Ian D. Graham

Lost in Knowledge Translation: Time for a Map?

&NA; There is confusion and misunderstanding about the concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. We review the terms and definitions used to describe the concept of moving knowledge into action. We also offer a conceptual framework for thinking about the process and integrate the roles of knowledge creation and knowledge application. The implications of knowledge translation for continuing education in the health professions include the need to base continuing education on the best available knowledge, the use of educational and other transfer strategies that are known to be effective, and the value of learning about planned‐action theories to be better able to understand and influence change in practice settings.

AGREE II: advancing guideline development, reporting and evaluation in health care

Clinical practice guidelines, which are systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions,[1][1],[2][2] frequently vary widely in quality.[3][3],[4][4] A strategy was needed to differentiate among guidelines and ensure that those

A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation

Although postmenopausal women are advised to consider their values when deliberating about potential benefits and risks of hormone therapy (HRT), feasible, effective methods of decision support in primary care have yet to be established. Using an explicit decision support framework, we developed a self-administered HRT decision aid and evaluated it in a before/after study of 94 women from six family practices. An audiotape guided women through an illustrated booklet including: detailed information about HRT benefits and risks tailored to a womans clinical risk, and a values clarification exercise to promote informed decision making consistent with personal values. After using the decision aid participants: had better general knowledge and more realistic personal expectations of HRT benefits and risks; and, felt more certain, informed, clear about values, and supported in decision making. Womens values elicited in the clarification exercise were 84% accurate in discriminating between decisions. Women with polarized preferences at baseline did not change their minds, but were better informed. Changes in preferences occurred in the uncertain group, with equal numbers accepting or declining HRT. Most participants found the decision aid comprehensible, acceptable in length and pace, and balanced. Decision aids are useful in preparing women for decision making about this complex, personal issue.

Defining knowledge translation

We cannot pick up a magazine or surf the Internet without facing reminders of the challenges to health care and the “sorry state” of health systems. [1][1] All health care systems are faced with the challenges of improving quality of care and reducing the risk of adverse events. [2][2] Globally

Toward a Comprehensive Interdisciplinary Model of Health Care Research Use

Numerous health care disciplines have noted that insufficient research evidence is used in clinical practice. This situation denies optimal care to patients and potentially increases system costs. A practical theoretical framework for policymakers intent on promoting an evidence-based approach to the transfer and use of research findings in clinical practice settings is presented. The Ottawa Model of Research Use (OMRU) has a comprehensive interdisciplinary focus and consists of six key elements: the practice environment, potential adopters of the evidence, the evidence-based innovation, research transfer strategies, the evidence adoption, and health-related and other outcomes. Model elements and the interactive relationships among them are described.

Geometric Function Theory in One and Higher Dimensions

Univalent functions: elementary properties of univalent functions Subclasses of univalent functions in the unit disc The Loewner theory Bloch functions and the Bloch constant Linear invariance in the unit disc Univalent mappings in several complex variables and complex Banach spaces Univalence in several complex variables Growth, covering and distortion results for starlike and convex mappings in Cn and complex Banach spaces Loewner chains in several complex variables Bloch constant problems in several complex variables Linear invariance in several complex variables Univalent mappings and the Roper-Suffridge extension operator.

Quality of life of individuals with Heart failure: A randomized trial of the effectiveness of two models of hospital-to-home Transition

Background. The growing number of patients with congestive heart failure has increased both the pressure on hospital resources and the need for community management of the condition. Improving hospital-to-home transition for this population is a logical step in responding to current practice guidelines’ recommendations for coordination and education. Positive outcomes have been reported from trials evaluating multiple interventions, enhanced hospital discharge, and follow-up through the addition of a case management role. The question remains if similar gains could be achieved working with usual hospital and community nurses. Methods. A 12-week, prospective, randomized controlled trial was conducted of the effect of transitional care on health-related quality of life (disease-specific and generic measures), rates of readmission, and emergency room use. The nurse-led intervention focused on the transition from hospital-to-home and supportive care for self-management 2 weeks after hospital discharge. Results. At 6 weeks after hospital discharge, the overall Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was better among the Transitional Care patients (27.2 ± 19.1 SD) than among the Usual Care patients (37.5 ± 20.3 SD;P = 0.002). Similar results were found at 12 weeks postdischarge for the overall MLHFQ and at 6- and 12-weeks postdischarge for the MLHFQ’s Physical Dimension and Emotional Dimension subscales. Differences in generic quality life, as assessed by the SF-36 Physical component, Mental Component, and General Health subscales, were not significantly different between the Transition and Usual Care groups. At 12 weeks postdischarge, 31% of the Usual Care patients had been readmitted compared with 23% of the Transitional Care patients (P = 0.26), and 46% of the Usual Care group visited the emergency department compared with 29% in the Transitional Care group (&khgr;2 = 4.86, df 1, P = 0.03). Conclusions. There were significant improvements in health-related quality of life (HRQL) associated with Transitional Care and less use of emergency rooms.

Development of the AGREE II, part 1: performance, usefulness and areas for improvement

Background: We undertook research to improve the AGREE instrument, a tool used to evaluate guidelines. We tested a new seven-point scale, evaluated the usefulness of the original items in the instrument, investigated evidence to support shorter, tailored versions of the tool, and identified areas for improvement. Method: We report on one component of a larger study that used a mixed design with four factors (user type, clinical topic, guideline and condition). For the analysis reported in this article, we asked participants to read a guideline and use the AGREE items to evaluate it based on a seven-point scale, to complete three outcome measures related to adoption of the guideline, and to provide feedback on the instrument’s usefulness and how to improve it. Results: Guideline developers gave lower-quality ratings than did clinicians or policy-makers. Five of six domains were significant predictors of participants’ outcome measures (p < 0.05). All domains and items were rated as useful by stakeholders (mean scores > 4.0) with no significant differences by user type (p > 0.05). Internal consistency ranged between 0.64 and 0.89. Inter-rater reliability was satisfactory. We received feedback on how to improve the instrument. Interpretation: Quality ratings of the AGREE domains were significant predictors of outcome measures associated with guideline adoption: guideline endorsements, overall intentions to use guidelines, and overall quality of guidelines. All AGREE items were assessed as useful in determining whether a participant would use a guideline. No clusters of items were found more useful by some users than others. The measurement properties of the seven-point scale were promising. These data contributed to the refinements and release of the AGREE II.

Some Theoretical Underpinnings of Knowledge Translation

A careful analysis of the definition of knowledge translation highlights the importance of the judicious translation of research into practice and policy. There is, however, a considerable gap between research and practice. Closing the research-to-practice gap involves changing clinical practice, a complex and challenging endeavor. There is increasing recognition that efforts to change practice should be guided by conceptual models or frameworks to better understand the process of change. The authors conducted a focused literature search, developed inclusion criteria to identify planned action theories, and then extracted data from each theory to determine the origins, examine the meaning, judge the logical consistency, and define the degree of generalizability, parsimony, and testability. An analysis was conducted of the concepts found in each theory, and a set of action categories was developed that form the phases of planned action. Thirty-one planned action theories were identified that formed the basis of the analyses. An Access database was created, as well as a KT Theories Users Guide that synthesizes all the planned change models and theories, identifies common elements of each, and provides information on their use. There are many planned change models and frameworks with many common elements and action categories. Whenever any planned change model is used, change agents should consider documenting their experiences with the model so as to advance understanding of how useful the model is and to provide information to others who are attempting a similar project.

Evidence‐Based Medicine and the Practicing Clinician

AbstractOBJECTIVE: To assess the attitudes of practicing general internists toward evidence-based medicine (EBM—defined as the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions) and their perceived barriers to its use. DESIGN: Cross-sectional, self-administered mail questionnaire conducted between June and October 1997. SETTING: Canada. PARTICIPANTS: Questionnaires were sent to all 521 physician members of the Canadian Society of Internal Medicine with Canadian mailing addresses; 296 (60%) of 495 eligible physicians responded. Exclusion of two incomplete surveys resulted in a final sample size of 294. MAIN RESULTS: Mean age of respondents was 46 years, 80% were male, and 52% worked in large urban medical centers. Participants reported using EBM in their clinical practice always (33, 11%), often (173, 59%), sometimes (80, 27%), or rarely/never (8, 3%). There were no significant differences in demographics, training, or practice types or locales on univariate or multivariate analyses between those who reported using EBM often or always and those who did not. Both groups reported high usage of traditional (non-EBM) information sources: clinical experience (93%), review articles (73%), the opinion of colleagues (61%), and textbooks (45%). Only a minority used EBM-related information sources such as primary research studies (45%), clinical practice guidelines (27%), or Cochrane Collaboration Reviews (5%) on a regular basis. Barriers to the use of EBM cited by respondents included lack of relevant evidence (26%), newness of the concept (25%), impracticality for use in day-to-day practice (14%), and negative impact on traditional medical skills and “the art of medicine” (11%). Less than half of respondents were confident in basic skills of EBM such as conducting a literature search (46%) or evaluating the methodology of published studies (34%). However, respondents demonstrated a high level of interest in further education about these tasks. CONCLUSIONS: The likelihood that physicians will incorporate EBM into their practice cannot be predicted by any demographic or practice-related factors. Even those physicians who are most enthusiastic about EBM rely more on traditional information sources than EBM-related sources. The most important barriers to increased use of EBM by practicing clinicians appear to be lack of knowledge and familiarity with the basic skills, rather than skepticism about the concept.