Overview

Currently, the most comprehensive systematic meta review of KT practices is that by Richard Grol and Jeremy Grimshaw (Grol, Richard, and Jeremy Grimshaw. "From best evidence to best practice: effective implementation of change in patients' care". The Lancet 362, 9391 (Oct 11, 2003): 1225.
This backgrounder to the Knowledge Translation Research Plan Template quotes segments of this paper to provide the novice template user with some background to assist their planning process. References are made to numbered citations from The Lancet publication, and are included here as well for easy reference because not all KT Plan users will necessarily have access to research articles. Other sources are also cited.

Main Messages from Grol & Grimshaw 2003

• In planning your KT activities it is important to consider potential barriers to changing practice
• A review of 76 studies in doctors (28) have shown that obstacles to change in practice can arise at different stages in the health-care system, at the level of the patient, the individual professional, the health-care team, the health-care organization, or the wider environment. (29-31)
• Most theories on implementation of evidence in health care emphasize the importance of developing a good understanding of such obstacles to develop an effective intervention. (29)
• Consider also that different theoretical perspectives are valuable when considering potential barriers to change and strategies to promote change. Barriers to change can act at different levels (individual, team, organization); (35-37) it is important to understand these and tailor strategies to them.

Main Conclusions from an Overview of 54 Reviews (11,42,43)

• Change is possible when a well-designed intervention is used; most interventions studied had some effects (average of about 10% for main targets). However, none of the interventions is superior for all changes in all settings.
• There is more evidence on professional-oriented interventions (education, reminders, feedback) than on those aimed at the organization or the patient.
• Economic assessment of performance strategies is scarce, as is information on patients' outcomes.
• Implementation of many studies could be improved.
• Different types of changes seem to need discrete types of interventions, but we do not have a good understanding of the probable effectiveness of different interventions for changes in other settings.
• Interventions targeted at specific obstacles to change seem to be more effective than interventions that are not.

Mostly Effective KT Interventions

Evidence: Small group interactive education with active participation (59) showed positive effects.

Educational outreach extends the impact of learning through such channels as public broadcasting and media services, educational materials, and collaborative activities designed to engage individuals and foster community participation in addressing issues of concern.

• Thomson (92) reviewed 18 trials and noted that the effect sizes for educational outreach are moderate and could be improved by use of additional interventions.
• At least eight reviews addressed educational outreach by experts or trained facilitators. (58,66,70,77,78,85,92,96) This approach proved to be especially effective for improving prescribing behaviour (85) and prevention in primary care. (70)
• In view of the feasibility and low costs of these interventions, printed educational materials could be important as part of a more comprehensive approach

Reminders (electronic, poster, etc) that support clinical practice, such as clinical guidelines.

• A general effect of reminders was noted in an analysis of 14 reviews. (44,53,58,67,68,70,74,77,83-85,95-97)
• In the second review by Grimshaw, (11) reminders had the largest average effect (13%) of all interventions studied. They seemed to be especially influential for prevention (vaccination, cancer screening).
• Shown to have a modest but sustained effect.

• A review by Balas (46) of almost 100 trials showed that about 75% had substantial improvements, particularly for provider prompts, computer-assisted treatment plans, and patients' prompts.
• Results of different systematic reviews on use of computers and computerized decision support (46,71,72,80,94) suggest that computerized decision support is more likely to be effective for management decisions than for diagnosis
• That simple prompting systems show more positive results than knowledge-based and advanced systems. (99)
• Hunt (68 studies) (71) and Walton (94) showed that computerized decision support is most effective for drug dosing and preventive care.
• In two reviews of the introduction of computers in primary care, (47,87) neutral to positive effects on clinical performance were reported.

• In five reviews, (52,69,79,86,98) reviewing the effects of collaboration and teamwork these interventions proved to have a range of effects in chronic patients, eg, for cancer, (69) stroke, (86) mental health, (52) or geriatric care, (79) resulting in a shorter stay in hospital, reduction of costs, or more patient's satisfaction.
• The topics in these reviews were too heterogeneous to come to final conclusions.

• Grilli (64) reviewed the effects of 22 studies of mass media on health-service use and reported that all studies showed improvements in care.
• Dealing with the Media

• Of six reviews (49,54,62,63,65,95) addressing financial interventions, fundholding was shown to have an effect on prescribing in particular. (62,65)
• Providing budgets instead of fees reduced drug costs and number of days in hospital. (54)

• In the recent review of 235 trials, (11) 73% of all interventions were multifaceted; 16 reviews addressed such interventions specifically. (57-9,61,67,70,73,74,77,83,84,89,90,95-97)
• Some of these (70,77,84,95) stated that combined interventions, addressing specific barriers to change, are more effective than single interventions, but the recent review (11) did not lend support to this conclusion.

Mixed Effects

• Use of local opinion leaders, looked at in three reviews, resulted in mixed effects (91)
• The feasibility of identifying opinion leaders in different settings is uncertain.
• This intervention seemed to be effective when targeting test ordering and prevention, but the effect size could be moderated by type of feedback, its source and format, and frequency or intensity of presentation. (42)
• Feedback is recommended in combination with education, outreach visits, or reminders. (96)

• Large conferences and courses showed mixed effects (59)

• Use of local opinion leaders, looked at in three reviews, resulted in mixed effects, (91)
• The feasibility of identifying opinion leaders in different settings is uncertain.

• At least nine systematic reviews have addressed distribution of educational materials to professionals (55,58,60,61,70,77,78,85,96)
• However, the number of studies with enough power, correct analysis, and substantial effects was small, leading reviewers to conclude that the effects of educational materials is limited. (60)
• A systematic review of guideline implementation strategies noted a median improvement of 8% across four cluster randomised trials. (11)
• In view of the feasibility and low costs of these interventions, printed educational materials could be important as part of a more comprehensive approach.

Interventions that are directly focused on patients in order to improve clinical practice

• Eight reviews (46,47,58,61,67,74,77,83) summarized results of studies on interventions directly focusing on patients to improve clinical practice, typically in the form of reminders or computerized education. Effects were noted for improved screening and vaccination rates.

• Performance feedback aimed at improving hand hygiene (personal and non-personalised, oral and written) was used in nine studies; results suggest that this intervention can improve practice, but the effect stops if feedback is not continued.

• Six reviews looked at expanding professional roles. (50,66,67,70,78,88) In three of these, expanding the pharmacist's role was noted to lead to better prescribing behaviour of doctors. (55,71,83) Results of a review on delegation of tasks to nurses showed no relevant effect, (88) and substitution of preventive tasks was effective in two others. (67,70)

Limited Effects

In one review (81) of 55 studies (13 multisite, three randomised controlled trials), the effects of continuous quality improvement and quality management were investigated. Interventions used were very different. Results of single-site studies showed positive results on clinical performance, but the randomised controlled trials did not.

The following strategies were not included in the meta review, but may facilitate KT and/or play a role in the dissemination, exchange, and uptake process.

Unknown Effects

An announcement of an event, performance, or other newsworthy item that is issued to the press. In health this is typically the function of a public affairs or communication office.

Protection of new technology (intellectual property) is done though patenting and copyrighting. Technologies are also marketed and licensed to industry for further development.

A patent is a set of exclusive rights granted by a state to an inventor or his assignee for a fixed period of time in exchange for a disclosure of an invention. The procedure for granting patents, the requirements placed on the patentee and the extent of the exclusive rights vary widely between countries according to national laws and international agreements. Typically, however, a patent application must include one or more claims defining the invention which must be new, inventive, and useful or industrially applicable. In many countries, certain subject areas are excluded from patents, such as business methods and mental acts. The exclusive right granted to a patentee in most countries is the right to prevent or exclude others from making, using, selling, offering to sell or importing the inventionm.

A patent is not a right to practice or use the invention. Rather, a patent provides the right to exclude others from making, using, selling, offering for sale, or importing the patented invention for the term of the patent, which is usually 20 years from the filing date. A patent is, in effect, a limited property right that the government offers to inventors in exchange for their agreement to share the details of their inventions with the public. Like any other property right, it may be sold, licensed, mortgaged, assigned or transferred, given away, or simply abandoned. (http://en.wikipedia.org/wiki/Patent)

Social marketing is the systematic application of marketing along with other concepts and techniques to achieve specific behavioral goals for a social good.

Craig Lefebvre and June Flora introduced social marketing to the public health community in 1988 where it has been most widely used and explored. They noted that there was a need for 'large scale, broad-based, behavior change focused programs' to improve public health (the community wide prevention of cardiovascular diseases in their respective projects), and outlined eight essential components of social marketing that still hold today. They are:

1. A consumer orientation to realize organizational (social) goals
2. An emphasis on the voluntary exchanges of goods and services between providers and consumers
3. Research in audience analysis and segmentation strategies
4. The use of formative research in product and message design and the pretesting of these materials
5. An analysis of distribution (or communication) channels
6. Use of the marketing mix - utilizing and blending product, price, place and promotion characteristics in intervention planning and implementation
7. A process tracking system with both integrative and control functions
8. A management process that involves problem analysis, planning, implementation and feedback functions ( Lefebvre & Flora 1988).

The use of theatre as a medium of research communication and social change is increasingly recognized (McCall, M. 2000. "Performance Ethnography: A Brief History and Some Advice." In N.K. Denzin and Y.S. Lincoln, eds., Handbook of Qualitative Research (2nd ed.) (pp. 421-33). Thousand Oaks, CA: Sage Publications). Arts-informed methodology brings together the "systematic and rigorous qualities of scientific inquiry with the artistic and imaginative qualities of the arts" (Cole & Knowles, 2001; 2008). Arts-informed research has the potential to reach out beyond academia to communities beyond (Cole & Knowles, 2001). There is a growing scholarly literature on the use of art as a basis for inquiry, a means for producing knowledge and contributing to human understanding, and representing the complexities of human experience (Gray, 2003, 2004; Mason, 2005; Knowles & Cole, 2007; Boydell, Jackson & Strauss, 2008). Many research products now contravene the conventional boundaries and forms of social scientific writing and include auto ethnographies, poetry, performance texts, layered accounts, and visual representations (Keen & Todres, 2006; Richardson, 1992; Bochner & Ellis, 2003; Boydell, Crawford, Gladstone et al, 1995; Denzin, 1997; Ellis & Bochner, 1996; Nisker, Martin, Bluhm, et al., 2006; Plummer, 2001). In addition, the arts-informed educational community has also contributed much to the field by demonstrating the power of alternative media in communicating research messages (Barone, 2000; Cole, 2002; Cole, Neilsen, Knowles, et al., 2003; Eisner, 1991, 1993, 1997; Perselli, 2005). [This paragraph review provided by Dr. Katherine Boydell; [references click here].