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Knowledge Translation: The steep path between evidence generation and application. Brian Haynes Health Information Research Unit Dep’t of Clinical Epidemiology and Biostatistics McMaster University. KNOWLEDGE IS THE ENEMY OF DISEASE.

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Knowledge translation the steep path between evidence generation and application
Knowledge Translation:The steep path between evidence generation and application

Brian Haynes

Health Information Research Unit

Dep’t of Clinical Epidemiology and Biostatistics

McMaster University


Knowledge is the enemy of disease

KNOWLEDGE IS THE ENEMY OF DISEASE

The application of what we know will have a bigger impact on health and disease than any single drug or technology likely to be introduced in the next decade.

Sir Muir Gray, UK National Library for Health


Knowledge translation
Knowledge Translation…

…the organization, retrieval, appraisal, refinement, dissemination, and uptake of knowledge (eg, important new knowledge from health research)


Generalizable knowledge for better clinical practice and healthcare
Generalizable knowledge for better clinical practice and healthcare

  • knowledge from research (sometimes called evidence)

  • knowledge from the analysis of routinely collected and audit data (sometimes called statistics)

  • knowledge from the experience of clinicians and patients.


Cost effectiveness of warfarin
Cost-effectiveness of warfarin* healthcare

  • Warfarin for atrial fibrillation

    • $25CDN saved per stroke averted

  • Aspirin for atrial fibrillation

    • $65CDN saved per stroke

*Gustafsson C, et al. Cost effectiveness of primary stroke prevention in atrial fibrillation: Swedish national perspective. BMJ. 1992;305:1457-60.


What proportion of patients with atrial fibrillation do not receive anticoagulants
What proportion of patients with atrial fibrillation do not receive anticoagulants?

50%

Bradley BC, et al. Frequency of anticoagulation for atrial fibrillation and reasons for its non-use at a Veterans Affairs medical center. Am J Cardiol. 2000 Mar 1;85(5):568-72.


In Hamilton, Ontario, receive anticoagulants?“The Clot Capital of the Universe,”the proportion of medical inpatients receiving clot prevention according to guidelines is…

…33%


Current guideline adherence for diabetes
Current guideline adherence for diabetes receive anticoagulants?

Intervention:

Ophthalmology assessment… 46% - 80%

Proteinuria assessment… 35% - 82%

Foot assessment… 30% - 72%

HbA1c… 16% - 87%

Cholesterol assessment… 55% - 68%

Smoking status assessment… 25% - 87%


In all, 73% of microalbuminuric patients were not on ACE-I/ARB. Hypertensive type II diabetic patients were often left untreated and only a minority of those treated were optimally controlled. The importance of an elevated systolic pressure is underestimated and the number of antihypertensive drugs prescribed, insufficient. Screening and treatment of albuminuria are inadequate.


The routine application of what we know can prevent or minimise
The routine application of what we know can prevent or minimise:

  • unknowing variation in clinical practice

  • errors of commission and omission

  • unsatisfactory patient experience


Evidence from research is necessary but of course not sufficient

Evidence (from research) is necessary but, of course, not sufficient…

...it has to be combined with the circumstances of the individual patient and the values of each patient. But without evidence it is improbable that patients, professionals, and those who manage resources, will to make good decisions.


researchers sufficient…

decision makers


application sufficient…

generation

synthesis

policy

5

4

decisions

3

1

MRC

CIHR

a

c

b

2

 Knowledge Translation 

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 of policy; 5. individual clinical decisions, including a) patient’s circumstances, b) patient’s wishes, and c) evidence from research




How much synthesis do we need
How much synthesis do we need? sufficient…

“..at least 10 000 Cochrane reviews are needed to cover a substantial proportion of the studies relevant to health care that have already been identified”

Susan Mallett & Mike Clarke

ACP Journal Club. 2003 Jul-Aug;139:A11.


When will we have our 10 000 reviews
When will we have our 10,000 reviews? sufficient…

Growth of Cochrane Reviews and Protocols

2003

Non-Cochrane reviews: >50% of all reviews

“…between 2010 and 2015”.

Mallett&Clarke, ACPJC 2003

2500 completed mid-2005

protocols

2000 completed mid-2004

1995

reviews



Step 4 a pplying evidence in practice
Step 4. A sufficient… pplying evidence in practice


The mcmaster plus project
The McMaster PLUS project sufficient…

  • only a tiny proportion of all research is “ready for application”

  • only a tiny fraction of the “ready” research is “relevant” to the practice of a given clinician

  • only a tiny proportion of the “relevant” research for a given practitioner is “interesting” in the sense of being something new, important, and actionable.


Evidence based journals

Critical Appraisal Filters sufficient…

Evidence-Based Journals

~2,500 articles/y

meet critical appraisal

and content criteria

(95% noise reduction)

50,000 articles/y

from 120 journals


Mcmaster plus project

Clinical Relevancy Filter (MORE) sufficient…

McMaster PLUS Project

~20 articles/yr for

clinicians (99.96%

noise reduction)

~2,500 articles/y meet critical appraisal

and content criteria

(95% noise reduction)

~5-50 articles/y for

authors of evidence-based clinical topic reviews


Dear Dr. Jones, sufficient… We want to alert you to NEW articles in the PLUS system.

These articles that have received very high relevancy and newsworthiness scores:

We hope that you will find these articles of value in your clinical practice.Best wishes from the PLUS Team


Plus trial northern ontario physicians
PLUS Trial – Northern Ontario Physicians sufficient…

344 consent eligible

134 non-

respondent

7 refused

consent

203 randomized: 10 communities

6 small clusters

4 large clusters

Group 1 (3)

Group 2 (3)

Group 1 (2)

Group 2 (2)

2 left study


Intervention

Self Serve Version sufficient…

Ovid

Stat!Ref

Pyramid of Evidence

Full Serve Version

Ovid

Stat! Ref

Pyramid of Evidence

PLUS Email Alerts

PLUS Search Engine

Intervention

  • Randomization to 2 different trial interfaces


Plus preliminary findings of participants using plus by month

RCT begins sufficient…

Control cross-over begins

PLUS Preliminary Findings: % of Participants Using PLUS by Month

Self-servevsFull-serve

Baseline (5 mo)

Full-Serve

70

60

50

40

30

20

10

0

Percentage Using PLUS

Relative increase 58.7%, P=0.001

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

03 03 04 04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05

Month

Self-serve Full-Serve


Free EBM literature updating service sufficient…

http://www.bmjupdates.com

Free at www.bmjupdates.com!

(sponsored by BMJ Publishing Group)


Step 4 applying evidence in practice
Step 4. sufficient… Applying evidence in practice



Who estimates us 100b yr for health related research
WHO estimates US$100B/yr for health-related research sufficient…

  • not enough is for application research

  • the balance is shifting slowly

  • should there be a Nobel Prize for applied research?


Step 5 making better clinical decisions
Step 5. Making better sufficient… clinical decisions


Effects of Computerized sufficient…

Clinical Decision Support Systems

on Practitioner Performance and Patient Outcomes

A Systematic Review

Amit Garg MD, Neill Adhikari MD, Heather McDonald MSc,

Patricia Rosas-Arellano MD,PhD, Phillip J. DevereauxMD,, Joseph Beyene PhD, Justina Sam, R. Brian Haynes MD, PhD

Departments of Clinical Epidemiology and Biostatistics, McMaster University

Departments of Medicine, McMaster University, University of Toronto, and

University of Western Ontario

Department of Biostatistics and Epidemiology, University of Western Ontario

Ref: Garg et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293:1323-38.


Context – Computerized Clinical Decision Support Systems sufficient…

  • Software designed to directly aid in clinical decision making in which characteristics of individual patients are matched to a computerized knowledge base for the purpose of generating patient specific assessments or recommendations.

Rules / Algorithms

  • INPUT

  • Patient characteristics

  • Automated through EMR

  • By extra research staff

  • By existing health care staff

  • By the patient

  • By the practitioner

Computer

  • OUTPUT

  • Recommendations

  • delivered to health

  • care provider

  • Directly by computer

  • By pager

  • By extra research staff

  • By existing health care staff

  • Outcomes

  • Provider performance

  • Patient outcomes

integrate into

workflow


Are CDSSs sufficient…

clinically effective?


  • Did CDSS improve sufficient… practitioner performance?

  • 100 studies

  • “counting positive results on ≥ 50% outcomes measured”

  • In 16 of 21 (76%) reminder systems

  • In 24 of 37 (65%) disease management systems

  • In 19 of 29 (66%) drug dosing or prescribing systems

  • In 4 of 10 (38%) diagnostic systems

Examined in 97 studies,

63 cited improvement (65%)


  • Did CDSS improve sufficient… patient outcome?

  • Update 100 studies

  • most had inadequate power to detect important difference

  • none proven to improve definitive outcome such as mortality

  • surrogate outcomes such as BP and HbA1C not meaningfully

    improved in most studies

Examined in 52 studies,

7 cited improvement (13%)


Reminder Systems sufficient…

40 studies

Improved Practitioner

Performance

- 76% -

Improved

Patient

Outcome

- 0% -

  • Screening, counseling, vaccination, testing, medication use, or the identification of at-risk behaviors

  • CDSS successes were typically demonstrated in ambulatory care, although one successful system was used in hospitalized patients


Disease Management Systems sufficient…

37 studies

Improved Practitioner

Performance

- 62% -

Improved

Patient

Outcome

- 19% -

Most are RECOMMENDATIONS.

Range of problems, for example:

- diabetes care

- cardiovascular prevention

- incontinence in the elderly

- advanced directives

- ventilator support

- infertility

- corollary orders

- reduce unneeded health care utilization



The weakest links
The weakest links sufficient…

  • Policy - especially at the local level

  • Coordination - 4P

  • Helping practitioners to recommend effective treatments

  • Helping patients to follow effective treatments


The strongest link
The strongest link sufficient…

  • Organization of health care knowledge according to the hierarchy of evidence (evidence-based medicine)


The evolution of sufficient… Evidence-Based information systems

Examples

Computerized decision support

Evidence-based textbooks

Evidence-based journal abstracts

Systematic reviews

Original journal articles


Knowledge is the enemy of disease1

KNOWLEDGE IS THE ENEMY OF DISEASE sufficient…

The application of what we know will have a bigger impact on health and disease than any single drug or technology likely to be introduced in the next decade.

Sir Muir Gray, UK National Library for Health


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