A Guide to Understanding Knowledge Translation

A Guide to Understanding Knowledge Translation Table of Contents Introduction... 2 Evolution of the Knowledge Translation Paradigm... 4 The Knowledge-to-Action Framework... 5 Knowledge Creation Phase... 6 Knowledge Application Phase... 8 Next Steps... 11 References... 12 Contact Information Katie Deering, PharmD, BCPS Vice President, Global HEOR EPI-Q, Inc. 1315 West 22nd Street, Suite 410 Oak Brook, IL 60523-2063 P: (630) 570-5505 F: (630) 570-5506 E: Katie.deering@epi-q.com 1

Introduction The exponential growth in scientific understanding of diseases and treatments is generating new healthcare knowledge at a rapid pace that is both exciting and challenging. This is exciting because of the potential for improvements in healthcare and challenging because of the significant lag time before knowledge (i.e., evidence) is incorporated into practice, known as the Knowledge-to-Action Gap. Strategies to expedite the integration of new knowledge and evidence into practice are critical because delays have potential consequences for patient care and healthcare cost. Knowledge Translation is a mechanism that is growing in importance because the application of its methods has been shown to be effective in closing the Knowledge-to-Action Gap. 1 This Knowledge-to-Action Gap is evident worldwide. The World Health Organization (WHO) states in its proceedings of a meeting focusing on Knowledge Translation, Bridging the Know-Do Gap, that bridging this gap is one of the most important public health challenges that we face today, and a mechanism to achieve this is through Knowledge Translation. 1 There is a gap between today s scientific advances and their application: between what we know and what is actually being done. Health work teaches us with great rigour that action without knowledge is wasted effort, just as knowledge without action is a wasted resource. 1 LEE Jon-wook WHO Director-General (2005) Importance of Translating Knowledge to Action Meaningful research requires significant time and resources, but return on investment is often minimized or not recognized because of slow diffusion of results into clinical practice. The gap between existing knowledge and action leads to consequences such as suboptimal use of effective treatments and overuse of ineffective or unproven treatments. This results in poor health outcomes, health inequities, and a waste of increasingly scarce resources. Consequently, patients fail to gain maximum benefit from advances in healthcare, resulting in a negative impact on quality of life, productivity, and resource utilization at an individual and societal level. Knowledge Translation is a process and strategy for employing proactive, systematic methods that address Knowledge Awareness and Knowledge Application that go beyond information dissemination. Knowledge Translation identifies the barriers to overcome and influences and improves the process of behavior change in end users. The Knowledge-to-Action Gap Knowledge Translation addresses how to narrow the gap between generating evidence from various research methods and the application of knowledge gained to clinical care. 2 This is referred to as the Knowledge-to-Action Gap. 2

The volume of evidence-based healthcare knowledge available and the speed in which it is generated overwhelms our current ability to disseminate, adopt, and apply it in clinical practice. The impact of this enigma is substantial relative to its effect on clinical and economic outcomes. 3,4 Studies published over the last 10-15 years document this lag between knowledge generation and diffusion into clinical practice. This issue came to the forefront of policy and practice discussion as a result of reports like Crossing the Quality Chasm 5 issued by the Institute of Medicine and the New Freedom Mental Health Report 6 issued by the Department of Health and Human Services. Figure 1. Knowledge Translation reduces the gap between evidence and its use in clinical care. Adapted from the Crossing the Quality Chasm report. 5 Concern has since been heightened with studies such as McGlynn s reporting on an evaluation of 439 quality-of-care indicators applied to 30 acute and chronic conditions. The author found only a little more than one-half of US patients received best practice care. 7 And, Shuster, et al. reported 20-30% of patients receive care that is not medically required or that is potentially harmful, bringing the additional gap issue of patient safety to the forefront. 8 Pathman and colleagues studied the adoption and use of clinical guidelines, finding a steady decline in clinician knowledge-to-action rates. 14 The following fallout was observed with the use of pertussis vaccine guidelines: 90% of clinicians were aware of the guidelines 67% of clinicians agreed with the guidelines 46% of clinicians adopted the guidelines 5% of clinicians adhered to the guidelines 3

Select Studies Illustrating the Knowledge-to-Action Gap 1997 Eisenberg and Garzon illustrate widespread variation in use of aspirin, calcium antagonists, beta blockers, and anti-ischemic drugs despite good evidence on their use. 9 2001 Grol, et al., describe failures in implementing evidence in primary and specialty care by all disciplines. 10 2001 Grimshaw, et al., report on physician practice audits showing failure to use published evidence. 11 2003 Casalino, et al., find that less than one-half of physician practices use recommended processes for care. 12 2005 Majumdar, et al., report that high-quality evidence was not being consistently applied in cardiovascular practice. 13 Evolution of the Knowledge Translation Paradigm Early initiatives promoting the use of knowledge provided the framework for designing and implementing Knowledge Translation programs in the clinical setting. Early initiatives included: 1997 Sackett, et al. defined Evidence-Based Medicine (EBM) as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. 15 1999 The Agency for Healthcare Research and Quality (AHRQ; then Agency for Health Care Policy and Research) introduced the Translating Research into Practice (TRIP) initiative to generate knowledge about approaches that promote the utilization of rigorously derived evidence to improve patient care. 16 2003 The National Institutes of Health (NIH) launched a translational research program as part of the NIH Roadmap for Medical Research with two goals, the second of which was to support research that enhanced the adoption of best practices in the community. 17 Knowledge Translation is a global phenomenon and accepted definitions were first introduced by the Canadian Institutes for Health Research (CHIR) and the World Health Organization (WHO). The CHIR has defined the concept of Knowledge Translation as: the dynamic and iterative process that includes 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 health care system. 2 The WHO then adapted and adopted the CHIR definition of Knowledge Translation as: the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people s health. 2 4

The Knowledge-to-Action Framework The critical concept emphasized in Knowledge Translation that sets it apart from early initiatives is the moving beyond simply communicating the results of research via the literature (e.g., passive), toward methods that promote the adoption and use of knowledge. 4 To maximize the effectiveness of methods promoting adoption and use, investigators noted that explicit actions that affect behavior change are also required. They observed this to be true regardless of whether the setting is an individual clinical practice or a larger organization. Knowledge Translation methods promoting adoption and use are based on an action model known as the Knowledge-to-Action Framework developed by Graham and colleagues. 18 The Knowledge-to-Action Framework model includes two phases 4 : Phase 1: Knowledge Creation This Knowledge Creation phase involves 3 steps to address knowledge understanding and the assessment of stakeholder attitudes. Step 1: Knowledge Generation (Inquiry) Step 2: Knowledge Synthesis Step 3: Knowledge Tools and Products Phase 2: Knowledge Application This phase involves the 7 step action cycle to address behavior and practice change. Step 1: Identify the gaps and select the knowledge needed Step 2: Adapt or customize the knowledge to the local context Step 3: Assess barriers and facilitators to knowledge use Step 4: Select, tailor, and implement interventions Step 5: Monitor knowledge use Step 6: Evaluate outcomes or impacts of using the knowledge Step 7: Determine strategies for ensuring sustained use of the knowledge Understanding the critical importance of the end users, encompassing policymakers, practitioners, and the patient-consumer-public, is the focus of Knowledge Translation and is the basis of the Knowledgeto-Action Framework. End users in this instance include policymakers, practitioners, and the patientconsumer-public. 5

Knowledge Creation Phase The Knowledge Creation Phase serves as a funnel to increasingly refine and tailor knowledge to facilitate awareness and agreement and to make the knowledge (evidence) more useful for the end user. 19 Figure 2. Knowledge Creation Phase. Adapted from Graham, et al. [2006]. 18 Step 1: Knowledge Generation The high volume of research produced every year and the lack of infrastructure or skills to access this amount of information negatively impacts the ability to routinely use evidence-based information. 4,20 Historically, passive diffusion vehicles (e.g., journal articles, guidelines) have promoted awareness of knowledge. These methods are often ineffective when used alone because the information may never be seen by the target population. 1 More recently, active diffusion processes such as journal scanning and alert services can more effectively manage knowledge and facilitate awareness of new knowledge. These mechanisms together enhance the effectiveness of assessing and prioritizing knowledge for physicians as well as patients. 6

Step 2: Knowledge Synthesis Better knowledge awareness management is necessary, but insufficient to change behavior. 4 Knowledge Synthesis is the process of using qualitative or quantitative methods to summarize a body of information. Grimshaw, et al. (2012) suggests that the basic unit of Knowledge Translation is up-to-date systematic reviews or other synthesis of the global evidence. 3 While systematic reviews successfully promote and push knowledge to end users and while criteria have been developed to improve and enhance the reporting of this information, the focus has been on the validity of the information rather than on its applicability. These reviews provide critical information but do not routinely promote or enable the application of this information. 4 Step 3: Knowledge Tools and Products The development of evidence-based tools and products creates an end-user, decision-making context for the application of the desired knowledge moving from awareness to the agreement step. 4 Examples of products and tools include clinical guidelines, algorithms, performance measures, and patient-decision aids. Examples for Knowledge Creation Steps Knowledge Generation Original knowledge inquiries Clinical trials Well-designed retrospective, observational, or prospective studies Knowledge Synthesis Literature reviews Systematic reviews and metaanalyses Consensus findings/statements Knowledge Tools and Products Clinical practice guidelines Patient decision aids Performance (quality) measures These products and tools integrate knowledge into patient care; however, without an active implementation plan their benefits are often compromised. This is illustrated in the case of hypertension treatment, where a concerted effort had been made to build awareness and agreement with the evidence through active information dissemination, guideline synthesis, and the development of multiple decision-making products and tools. Because there were no comprehensive implementation plans, however, most cases of hypertension were undetected, untreated, or inadequately controlled. 21 7

Knowledge Application Phase Activities during the Knowledge Creation Phase build awareness about the evidence generated, and promote adoption and adherence. Knowledge Application is the second phase of the Knowledge-to- Action Framework and is composed of an action cycle addressing behavior and practice. This phase includes much-needed implementation plans promoting adoption and adherence to the evidence. This overall Knowledge Action Cycle focuses on deliberately engineered change using dynamic processes that can be practically applied to variables that increase or decrease the likelihood of occurrence of change in systems and individuals. 4,22 Figure 2. Knowledge-to-Action Framework. Adapted from Graham, et al. [2006]. 18 8

The Knowledge Action Cycle consists of a 7-step dynamic and practical process: 4 Step 1: Identify the gaps and select the knowledge needed Identifying the problem is the critical starting point in the action cycle. It requires measuring the current gap(s) between desired and actual practice using appropriate methods to determine the magnitude of the problem. Of particular importance in a resource constrained environment is selecting which gaps to target. 23 Step 2: Adapt or customize the knowledge to the local context Select an evidence-based tool or product to address the gaps identified in the previous step. One approach found to be useful is to apply the Knowledge Creation funnel described earlier when selecting a tool or product. For example, an evidence synthesis or a knowledge-based product or tool, such as a clinical guideline or a patient-decision aid, may be a useful tool to enable knowledge adoption. EPI-Q believes Steps 1, 3, & 4 are critical, yet often underutilized, steps in the Knowledge-to-Action cycle. Look for our future whitepaper Overlooked Knowledge Translation Pivotal Steps for more information about the importance and execution of these steps. Step 3: Assess barriers and facilitators to knowledge use Personal and organizational barriers influence successful adoption of evidenced-based practice. 8,24 Once such barriers are identified, use qualitative approaches, such as focus groups, interviews, or questionnaires, to inform how the implementation strategy can be tailored to local realities. Step 4: Select, tailor, and implement interventions Evidence is selected in the context of the defined objectives. 23 Tailoring selected evidence to the unique circumstances of the end users preserves the integrity of the knowledge because it addresses the identified barriers to change. 3 Implementation considers the unique circumstances of the desired behavior change and may require education (information), training, or use of tools that facilitate decision-making from the Knowledge Creation Phase. Pilot implementation programs afford the opportunity to test the effectiveness of the intervention and identify if modifications are necessary before expending more resources than required. Pilots may also provide proof-of-concept. 9

Step 5: Monitor knowledge use Step 6: Evaluate outcomes or impacts of using the knowledge Steps 5 and 6 use explicit, rigorous methods to test the impact of the intervention. Measurement of outcomes related to the original goals determines to what degree the engineered change has narrowed the gap between evidence and actual practice identified in Step 1 of the Knowledge Action Cycle. Measurement can consider the impact on patients, providers, or organizations using process or outcome measures (e.g., performance measures, indicators). Examples of outcomes by stakeholder might include: Patients: Change in health status, quality of life, satisfaction Providers: Change in use of processes, satisfaction Organizations: Change in systems, waiting lists, LOS, costs, etc. Step 7: Determine strategies for ensuring sustained use of the knowledge Selecting and implementing strategies to maintain behavior/practice changes is critical to ensure that gains are not lost over time. 18 Maintenance strategies can be as simple as reminder systems that prompt providers or patients when action is required, or more complex strategies such as health-information, technologyassisted clinical protocols or algorithms. Regardless of whether the strategies are simple or complex, all should be monitored for their impact. These 7 steps can also be grouped into the classic quality improvement cycle Plan (Steps 1 &2) Do (Steps 3&4) Check (Steps 5&6) Act (Step 7). Look for our future whitepaper on Knowledge Translation and Quality Improvement Initiatives for more details. 10

Next Steps The exponential growth in scientific understanding of diseases and treatments is generating new healthcare knowledge at such a rapid pace that its uptake and application lags behind, with potential adverse consequences on patient care and economic resources. Knowledge Translation research has identified methods to close the Knowledge-to-Action Gap. With more than 18 years of experience in all areas of Knowledge Creation and Knowledge Application, EPI-Q recommends consideration of the use of Knowledge Translation methods and processes when approaching a clinical change program or project. As a consulting company founded on the principles of quality improvement initiatives that include designing, implementing, and monitoring the impact of interventions that facilitate the incorporation of best evidence into clinical care the use of wellresearched planned-action models, such as the Knowledge-to-Action Framework, reflects our extensive practice offerings. Please contact us to discuss opportunities for using Knowledge Translation processes for your unique knowledge translation issue. Future EPI-Q Implementation Resources Overlooked Knowledge Translation Pivotal Steps Knowledge Translation and Quality Improvement Initiatives Application of Knowledge Translation to Patient-Centered Care 11

References 1 Bridging the Know Do Gap; Meeting on Knowledge Translation in Global Health; 10-12 October 2005 World Health Organization Geneva, Switzerland; Printed by the WHO Document Production Services, Geneva, Switzerland; 2006. Available at: http://www.who.int/kms/ktgh%20meeting%20report,%20oct%2705.pdf. 2 Oborn E, Barret M, Racko G. Knowledge translation in healthcare: a review of the literature. Working Paper Series Cambridge Judge Business School, 5/2010. Available at: http://www.jbs.cam.ac.uk/research/working_papers/2010/wp1005.pdf. 3 Grimshaw J, Eccles M, Lavia J, Hill S, Squires J. Knowledge translation of research findings. Implement Sci. 2012;7:50. 4 Straus, SE, Tetroe, JM, Graham, ID. Defining knowledge translation. CMAJ. 2009;181:165-168. 5 Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 6 President s New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America. Final Report, # SMA-03-3823. Rockville, MD: US Department of Health and Human Services; 2003. 7 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. NEJM. 2003;348:2635-2645. 8 Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? 1998. Milbank Q. 2005;83:843-895. 9 Eisenberg MJ, Garzon P. Use of evidence-based medical therapy in patients undergoing percutaneous coronary revascularization in the United States, Europe, and Canada. Am J Cardiol. 1997;79:867-872. 10 Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39:1146-1154. 11 Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8 suppl 2):112-145. 12 Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289:434-441. 13 Mujumdar SR, McAlister FA, Furberg DC. From knowledge to practice in chronic cardiovascular disease: a long and winding road. J Am Coll Cardiol. 2004;43:1738-1742. 12

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