Knowledge Translation in Health Care

Moving from Evidence to Practice

Sharon E. Straus, Jacqueline Tetroe, Ian D. Graham, Sharon Straus, Jacqueline Tetroe, Ian D. Graham

• Publisher: BMJ Books
• Year: 2013
• ISBN:
  9781118413579
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Knowledge Translation in Health Care is a practical introduction to knowledge translation for everyone working and learning within health policy and funding agencies, and as researchers, clinicians and trainees. Using everyday examples, it explains how to use research findings to improve health care in real life. This new second edition defines the principles and practice of knowledge translation and outlines strategies for successful knowledge translation in practice and policy making. It includes relevant real world examples and cases of knowledge translation in action that are accessible and relevant for all stakeholders including clinicians, health policy makers, administrators, managers, researchers, clinicians and trainees. From an international expert editor and contributor team, and fully revised to reflect current practice and latest developments within the field, Knowledge Translation in Health Care is the practical guide for all health policy makers and researchers, clinicians, trainee clinicians, medical students and other healthcare professionals seeking to improve healthcare practice.

Section 1

Introduction

Chapter 1.1

Introduction

Knowledge Translation: What it is and what it isn't

Sharon E. Straus,¹ Jacqueline Tetroe,² and Ian D. Graham³

¹ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada

² Knowledge Translation Portfolio, Canadian Institutes of Health Research, Ottawa, ON, Canada

³ School of Nursing, University of Ottawa, Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada

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Key Learning Points

• Gaps between evidence and decision making occur across all decision makers including patients, health care professionals, managers, and policy makers.
• Knowledge translation is the synthesis, dissemination, exchange, and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system.

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Globally health care systems are experiencing the challenges of improving the quality of care and decreasing the risk of adverse events [1]. Health systems fail to optimally use evidence (i.e. underuse, overuse, misuse of therapies, system failures) with resulting inefficiencies and reduced quantity and quality of life [2, 3]. For example, McGlynn and colleagues found that US adults received less than 55% of recommended care [4]. Simply providing evidence from clinical research (such as through publication in journals or presentation at scientific meetings) is necessary but not sufficient for the provision of optimal care or decision making. Indeed, the “know–do” gap in health care practice and health systems management creates an “ethical urgency” for both the practice and science of knowledge translation (KT) to answer these challenges and to optimize the return on investment in research. The growing emphasis on KT (and recognition that our knowledge about how to achieve KT is incomplete) has created interest in KT which we define as the methods for closing the knowledge-to-action gaps.

What is Knowledge Translation?

There have been many terms used to describe the process of putting knowledge into action [5]. In their work to create a KT search filter, McKibbon and colleagues have so far identified more than 100 terms for research use which may contribute to confusion about what KT is and thus, hinder its advance [6]. In the UK and Europe, the terms implementation science or research utilization are commonly seen in this context. In the USA, the terms dissemination and implementation, research use, knowledge transfer and uptake are often used. In Canada, the terms knowledge transfer and exchange and knowledge translation are commonly used. The term knowledge translation has largely been adopted in Canada because the Canadian Institutes of Health Research (the federal health research funding agency) has translation of research embedded in its mandate. In this book we use the terms knowledge translation and knowledge to action interchangeably.

For those wanting a formal definition of KT, the Canadian Institutes of Health Research (CIHR) defines KT as “a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products and strengthen the healthcare system” [7]. This definition has been adapted by the US National Center for Dissemination of Disability Research and the World Health Organization. The common element to these different terms is the move beyond simple dissemination of knowledge and into actual use of knowledge. It is clear that knowledge creation (first generation research), distillation (creation of systematic reviews or second generation research), and dissemination (appearance in journals) are not usually sufficient on their own to ensure appropriate knowledge use in decision making.

We would also like to note the distinction between the concept of knowledge translation and research translation, where the later refers exclusively to the communication and use of research findings and the former encompasses all ways of knowing. By using the term “knowledge” we are recognizing that there are many forms of evidence, including research data, local (e.g. administrative) data, evaluation findings, organizational priorities, organizational culture and context, patient experience and preference, and resource availability.

We should also clarify what KT isn't. Some organizations may use the term knowledge translation synonymously with commercialization or technology transfer but this is a very narrow view and does not consider the various stakeholders involved or the actual process of using knowledge in decision making. Similarly, some confusion arises around continuing education versus knowledge translation. Certainly educational interventions (such as journal clubs and educational outreach) are a strategy for knowledge implementation but it must be kept in mind that the audience for knowledge translation is larger than the health care professionals who are the targets for continuing medical education or continuing professional development. KT strategies may vary according to the targeted user audience (e.g. researchers, clinicians, policy makers, public), and the type of knowledge being translated (clinical, biomedical, policy) [2].

What is End of Grant KT?

We have found it helpful to categorize KT activities into end of grant and integrated KT research (http://www.cihr-irsc.gc.ca/e/45321.html, accessed September 2012). End of grant KT refers to the development and implementation of a plan for making knowledge users aware of the results of a research project. There is a spectrum of end of grant KT activities; it can range from the typical dissemination and communication activities undertaken by most researchers such as publication of journal articles and presentation of research at relevant meetings to more intensive dissemination and implementation activities. For example, dissemination activities can include activities that tailor the message and medium to specific knowledge user audiences. More interactive approaches focused on knowledge implementation can also be considered such as small group educational sessions with patients or policy makers.

When considering end of grant KT activities, it is critical to consider the strength of the evidence and its significance and tailor our strategies as appropriate. For example, we shouldn't develop an elaborate, multi-component strategy to disseminate and implement the results of a study involving just 20 people. The initial question to consider when planning our strategy is whether we want to focus on dissemination and/or implementation. If dissemination is the goal, we should consider which audience we want to target namely other researchers, clinicians, funders, managers, members of the public or policy makers. When targeting dissemination to researchers we can consider which journal audiences we want to target. Similarly for presentation of research at meetings we consider which target audiences would be interested in our research. If implementation is our goal, we need to decide if we want to use the knowledge to promote change in attitudes, behavior or influence decision making.

There are challenges to consider when crafting our end of grant KT approach. First, when we are submitting a grant for funding and are drafting its end of grant KT plan, we don't know the results of the research. Therefore, we must anticipate the results and provide flexibility in our approach. Second, we need to ensure that we don't overestimate the potential impact of our research and create an overly ambitious and impractical plan. We like to use “common sense KT” as our mantra

. See Chapter 2.4 for more detailed discussion on how to develop an end of grant KT plan.

What is Integrated KT Research?

Integrated KT research is an approach to conducting research that applies the principles of KT to the entire research process. It is a collaborative or participatory approach that engages knowledge users in the research and shares similarities with participatory research, action oriented research, co-production of knowledge approaches and Mode 2 knowledge production. Integrated KT research reflects a spectrum of activity from engaging the knowledge user in development or refinement of the research questions, selection of the methodology, data collections and tools development, selection of the outcome measures, interpretation of the findings, crafting of the message, dissemination, and implementation of the results (http://www.cihr-irsc.gc.ca/e/45321.html, accessed September 2012). The idea behind this approach is that if knowledge users are involved with the research, the research will be more solutions focused and more likely to yield results that they will use in decision making. Chapter 1.2 describes in greater detail the relatively new research paradigm of integrated KT research or engaged scholarship. In most chapters, the authors provide suggestions on how the content of their chapters might be used in integrated KT research.

Why is KT Important?

Failures to use research evidence to inform decision making are evident across all decision maker groups including health care providers, patients, informal carers, managers, and policy makers, in developed and developing countries, in primary and specialty care and in care provided by all disciplines. Practice audits performed in a variety of settings have revealed that high-quality evidence is not being consistently applied in practice [8]. For example, although several randomized trials have shown that statins can decrease the risk of mortality and morbidity in post-stroke patients, statins are considerably underprescribed [9]. In contrast, antibiotics are overprescribed in children with upper respiratory tract symptoms [10]. A synthesis of 14 studies showed that many patients (26% to 95%) were dissatisfied with information given [11]. Lavis and colleagues [12] studied eight health policymaking processes in Canada. Citable health services research was used in at least one stage of the policymaking process for only four policies, and only one of these four policies had citable research used in both stages of the policymaking process. Similarly, evidence from systematic reviews was not frequently used by WHO policy makers [13]. And, Dobbins and colleagues observed that while systematic reviews were used in making public health guidelines in Ontario, the recommendations were not adopted at the policy level [14].

Increasing recognition of these knowledge to action gaps has led to attempts to effect behavior, practice or policy change. Changing behavior is a complex process requiring evaluation of the entire health care organization including systematic barriers to change (such as lack of integrated health information systems) and targeting of all those involved in decision making including clinicians, policy makers and patients [2]. Effo...