Knowledge Translation: The steep path between evidence generation and application Brian Haynes Health Information Research Unit Dep’t of Clinical Epidemiology and Biostatistics Mc. Master University
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… …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 • 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* • Warfarin for atrial fibrillation – $25 CDN saved per stroke averted • Aspirin for atrial fibrillation – $65 CDN 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? 50% Bradley BC, et al. Frequency of anticoagulation for atrial fibrillation and reasons for its nonuse at a Veterans Affairs medical center. Am J Cardiol. 2000 Mar 1; 85(5): 568 -72.
In Hamilton, Ontario, “The Clot Capital of the Universe, ” the proportion of medical inpatients receiving clot prevention according to guidelines is… … 33%
Current guideline adherence for diabetes Intervention: Ophthalmology assessment… Proteinuria assessment… Foot assessment… Hb. A 1 c… 87% Cholesterol assessment… Smoking status assessment… 46% - 80% 35% - 82% 30% - 72% 16% 55% - 68% 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: • unknowing variation in clinical practice • errors of commission and omission • unsatisfactory patient experience
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 decision makers
generation synthesis policy application a c 1 3 4 5 b decisions 2 Knowledge Translation MRC Steps from evidence generation to clinical application CIHR 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
Step 1. Generating Research Evidence Barrier • too little research addressing “real world” problems Solutions • large, simple randomized trials • “head to head” comparisons
Step 2. Synthesizing Research Evidence Barrier • size and noise of the research enterprise Solutions • research into rating, abstracting, and synthesizing research
How much synthesis do we need? “. . 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: A 11.
When will we have our 10, 000 reviews? Growth of Cochrane Reviews and Protocols 2003 Non-Cochrane reviews: >50% of all reviews 2500 completed mid-2005 protocols 2000 completed mid-2004 1995 reviews “…between 2010 and 2015”. Mallett&Clarke, ACPJC 2003
Step 3. Developing Policy Barrier • problems in developing evidence -based clinical and health policy Solutions • national drug and technology assessment agencies • local leadership
Step 4. Applying evidence in practice Barrier • poor access to current best evidence and guidelines Solutions • development and testing of information systems that integrate evidence and guidelines with patient care (eg Diabetes In. CHARGE)
The Mc. Master PLUS project • 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 50, 000 articles/y from 120 journals ~2, 500 articles/y meet critical appraisal and content criteria (95% noise reduction)
Mc. Master PLUS Project Clinical Relevancy Filter (MORE) ~2, 500 articles/y meet critical appraisal and content criteria (95% noise reduction) ~20 articles/yr for clinicians (99. 96% noise reduction) ~5 -50 articles/y for authors of evidencebased clinical topic reviews
Dear Dr. Jones, We want to alert you to NEW articles in the PLUS system. These articles that have received very high relevancy and newsworthiness scores: 1. Bohlius J, et al. Erythropoietin for patients with malignant disease. Cochrane Database Syst Rev 2004; (3): CD 003407. Rated by: IM/General (patients referred from Primary Care) Relevance: 6 of 7 Newsworthiness: 6 of 7 2. Gourlay S, et al. Clonidine for smoking cessation. Cochrane Database Syst Rev 2004; 3: CD 000058. Rated by: IM/General (patients referred from Primary Care) Relevance: 6 of 7 Newsworthiness: 6 of 7 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 134 nonrespondent 344 consent eligible 7 refused consent 203 randomized: 10 communities 6 small clusters Group 1 (3) Group 2 (3) 4 large clusters Group 1 (2) Group 2 (2) 2 left study
Intervention • Randomization to 2 different trial interfaces Self Serve Version Full Serve Version • Ovid • Stat!Ref • Stat! Ref • Pyramid of Evidence • PLUS Email Alerts • PLUS Search Engine
PLUS Preliminary Findings: % of Participants Using PLUS by Month Self-serve vs Full-serve Percentage Using PLUS Baseline (5 mo) Full-Serve 70 60 50 40 30 20 Relative increase 58. 7%, P=0. 001 10 0 RCT begins Control cross-over begins 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 Month Self-serve 05 05 05 Full-Serve 05
Free EBM literature updating service http: //www. bmjupdates. com Free at www. bmjupdates. com! (sponsored by BMJ Publishing Group)
Step 4. Applying evidence in practice Barrier • ineffectual continuing education Solution • effective continuing education and quality improvement programs for practitioners
Step 4. Applying evidence in clinical decisions Barrier • ignorance about barriers and their solutions Solution • shift a portion of health investment from services to quality improvement
WHO estimates US$100 B/yr for health-related research • 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 Barrier • not having the right information at the right time Solutions • Computerized decision support
Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes A Systematic Review Amit Garg MD, Neill Adhikari MD, Heather Mc. Donald MSc, Patricia Rosas-Arellano MD, Phillip J. Devereaux Justina Sam, R. Brian Haynes MD, Ph. D MD, , Joseph Beyene , Ph. D Departments of Clinical Epidemiology and Biostatistics, Mc. Master University Departments of Medicine, Mc. Master 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 Ø 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 Outcomes • Provider performance • Patient outcomes integrate into workflow • Directly by computer • By pager • By extra research staff • By existing health care staff
Are CDSSs clinically effective?
Did CDSS improve practitioner performance? 100 studies “counting positive results on ≥ 50% outcomes measured” Examined in 97 studies, 63 cited improvement (65%) Ø In 16 of 21 (76%) reminder systems Ø In 24 of 37 (65%) disease management systems Ø In 19 of 29 (66%) drug dosing or prescribing systems Ø In 4 of 10 (38%) diagnostic systems
Did CDSS improve patient outcome? Update 100 studies Examined in 52 studies, 7 cited improvement (13%) Ø most had inadequate power to detect important difference Ø none proven to improve definitive outcome such as mortality Ø surrogate outcomes such as BP and Hb. A 1 C not meaningfully improved in most studies
Reminder Systems 40 studies Improved Practitioner Performance - 76% - Improved Patient Outcome - 0% - Ø Screening, counseling, vaccination, testing, medication use, or the identification of at-risk behaviors Ø CDSS successes were typically demonstrated in ambulatory care, although one successful system was used in hospitalized patients
Disease Management Systems 37 studies Improved Practitioner Performance - 62% - 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 Improved Patient Outcome - 19% -
Step 5. Improving health care decisions Barrier • low patient adherence to treatments Solutions • adoption of effective strategies to assist patients to follow evidence -based health care
The weakest links • Policy - especially at the local level • Coordination - 4 P • Helping practitioners to recommend effective treatments • Helping patients to follow effective treatments
The strongest link • Organization of health care knowledge according to the hierarchy of evidence (evidencebased medicine)
The evolution of Evidence-Based information systems Summaries Synopses Syntheses Studies Examples Computerized decision support Evidence-based textbooks Evidence-based journal abstracts Systematic reviews Original journal articles
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
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