Knowledge translation research and implementation science: the - - PowerPoint PPT Presentation

Brian Haynes McMaster University

Knowledge translation research and implementation science: the missing links between research and practice

Speaker: R Brian Haynes: Closing the loop on scientific discovery. 19/10/2013

None for this presentation

Conflict Disclosures

How successful is EBM? (as a % of potential)

• <25%
• 25-49%
• 50-74%
• 75-100%

How successful is EBM now? % of audience <25% 25-49% 50-74% 75-100%

Attributed by Richard Smith to The Idealist

Premises

• A barrier, the ‘knowledge-practice gap’, largely blocks

the application of health research in clinical and population settings.

• Overcoming ‘gap’ problems would save many lives.
• Knowledge translation research (KTR) is a youthful

enterprise, trying to understand ‘gap’ problems and find ways to overcome them.

By the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence. IOM Roundtable on Evidence-Based Medicine

This can’t happen without better understanding

• f how to translate knowledge into practice.

KT Type 1

Knowledge Translation Research

Lab Clinical research Health care

KT Type 2

† Hulley et al. Designing Clinical Research, 2007

* Zerhouni. JAMA. 2005;294:1352-1358

†

*

Implementation Science Comparative effectiveness research; Patient centred outcomes research; Dissemination and Implementation

E X KT2 = ROI

Efficacy

Knowledge Translation (type 2) Return on Investment Real Outcomes of Importance

E X KT2 = ROI

Where: E is typically ≤ 0.25 KT2 is typically ≤ 0.25

Clinician adherence ~ 50% Patient adherence ~50%

.25 X .25 = .06

So: ROI is typically...

E X KT2 = ROI

Where: E is typically ≤ 0.25 KT2 is typically ≤ 0.25

Clinician adherence 50% Patient adherence 50% 75%

.25 X .25 = .06

So: ROI is typically...

.38 .09

E X KT2 = ROI

Where: E is typically ≤ 0.25 KT2 is typically ≤ 0.25

Clinician adherence 50% 75% Patient adherence 50% 75%

.25 X .25 = .06

So: ROI is typically...

.56 .14

Clinician adherence 50% 75%

For atrial fibrillation: E Efficacy of warfarin for preventing stroke = 62% KT2 Physician adherence = 50% Patient adherence = 41% ROI = 12%

Knowledge Translation

1 2 3 4 5

generation synthesis policy application decisions

Steps from evidence generation to clinical application

• 1. generation of evidence from research; 2. evidence summary and

synthesis; 3. forming clinical policy; 4. application of policy; 5. individual clinical decisions, including a) patient’s circumstances, b) patient’s wishes, and c) evidence

Research funding

Barrier Solutions

• too little

research addresses “real world” problems

• large, simple RCTs with

patient-important outcomes

• “head to head” comparisons

Step 1. Generating Research Evidence

“Can this work?” trials “Does this work?” trials

“Is it worth it?” trials

Look AHEAD Research Group, Wing RR, Bolin P, et al. Cardiovascular effects of intensive lifestyle intervention in type 2

• diabetes. N Engl J Med. 2013;369:145-54.

Conclusion In patients with type 2 diabetes mellitus who were

• verweight or obese, an intensive lifestyle intervention

for weight loss did not reduce major cardiovascular events compared with diabetes support and education.

Steps from evidence generation to clinical application

Steps: 1. generation of evidence from research; 2. evidence summary and synthesis; 3. forming clinical policy; 4. application

• f policy; 5. individual clinical decisions, including a) patient’s

circumstances, b) patient’s wishes, and c) evidence from research

a b c

 Knowledge Translation 

drugs

Steps from evidence generation to clinical application

Steps: 1. generation of evidence from research; 2. evidence summary and synthesis; 3. forming clinical policy; 4. application

• f policy; 5. individual clinical decisions, including a) patient’s

circumstances, b) patient’s wishes, and c) evidence from research

a b c

 Knowledge Translation 

devices & services

Step 5. Influencing individual patient decisions, actions and outcomes

Barrier Solutions

• failure to engage

patients

• encouraging

adherence to recommended treatments decisions

5

Detection

Doctors’ judgements of their patients’ adherence:

• sensitivity

10%

• specificity

88% Gilbert et al, CMAJ 1980 no better than chance accuracy

How frequent is nonadherence?

TASK NON- ADHERENCE RATES*

Screening in community 35%-90% Referral from screening 50%-65% Staying in care 31%-66% Follow-up appointments 16%-84% Medications 31%-58% Weight loss 29%-100% Smoking cessation 71%-96%

ACEi statin ASA metformin po polyp ypill ill

UMPIRE Trial (Thom et al. JAMA. 2013;310:918) Adherence: polypill 86% vs individual pills 65% Delta SBP: – 2.6 (95%CI -4 to -1.10) Delta LDL-C: – .11 mmol/L (-4.2 mg/dL) Limitations

• Polypill provided free
• Adherence measured by self report, in an

unblinded trial

• No patient important outcomes

Heart bar…

Intervention Communities were randomised to receive CHAP (n=20) or no intervention (n=19). In CHAP communities, residents aged 65 or over were invited to attend volunteer run cardiovascular risk

assessment and education sessions held in community based pharmacies

• ver a 10 week period; automated blood

pressure readings and self reported risk factor data were collected and shared with participants and their family physicians and pharmacists.

Reduced admission rates for a composite of MI, CHF, stroke

Cardiovascular Health Awareness Project Kaczorowski et al, BMJ 2011

CIHR Trial of the Year 2012

Knowledge Translation

1 2 3 4 5

generation synthesis policy application decisions

Steps from evidence generation to clinical application

• 1. generation of evidence from research; 2. evidence summary and

synthesis; 3. forming clinical policy; 4. application of policy; 5. individual clinical decisions, including a) patient’s circumstances, b) patient’s wishes, and c) evidence

Research funding

Key resources if you are interested in Knowledge Translation research: http://plus.mcmaster.ca/kt/

By the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence. IOM Roundtable on Evidence-Based Medicine

This can happen if our understanding of knowledge translation improves – and we discover how to apply what we learn. Could this be the final frontier in evidence-informed health care? How could you help?