STEP UP 2010 March 30, 2010

Alison M. Hoens 1

TRANSLATING RESEARCH TRANSLATING RESEARCH INTO PRACTICEINTO PRACTICE

Alison HoensPhysical Therapy Knowledge Broker

UBC, PABC, BC RSRNet

Clinical Associate Professor; UBCResearch, Education & Practice Coordinator, PHC

OUTLINETranslating Research Into Practice

What does it mean?

What is happening currently?

What do we want in the future?

How can we get there?

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Translating research into practice: What does it mean?

33

Translating research into practice: What does it mean?

Translate

– To restate from one language into another

– To change from one form or medium into another

– To understand: make sense of

– To express in simple & less technical language

– To bring to a certain spiritual state44

Translating research into practice: What does it mean?

What is knowledge?

– Expertise and skills acquired by a person

through experience or education

– Awareness or familiarity gained by experience of a fact or situation

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Translating research into practice: What does it mean?

Ask Answer

Do Know

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The Know-Do Gap

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Translating research into practice: What does it mean?

Applied health researchDiffusionDissemination ImplementationKnowledge cycleKnowledge exchange Knowledge managementKnowledge translationKnowledge to action

Knowledge mobilization Knowledge transfer Linkage and exchangeParticipatory researchResearch into practiceResearch transferResearch translation Transmission Utilization

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Translating knowledge to practice

What is happening currently?

Ranking of importance of factors

influencing current practice:

– Experience

– Continuing education (practical)

– Colleague influence

– Continuing education (theory)

– Professional literature *secondary sources

– Entry level trainingStevenson et al (2005)

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Translating knowledge to practice

What is happening currently?

PTs’ interventions for hypothetical

typical patient with acute LBP

– 68% used Rx with strong or mod evidence of effectiveness

– 90% used Rx with limited evidence of

effectiveness

– 96% used Rx with absence of evidence of

effectivenessMikhail et al, 2005

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Translating knowledge to practice

What is happening currently?

Challenges:

– Time

– Not enough evidence

– Too much evidence

– Acquiring evidence

– Appraising evidence

– Synthesizing evidence

– Applying evidence

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Translating knowledge to practice

What is happening currently?

Too much evidence

– PT :1, 400 articles published per year

– To keep up need to read 4 articles per day

– If read 1 per day, after 1 year, 3 years behind

Paul Stratford, 2003

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Translating knowledge to practice

What is happening currently?

– The evidenceAccessibility, presentation, applicability

– The individualIndividual skills for EBP

– The professionIncentives

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Translating knowledge to practice

What is happening currently?

– The partnersPre-licensure training, healthcare organization structure & resources

– The patientsGreater access & desire

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Translating knowledge to practice

What is happening currently?

Practice styles are an important

influence on evidence-informed practice

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Translating knowledge to practice

What is happening currently?

Seeker– Evidence > experience

Receptive– Evidence-oriented but relies on judgement of

respected others

Traditionalist– Clinical experience and authority most important

Pragmatist– Focuses on day to day demands– Primary concern is efficiency

Green et al (2002). J of Family Practice 51(11)1616

Translating knowledge to practice

What is happening currently?

PTs

– 14% seekers

– 68% pragmatistsKorner-Bitensky et al, 2007

We need to address how we provide

evidence so that pragmatists can have their type of practice style needs met!

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Translating knowledge to practice

What do we want in the future?

Help with:

– Optimal assessment / diagnosis

– Optimal interventions

– Optimal evaluation of effectiveness

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Translating knowledge to practice

What do we want in the future?

Selection of best questions & tests to

use for assessment / diagnosis

– Reliability

– *Diagnostic accuracy

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Carpal TunnelClinical Questions for Diagnosis

Test Sensitivity Specificity +LR -LR

Numbness disappears if

shakes hand

.90 .30 1.29 .33

Night pain .96 .59 2.34 .07

2020

Sensitivity = detect those who actually DO have the conditionSpecificity = detect those who actually DO NOT have the condition

Likelihood ratio – combine sensitivity & specificity; shift in probability

+LR>10 –LR < 0.1 quite conclusive+LR 5-10 –LR < 0.1-0.2 moderately conclusive

+LR 1-2 –LR 0.5-1 small & rarely important

Carpal TunnelClinical Tests for Diagnosis

Test Sensitivity Specificity +LR -LR

Phalen sign .68 .90 6.80 .36

Tinel sign .68 .91 1.15 .78

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Sensitivity = detect those who actually DO have the condition

Specificity = detect those who actually DO NOT have the condition

Likelihood ratio – combine sensitivity & specificity; shift in probability

+LR>10 –LR < 0.1 quite conclusive

+LR 5-10 –LR < 0.1-0.2 moderately conclusive

+LR 1-2 –LR 0.5-1 small & rarely important

Translating knowledge to practice

What do we want in the future?

Selection of best interventions

– What is the ‘best’ evidence and how do I

get it quickly?

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Translating knowledge to practice

What is happening currently?

I had considerable freedom of clinical

choice of therapy: my trouble was that I did not know which to use and when. I

would gladly have sacrificed my

freedom for a little knowledge.

Sir Archie Cochrane

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SYNTHESIZING INFORMATION

Synthesis of RCTs

+ RCT

+ RCT

-RCT

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LEVELS OF EVIDENCE

Meta-analysis

Systematic review

Randomized controlled trials

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Same outcome measures

Different outcomemeasures

META-ANALYSIS

FORREST PLOT

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Favors treatment Favors control

AA

BB

CC

DD

EE

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EFFECTIVENESS OF INTERVENTIONS ON KNEE OA PAIN

Manual

Therapy& exercise

L/E

strengthening

Ottawa Panel

Translating knowledge to practice

What do we want in the future?

Selection of best evaluation of

effectiveness

– What outcome measures should be used?

– When should they be used?

– How should they be used?

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Use of Outcome MeasuresWHEN

Admission Discharge

T1

T2

Ac

tivit

y-L

eve

l F

un

cti

on

Sc

ale

0

100

Good Outcome?

2929A. Kozlowski

Use of Outcome MeasuresWHEN

Admission Discharge

T1

T2

Ac

tivit

y-L

eve

l F

un

cti

on

Sc

ale

0

100

It is important to measureat more than 2 time points

Patient A

Patient B

3030A. Kozlowski

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Use of Outcome MeasuresWHAT

Use of standardized outcome measures

will help:

– Program evaluation

– Individual patient care: creation of ‘recovery curves’ so that we can identify

who requires more or less

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Use of Outcome Measures

WHAT?

Males0.0

1.0

2.0

3.0

4.0

5.0

6.0

0 20 40 60 80 100 120 140 160

Days from Surgery

Deg

ree

s o

f K

nee

Exte

ns

ion

Red = 25th percentileBlue = 50th percentile

Green = 75th percentile

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McAuley et al.

RECOVERY CURVES POST TKA

Days from Surgery

Use of Outcome MeasuresWHAT

Selection of best OM for the population

– TUG

– Elderly Mobility Scale

Reliability

Validity

Ceiling effect

Floor effect

Easy to undertake, score & interpretDe Morton et al (2008). A systematic review of

Mobility instruments and their measurement

Properties for older acute medical patients.

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Use of Outcome MeasuresHOW?

Admission Discharge

T2

Ac

tivit

y-L

eve

l F

un

cti

on

Sc

ale

0

100Minimal Detectable

Change (MDC)

Minimal Important Difference (MID)

Minimal Clinically

Important Difference (MCID)

T1

3434A. Kozlowski

Use of outcome measuresHow much change is meaningful?

MID for 6MWD in COPD: 25 meters Updating the Minimal Important Difference for Six-Minute Walk Distance in Patients With Chronic Obstructive Pulmonary Disease. Holland et al 2010

MICD for gait speed post hip fracture: 0.10 m/sDetermining meaningful changes in gait speed after hip fracture. Palmbaro et al, 2006

MDC for LEFS: 9 pointsLEFS: Scale development, measurement properties and clinical application. Binkley et al, 1999

MCID for Oswestry: 5.4 pointsOutcome Measurement for Patients with Low Back Pain. Resnick & Dobrykowski, 2005

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Translating knowledge to practice

What do we want in the future?

Evidence-based practice

– The consciousness, explicit, and judicious use of current best evidence in making decisions about the care of individual

patients (1996)

– The integration of best research evidence with clinical expertise and patient values (2000)

Evidence-informed practice 3636

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EVIDENCE - INFORMED PRACTICE

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ASK

ACQUIRE

APPRAISE /

SYNTHESIZEAPPLY

EVALUATE

Translating knowledge to practice

How can we get there?

Help

– Professional Association: PABC

Library resources

– Librarian

– Tutorials

– Resources: eg. getting articles from 22 top journals

– The University

Faculty – academic & clinical

– Community Engagement initiative

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Translating knowledge to practice

How can we get there?

Help:

– The Health Care Organization: VCH, PHC

Library resources

Professional Practice Leaders, clinical specialists, education leaders, research leaders

* Clinician Scientist positions

Research bodies: VCHRI, PHCRI

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Translating knowledge to practice

How can we get there?

Knowledge Broker resources

– Webpages: PABC, UBC Dept of PT

Links

Tools *Tutorials on asking, acquiring, appraising (BC RSRNet)

Research Collaboration Registry

Summaries of projects:

– SAFEMOB – Decision-making tool for safe mob of acutely ill patient

– TJAOM – Enhancing use of outcome measure in TJA

– Seating GAWG - Guidelines for provision of

wheelchairs in progressive neuromuscular disease

– Skin & Wound Care supports for EBP 4040

Translating knowledge to practice

How can we get there?

Little to no effect (Median effect size 8.1%)– Educational materials

– Didactic sessions

Sometimes effective (Median effect size 7.0%)– Audit & feedback

– Local opinion leaders

– Local consensus project

– Patient mediated interventions

Consistently effective (Median effect size 14.1%)– Reminders

– Interactive education (with discussion of practice)

– Social marketing(Bero et al., 1998, Grimshaw et al., 2001)

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Translating knowledge to practice

How can we get there?

Other ideas:

– Article alerts * PABC, self

– Journal clubs *PABC May 6th!

– Research updates *UBC

– Special interest groups

– Hot topic alerts/debates

eg. midportion tendinopathy – a cardiovascular disease?

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Translating knowledge to practice

How can we get there?

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Canadian Agency for Drugs and Technologies in Health (CADTH)

www.cadth.ca

Translating knowledge to practice

How can we get there?

4444Houghton, Nussbaum & Hoens.Physiotherapy Canada. In press

Translating knowledge to practice

How can we get there?

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1. Clarity & simplicity of the message2. Readiness for change3. Engagement4. Leadership5. Consistency6. Local context7. Effective relationships

Physio Canada 61(4)

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1. We are all important pieces of the puzzle2. Each piece is equally important3. The puzzle is not complete if a piece is missing

THANK YOU

UBC Dept of PT

PABC

BC RSRNet

SAFEMOB

– Dr. E Dean

– Dr. D Reid

– Frank Chung

– Simone Gruenig

– Rosalyn Jones

– Stakeholder input

Skin & Wound KT– Nancy Cho

– Sarah Rowe

– Oksana Peczeniuk

– Rebecca Packer

– Michelle Jacobs

– Leah Keiffer

– Rochelle Graham

– Angela Ng

– Devon Tyler

– Sondra Ng

– Fiona Wright

– Heather Newsome4747

THANK YOUTHANK YOU

PABC Practice Guidelines Task Force

– Martin Heroux

– Becky Packer

– Christa Morrison

– Farah Walji

– Rachel Oates

W/C GAWG– Lori Roxborough

– Linda Del Fabro Smith

– Janice Evans

– Bonnie Sawatzky

– Cheryl Sheffield

– Debbie Scott-Kerr

– Maureen Story

– Susan Garret

– Lorelyn Meisner

– Shannon Sproule

– Ian Denison

– Roslyn Livingstone

– Sarah Pike

– Susan Stacey

– Catherine Husken 4848

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THANK YOUTHANK YOU

TJAOM

– How: Program Eval’n

Phil Lawrence

Greg Noonan

Fatima Inglis

Tracy Wong

Susan Carr

– Why: Barriers / Facilitators

Maureen Duggan

– What: PRAG

Dave Troughton

Catherine McAuley

Marie Westby

Ronda Field

Irene Goodis

Marisa Twaites

Maureen Duggan

Melissa Idle

Rubyanne Meda

Stan Metcalfe

Wendy Watson

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THANK YOUTHANK YOU

TJAOM – PRAG (Survey)

– MPT students

Lauren Welch

Belinda Wagner

Nick Klopper

Drey Voros

Danielle Balik

Veronica Naing

SAFEMOB –AECOPD (Delphi)

Dr. Pat Camp

Dr. D. Reid

– MPT students:

Paolo Macapagal

Debbie Kan

Colin Beattie

Tay il Yoon

Param Bakshi

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THANK YOUTHANK YOU

Providence Health Care research

– Janice Wilson

– Katie Steele

– Jo Moorhen

– Treena Denny

– Nellie Yee

– Fatima Inglis

– Jill Kipnis

– Sandra Squire

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AND THANK YOU!AND THANK YOU!

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