiving research evidence to integrate into the decision-making process.

METHODS

Semistructured interviews were conducted with a purposive sample of 16 Ontario public health decision-makers from six Ontario public health units in this fundamental qualitative descriptive study. The sample included nine program managers, six directors, and one Medical Officer of Health. Participants were asked to define the term evidence-based decision-making and identify preferred research dissemination strategies. The interviews were audio-taped, transcribed verbatim, and coded for emerging concepts.

RESULTS

Participants defined evidence-based decision-making as a process whereby multiple sources of information were consulted before making a decision concerning the provision of services. To facilitate integration of research evidence into the decision-making process, public health administrators appreciate receiving, in both electronic and hard copy, systematic reviews, executive summaries of research, and clear statements of implications for practice from health service researchers.

CONCLUSIONS

Although consensus exists among participants concerning the definition of evidence based public health decision-making, ongoing efforts are required to continue to promote the use of research evidence in program planning and public health policy. It is also important to continue to improve the ease with which public health decision-makers access systematic reviews, as well as to ensure the relevance and applicability of the results to the practice setting.

Fostering knowledge exchange between researchers and decision-makers: exploring the effectiveness of a mixed-methods approach

OBJECTIVES

Knowledge exchange is thought to enhance research utilization by decision-makers but there is little guidance on appropriate methods. This study evaluated the effectiveness of a research planning exercise utilizing technical (ranking, rating) and interpretive strategies (interdisciplinary workshop deliberation).

METHODS

Participants were surveyed to establish research priorities and professional roles. Observation was used to examine actual contribution and outcomes. Semi-structured interviews with participants elicited perceived outcomes, commitment, contribution and learning. Survey data was reported with summary statistics. Transcripts were analyzed qualitatively.

RESULTS

Stakeholders were satisfied with the overall process, gaps in research were prioritized, and research questions were proposed, but anticipated intermediate or lateral outcomes were not achieved. Identifying differing perspectives and establishing relationships were unanticipated outcomes. Barriers included group dynamics, lack of clarity on objectives and processes, and minimal experience or interest in interpretive activities.

CONCLUSIONS

A conceptual framework for evaluating factors influencing knowledge exchange outcomes had not been previously investigated. Strategies for overcoming identified barriers include better facilitation, involving a critical volume of non-clinicians, in-person sharing of background information, and incentives for decision-makers. Further research is required to examine the effectiveness of different forms of knowledge exchange, and the degree to which they are currently being practiced.

Development and implementation of the Ontario Stroke System: the use of evidence

INTRODUCTION

The Ontario Stroke System was developed to enhance the quality and continuity of stroke care provided across the care continuum.

RESEARCH OBJECTIVE

To identify the role evidence played in the development and implementation of the Ontario Stroke System.

METHODS

This study employed a qualitative case study design. In-depth interviews were conducted with six members of the Ontario Stroke System provincial steering committee. Nine focus groups were conducted with: Regional Program Managers, Regional Education Coordinators, and seven acute care teams. To supplement these findings interviews were conducted with eight individuals knowledgeable about national and international models of integrated service delivery.

RESULTS

Our analyses identified six themes. The first four themes highlight the use of evidence to support the process of system development and implementation including: 1) informing system development; 2) mobilizing governmental support; 3) getting the system up and running; and 4) integrating services across the continuum of care. The final two themes describe the foundation required to support this process: 1) human capacity and 2) mechanisms to share evidence.

CONCLUSION

This study provides guidance to support the development and implementation of evidence-based models of integrated service delivery.

Information transfer: what do decision makers want and need from researchers?

PURPOSE

The purpose of this study was to undertake a systematic assessment of the need for research-based information by decision-makers working in community-based organizations. It is part of a more comprehensive knowledge transfer and exchange strategy that seeks to understand both the content required and the format/methods by which such information should be presented.

METHODS

This was a cross-sectional telephone survey. Questions covered current practices, research use, and demographic information, as well as preferences for receiving research information. Three types of organizations participated: Children's Treatment Centres of Ontario (CTCs); Ontario Community Care Access Centres (CCACs); and District Health Councils (DHCs). The analysis used descriptive statistics and analyses of variance (ANOVA) to describe and explore variations across organizations.

RESULTS

The participation rate was 70%. The highest perception of barriers to the use of research information was reported by the CCAC respondents, followed by CTCs and DHCs. The CTCs and DHCs reported greater use of research evidence in planning decisions as compared to the CCACs. Four sources of information transfer were consistently identified. These were websites, health-related research journals, electronic mail, and conferences and workshops. Preferred formats for receiving information were executive summaries, abstracts, and original articles.

CONCLUSION

There were a number of similarities across organization type with respect to perceived barriers to research transfer, as well as the types of activities the organizations engaged in to promote research use in decision-making. These findings support the importance of developing interactive, collaborative knowledge transfer strategies, as well as the need to foster relationships with health care decision-makers, practitioners and policymakers.

Gaps between knowing and doing: understanding and assessing the barriers to optimal health care

INTRODUCTION

A significant gap exists between science and clinical practice guidelines, on the one hand, and actual clinical practice, on the other. An in-depth understanding of the barriers and incentives contributing to the gap can lead to interventions that effect change toward optimal practice and thus to better care.

METHODS

A systematic review of English language studies involving human subjects and published from January 1998 to March 2007 yielded 256 articles that fulfilled established criteria. The analysis was guided by two research questions: How are barriers are assessed? and What types of barriers are identified? The studies abstracted were coded according to 33 emerging themes; placed into seven categories that typified the barriers; grouped as to whether they involved the health care professional, the guideline, the scientific evidence, the patient, or the health system; and organized according to relationship pattern between barriers.

RESULTS

The results expand our understanding of how multiple factors pose barriers to optimal clinical practice. The review reveals increasing numbers of behavioral and system barriers. Quantitative survey type assessments continue to dominate barrier research; however, an increasing number of qualitative and mixed-method study designs have emerged recently.

DISCUSSION

The findings establish the evolution of research methodologies and emerging barriers to the translation of knowing to doing. While many studies are methodologically weak, there are indications that designs are becoming more aligned with the complexity of the health care environment. The review provides support for the need to examine multiple factors within the knowledge-to-action process.

A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines Research and Evaluation criteria

Clinical practice guidelines have been elaborated to summarize evidence related to the management of knee osteoarthritis and to facilitate uptake of evidence-based knowledge by clinicians. The objectives of the present review were summarizing the recommendations of existing guidelines on knee osteoarthritis, and assessing the quality of the guidelines using a standardized and validated instrument--the Appraisal of Guidelines Research and Evaluation (AGREE) tool. Internet medical literature databases from 2001 to 2006 were searched for guidelines, with six guidelines being identified. Thirteen clinician researchers participated in the review. Each reviewer was trained in the AGREE instrument. The guidelines were distributed to four groups of three or four reviewers, each group reviewing one guideline with the exception of one group that reviewed two guidelines. One independent evaluator reviewed all guidelines. All guidelines effectively addressed only a minority of AGREE domains. Clarity/presentation was effectively addressed in three out of six guidelines, scope/purpose and rigour of development in two guidelines, editorial independence in one guideline, and stakeholder involvement and applicability in none. The clinical management recommendation tended to be similar among guidelines, although interventions addressed varied. Acetaminophen was recommended for initial pain treatment, combined with exercise and education. Nonsteroidal anti-inflammatory drugs were recommended if acetaminophen failed to control pain, but cautiously because of gastrointestinal risks. Surgery was recommended in the presence of persistent pain and disability. Education and activity management interventions were superficially addressed in most guidelines. Guideline creators should use the AGREE criteria when developing guidelines. Innovative and effective methods of knowledge translation to health professionals are needed.