L’état des connaisances sur la recherche en
transfert des connaissances
Jeremy Grimshaw MBChB, PhD, FRCGP, FCAHS
Clinical Epidemiology Program, OHRI
Department of Medicine, University of Ottawa
Canada Research Chair in Health Knowledge Transfer and Uptake
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.
• This process takes place within a complex system of
interactions between researchers and knowledge users
which may vary in intensity, complexity and level of
engagement depending on the nature of the research
results and on the needs of the particular knowledge
user.
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
• End point of knowledge translation to health care
professionals should be evidence based
behaviours
Approaches to knowledge translation
Knowledge to
action
Graham et al
(2006). Lost in
Knowledge
Translation. Time
for a Map? Journal
of Continuing
Education for
Health
Professionals
Assessing barriers to KT
• 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)
Selecting knowledge translation
interventions
• 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
Cochrane Effective Practice and
Organisation of Care (EPOC) Group
• EPOC aims to undertake systematic reviews of
professional, organisation, financial and
regulatory interventions to improve health care
systems and health care delivery
• Register of 6000+ primary studies
• 50 reviews, 41 protocols
http://www.cadth.ca/index.php/en/compus/optimal-ther-resources/interventions
Overview of reviews of professional
behaviour change strategies
•
•
•
•
•
•
•
•
Educational materials
Educational meetings
Educational outreach
Local opinion leaders
Audit and feedback
Reminders and prompts
Tailored interventions
Multifaceted interventions
Educational outreach
• Educational outreach - Use of a trained person
who met with providers in their practice settings
to give information with the intent of changing
the provider’s practice. The information given
may have included feedback on the
performance of the provider(s).
Educational outreach
• Derives from social marketing approach
• Use social persuasion methods to target
individual’s knowledge and attitudes
• Typically aim to get maximum of 3 messages
across in 10-15 minutes using approach tailored
to individual health care provider
• Typically use additional strategies to reinforce
approach
• Typically focus on relatively simple behaviours in
control of individual physician eg choice of drugs
to prescribe
Educational outreach
O’Brien (2007) Cochrane Library
• High quality review
• 69 studies (RCT, CCT)
• Multifaceted educational outreach visits were
generally effective for improving appropriate care
• Prescribing behaviours - median effect across 17
comparisons 4.8% absolute improvement,
interquartile range 3.0% to 6.5%
• Other behaviours – median effect across 17
comparisons 6.0% absolute improvement,
interquartile range 3.6% to 16.0%
Overview of reviews summary
Summary
• Variety of interventions to change health
professional behaviour – effects tend to be
modest but important from population
perspective
• However ‘No Magic Bullets’ – effects of
interventions appears to vary across targeted
behaviours, professionals and settings
• Feasibility and resources required for
interventions also likely to vary
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
• Educational, 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.
UK MRC Framework for Evaluating
Complex Interventions
Phase IV
Phase III
Phase II
Phase I
Pre-clinical
Diagnostic
Modelling
Exploratory trial
Continuum of increasing evidence
Definitive RCT
Long term
implementation
UK MRC Framework for Evaluating
Complex Interventions – Diagnostic Phase
• Formal assessment of context, likely barriers to KT
• Consideration of potential theories (behavioural,
organisational) that might be helpful
• Mixed methods
• Literature review
• Informal consultation
• Focus groups
• Surveys
• Needs interdisciplinary perspective
UK MRC Framework for Evaluating
Complex Interventions – Diagnostic Phase
• Ferlie and Shortell suggest four levels of
interventions to improve the quality of health care:
• the individual health professional;
• health care groups or teams;
• organisations providing health care;
• the larger health care system or environment in
which individual organizations are embedded.
• Different types of theory will be relevant to
interventions at different levels
Ferlie, Shortell (2001). Milbank Quarterly
UK MRC Framework for Evaluating
Complex Interventions – Diagnostic Phase
• Given that clinical practice is a form of human
behaviour, we are currently exploring the
applicability of predictive theories of human
behaviour from other similar settings.
• Focus has been on theories that:
• (Have standard approaches to measurement)
• Have been empirically tested.
• Explain behavior in terms of factors that are
amenable to change.
• Include non volitional factors.
UK MRC Framework for Evaluating
Complex Interventions – Diagnostic Phase
Walker (2001) Br J Hlth Psych
UK MRC Framework for Evaluating
Complex Interventions – Diagnostic Phase
Available from: http://www.rebeqi.org/
UK MRC Framework for Evaluating
Complex Interventions – Diagnostic Phase
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
UK MRC Framework for Evaluating
Complex Interventions – Modelling Phase
Phase 1 – Modelling
• Intervention mapping
• Specify intervention objectives
• Select methods and strategies
• Design program
• Usability testing
UK MRC Framework for Evaluating
Complex Interventions – Modelling Phase
Intervention mapping
UK MRC Framework for Evaluating Complex
Interventions – Exploratory Phase
Phase 2 – Exploratory studies
• Small scale studies to demonstrate that
unit/patient recruitment is likely achievable,
intervention is deliverable in study settings, data
collection is feasible
• Randomised or non randomised
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
• 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
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
• Rigorous evaluations (mainly randomised
controlled trials) provide the best evidence of
causal description of different interventions
because:
• Effects of interventions are modest
• Limited understanding of likely confounders
• Substantial opportunity costs if ineffective or
inefficient dissemination and implementation
strategies used
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
• 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.
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
• Evaluated effects of short educational messages on test
ordering reports and audit and feedback on subsquent
test ordering behaviour
NEXUS
DRAM
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
60
60
50
50
practices
Number
Numberofofpractices
40
40
Requests for
knee x-rays
30
30
20
20
10
10
Your practice
Your practice
0
0
Requests
Requests per
per 1000
1000 patients
patients
Std. Dev = 16.93
Std. Dev = 16.93
Mean = 15.8
Mean = 15.8
N = 247.00
N = 247.00
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
• NEXUS and DRAM short educational messages led to
15-30% reduction in subsequent test ordering
• NEXUS feedback – no effect
• DRAM feedback – 10-15% reduction in subsequent test
ordering
• Take home messages
• Simple (and cheap) interventions may lead to
improved professional behaviour
• Minor changes in audit and feedback design may lead
to different results
• Importance of replicating studies
UK MRC Framework for Evaluating
Complex Interventions – definitive phase
• Other forms of enquiry needed to determine
causal explanation
• Process evaluations (qualitative case studies)
• Theory based process evaluations (mediating
pathways)
• Secondary analyses (moderator analyses)
• Temporal analyses
• Embedded economic evaluations
Summary - KT
• Knowledge translation is about ensuring that
stakeholders are aware of and use research evidence to
inform their decision making
• Knowledge to action loop provides framework for
thinking about knowledge translation
• Different approaches likely to be needed depending on
innovation, barriers to adoption, targeted stakeholders
and health care system
• Evidence base about how to do KT is incomplete
especially for policy makers
• Nevertheless opportunities for researchers to be more
thoughtful about KT throughout research process
Summary – 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
• Substantial challenges to establishing KT research as a
distinct field
Contact details
• Jeremy Grimshaw
jgrimshaw@ohri.ca
• EPOC
epoc@uottawa.ca
http://www.epoc.uottawa.ca/index.htm
• Implementation Science
http://www.implementationscience.com