Knowledge translation.

Abstract

Seventeen years. That is the often-quoted figure for approximately how long it takes to incorporate research discoveries into the practice of health-care providers.1 This lag can be much longer, if at any point from bench or animal studies to human trials, the effects are smaller when tested in larger human trials or inconsistent findings are reported when the studies are replicated.2 Despite spending billions of dollars on clinical research, quality improvement initiatives, clinical practice guideline development, training of health-care professionals and risk assessments, effective interventions and programs do not always reach the patients that could benefit from them.3 The Canadian Institute of Health Research reported that one-third of patients do not receive treatments that are proven to be effective, and one-quarter of patients receive care that is not needed or is potentially harmful.4 In a similar analysis, the CareTrack study found that adults in Australia received appropriate care (according to relevant guidelines) only 57% of the time.5 In an examination of underuse of effective medical services around the world, failure of practitioners to know about or act upon evidence for a variety of reasons contributed to suffering, disability and loss of life in both low- and high-income countries ‘regardless of payment model or health system, and in clinical settings ranging from rural clinics to tertiary hospitals’.6 With the current pressures both to deliver evidence-based practice and achieve cost-effective outcomes, dietitians, like the other health-care practitioners with whom they work, are expected to identify and incorporate best evidence into their practices in a timely way and monitor this impact on health outcomes. Addressing the gap between the creation of knowledge and its uptake by stakeholders to create efficiencies in care delivery and improve the health outcomes of individuals and populations has come to be known as knowledge translation (KT). A more specific definition of KT was developed by the Canadian Institute of Health Research: Knowledge translation is ‘a 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’.7 In Europe, it may be referred to as implementation science and while translational research, continuing education and professional development can be part of the knowledge transfer process, they are not synonymous with it.8 Graham et al.'s Knowledge-to-Action (KTA) framework has been central to KT strategies since its publication in 2006.8 The Knowledge Creation component of the framework relates to distilling the vast amount of knowledge available in health care so that the most valid and useful is accessible to stakeholders. This knowledge is derived from high-quality primary research (knowledge inquiry), the most relevant of which is then replicated, appraised and synthesised in the form of systematic reviews or meta analyses (knowledge synthesis), which are further refined into tools such as clinical practice guidelines, decision aids, care pathways and evidence summaries (tools and products). These final tools are meant to provide clear recommendations to inform and guide the actions of the various stakeholders such as health-care providers, patients and policy-makers. Experiential knowledge can and should be incorporated, as ideally creators of knowledge (researchers) collaborate throughout the process with end-users of the knowledge (stakeholders). Grol remarked that ‘evidence-based medicine should be complemented by evidence-based implementation’10 and while there are gaps in our knowledge about effective strategies for enhancing KT, there are a growing number of resources to inform KT activities. Cochrane has developed a KT framework11 to ensure their reviews are relevant and follow stringent methodological processes and utilise reviews conducted by their Effective Practice and Care Group12 and Consumer and Communications Review Group13 to ensure their KT activities are grounded in best practices for dissemination and uptake. The Appraisal of Guidelines for Research and Evaluation AGREE II Scorecard for rating the quality of clinical practice guidelines has included ranking on domains relevant to improving their uptake (KT) since 2003.14 A scoping review by Wilson et al.15 identified that the steps in KT frameworks relating to adapting knowledge to the local context, assessing barriers to knowledge use and implementing interventions to promote knowledge use (referred to as dissemination in his review) were generally underpinned by at least one of the following theories: persuasive communication, diffusion of innovations theory or social marketing. Parks et al.16 provide a detailed methodology for enhancing the dissemination and update of programs and policies to enhance diabetes-related care in local health departments using some of these frameworks. Kastner and Straus illustrate how the knowledge to action framework was used to create a clinical support tool to enhance osteoporosis disease management by primary care providers.17 Both these examples illustrate KT strategies designed to consider the local practice settings in which the knowledge or innovation will be used. Another key factor in a KT plan is the identification of barriers to knowledge uptake. Barriers can be individual such as lack of knowledge, skills, time, resistance to change or occur during the interaction between the practitioner and patient.18 This issue of Nutrition & Dietetics includes a report on a pilot study examining empathy scores of Malaysian dietitians using a validated survey tool.19 If the patient is the target for a particular KT intervention, examining the provider–patient relationship can enhance communication and improve outcomes, the ultimate goal of KT. Replacing older knowledge with new evidence is another KT challenge.20 Clinical practice guidelines that have been widely adopted into practice and reinforced by institutional care protocols can become resistant to newer evidence, and peer groups whose standards are inconsistent with best practices can make adoption of new knowledge or evidence challenging at an individual level.18 Mathews et al.21 explore these phenomena in their examination of dietitians’ opinions regarding the prevalence, diagnosis and effective monitoring of refeeding syndrome in 11 countries. Their findings of variability in dietitians’ assessment of prevalence of refeeding syndrome and differences in the role dietitians play in diagnosing and monitoring this condition lead them to recommend that updated, international, evidence-based clinical practice guidelines are needed. Barriers can also arise from organisational, institutional or even environmental factors. Organisational barriers can result from staff turnover and a loss of momentum, lack of institutional support for evidence-based practices, incentives that do not support best practice and a disconnect between multidisciplinary team members or the researcher/educator and the end user of the knowledge or intervention. Young et al.22 described a quality improvement initiative designed to improve nutritional and functional outcomes in older patients with or at risk of malnutrition. Using a participatory research approach to engage the multidisciplinary care providers and patients, they conducted a feasibility study to examine local processes related to discharge planning and follow up. Informed by this experience and enhanced by extensive consultations with stakeholders in the hospital and community environments, they then designed and implemented a dietitian-led discharge planning and follow-up program. While the improvements in nutritional or functional outcomes were modest, the improved communication, collaboration and discharge processes likely contributed to a shorter length of stay. The introduction of the National Disability Insurance Scheme in Australia is an example of an environmental shift that has implications for dietetic practice, training and workforce planning. Butler et al.23 surveyed course contacts from accredited dietetics programs to gain insight into how disability-related topics were addressed during dietitian undergraduate and postgraduate master's training. The development of policy documents such as role statements and core standards along with online learning modules can be key KT tools to ensure evidence-based practices are taught and practiced by those entering this emerging area of dietetic practice. While much of the KT literature seeks to address the lag between knowledge generation and actual uptake into practice, Balas and Chapman outline several factors that contribute to situations where overzealous KT and implementation has also lead to harm.20 Describing it as impulsive adoption they refer the 2001 clinical trial that concluded that intensive insulin therapy could reduce morbidity and mortality in patients in intensive care units (ICUs).24 The practice was quickly and widely recommended, and its uptake enhanced in USA as some jurisdictions tied reimbursement to protocols advocating for tight control of serum glucose levels. Eight years later, a much larger trial found that intensive glucose control actually increased mortality in patients in the ICU.25 Thousands of unnecessary deaths have been attributed to the overly quick adoption without adequate replication studies confirming the intervention was safe in the diverse patient population seen in the ICU. Misguided announcements20 are particularly problematic in today's social media landscape where unscientific advice, often amplified by celebrity endorsements, can lead to products and interventions being widely adopted or alternatively shunned irrespective of evidence. Information overload20 resulting from so many new studies being published and making headlines, makes it difficult for practitioners to quickly assess the really important ones and implement them in a timely manner. Studies with small sample sizes, large numbers of observational studies being published which are then refuted in subsequent observational studies or randomised control trials can also ultimately discourage the uptake of valuable research by consumers and create mistrust of credible nutrition guidelines.26 Finally, there is a new phenomenon in the KT arena. FOAM or Free Open Access Medical education was named by an international group of emergency physicians and refers to any free online medical education including blogs, podcasts, videos, tweet threads, chats etc.27 While these reduce the time for research to reach practitioners, others worry that this rapid dissemination may avoid the replication step and lead to harm; that adequate critical appraisal, peer review or editorial oversight may be omitted, or that active, charismatic online practitioners may over-influence the adoption of knowledge, research or innovations into clinical practice.28 FOAM proponents suggest that those concerns can be mitigated by ensuring that clinicians have adequate critical thinking skills and tools to evaluate these online knowledge offerings. They encourage educators and communications experts to work with scientists to utilise these online platforms as rapid dissemination vehicles and engagement platforms. Dietitians around the world are active in social media and online platforms and are increasingly using them to inform their practice and to share their knowledge with others. Chan et al.28 provide a toolkit for interested practitioners to explore how this once ‘disruptive’ form of knowledge exchange can be used effectively alongside other more traditional KT strategies to enhance the uptake and exchange of knowledge and support evidence-based practice. Dietitians are both recipients and disseminators of research knowledge. Utilising effective and relevant KT strategies that are tailored to the local circumstances and the target audience can enhance the delivery of care and programs offered by dietitians and improve the health outcomes of those they serve. The author received no funding to write this Editorial. The author is Director of PEN: Practice-based Evidence in Nutrition. JT is the sole author of this manuscript.