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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. - PowerPoint PPT Presentation
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Knowledge Translation:The steep path between evidence
generation and application
Brian HaynesHealth Information Research Unit
Dep’t of Clinical Epidemiology and BiostatisticsMcMaster 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– $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?
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, “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… 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:• 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.
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
a
bc
1
generation
2
synthesis
3
policy
4
application
5
decisions
Knowledge Translation
CIHRMRC
Barrier Solutions
• too little research addressing “real world” problems
• large, simple randomized trials• “head to head” comparisons
Step 1. Generating Research Evidence
Barrier Solutions• size and noise of the research enterprise
• research into rating, abstracting, and synthesizing research
Step 2. Synthesizing Research Evidence
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:A11.
When will we have our 10,000 reviews?
“…between 2010 and 2015”.Mallett&Clarke, ACPJC 2003
Growth of Cochrane Reviews and Protocols
1995
2003
2000 completed mid-2004
reviews
protocols2500 completed mid-2005Non-Cochrane reviews: >50% of all reviews
Barrier Solutions
• problems in developing evidence-based clinical and health policy
• national drug and technology assessment agencies• local leadership
Step 3. Developing Policy
Step 4. Applying evidence in practice
Barrier Solutions• poor access to current best evidence and guidelines
• development and testing of information systems that integrate evidence and guidelines with patient care(eg Diabetes In-CHARGE)
The McMaster 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.
50,000 articles/yfrom 120 journals
~2,500 articles/ymeet critical appraisaland content criteria(95% noise reduction)
Evidence-Based Journals
Critical Appraisal Filters
~2,500 articles/y meet critical appraisaland content criteria(95% noise reduction)
McMaster PLUS Project
Clinical Relevancy Filter (MORE)
~20 articles/yr for clinicians (99.96%noise reduction)
~5-50 articles/y for authors of evidence-based 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):CD003407.
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:CD000058.
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
203 randomized: 10 communities
6 small clusters 4 large clusters
Group 1 (3) Group 2 (3) Group 1 (2) Group 2 (2)
7 refused consent
344 consent eligible
2 left study
134 non-respondent
PLUS Trial – Northern Ontario Physicians
Intervention
Self Serve Version• Ovid• Stat!Ref• Pyramid of Evidence
Full Serve Version• Ovid• Stat! Ref• Pyramid of Evidence• PLUS Email Alerts• PLUS Search Engine
• Randomization to 2 different trial interfaces
PLUS Preliminary Findings: % of Participants Using PLUS by Month
Pe
rce
nta
ge
Us
ing
PL
US
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 05Month
70
60
50
40
30
20
10
0
Baseline (5 mo) Self-serve vs Full-serve Full-Serve
Self-serve Full-Serve
Relative increase 58.7%, P=0.001RCT begins Control cross-over begins
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 Solution
• ineffectual continuing education
• effective continuing education and quality improvement programs for practitioners
Step 4. Applying evidence in clinical decisions
Barrier Solution
• ignorance about barriers and their solutions
• shift a portion of health investment from services to quality improvement
WHO estimates US$100B/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 Solutions
• not having the right information at the right time
• 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 McDonald MSc,
Patricia Rosas-Arellano MD,PhD, Phillip J. Devereaux MD,, Joseph Beyene PhD, Justina Sam, R. Brian Haynes MD, PhD
Departments of Clinical Epidemiology and Biostatistics, McMaster UniversityDepartments of Medicine, McMaster University, University of Toronto, and University of Western OntarioDepartment 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
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
Computer
INPUTPatient characteristics• Automated through EMR• By extra research staff• By existing health care staff• By the patient• By the practitioner
OUTPUTRecommendations 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
Did CDSS improve 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 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%)
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
Improved Practitioner
Performance- 76% -
Improved Patient Outcome
- 0% -
Reminder Systems40 studies
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 Practitioner
Performance- 62% -
Improved Patient Outcome
- 19% -
Disease Management Systems37 studies
Step 5. Improving health care decisions
Barrier Solutions• low patient adherence to treatments
• adoption of effective strategies to assist patients to follow evidence-based health care
The weakest links
• Policy - especially at the local level
• Coordination - 4P• 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 (evidence-based medicine)
Systems
Summaries
Synopses
Syntheses
Studies
Examples
Computerized decision support
Evidence-based textbooks
Evidence-based journal abstracts
Systematic reviews
Original journal articles
The evolution of Evidence-Based information systems
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