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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