Turning Knowledge Into Action: Using Research to Improve Patient Care

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Introduction

Knowledge translation (KT) is "the use of knowledge in healthcare decision making," and it is often discussed in the context of intentionally changing clinical decisions and behaviors based on evidence from formal research. More than 90 terms have been identified for research use, including implementation science, research utilization, and knowledge-to-action. Dissemination and diffusion and knowledge transfer and uptake are used in the United States to describe this process.¹

Using research to improve patient care is a multistep process involving the creation of new knowledge (research), communicating that knowledge to practitioners (which usually involves an educational strategy), and applying that new knowledge by making different decisions in clinical practice. Numerous strategies have been used to facilitate the use of research in practice, including the development of clinical practice guidelines (CPGs). CPGs are clinical recommendations derived from a synthesis of relevant research evidence. However, changes in practice behavior require more than just access to information. In an article addressing barriers to use of CPGs, Harrison et al. point out that while "a guideline or other tool of knowledge is a key component of the knowledge-to-action cycle," even high-quality guidelines "are not sufficient to ensure evidence-based decision making."²

Working through the process of putting research evidence to use in clinical care is a challenge in all medical professions. According to Strauss et al., "Despite significant investment in and substantive productivity of biomedical, clinical, health services, and population health research, consistent evidence shows that health systems fail to optimally use evidence with resulting inefficiencies and reduced quality of life."¹ This article offers insights into the KT process in O&P based on an informal review of published research on KT in other health professions. Evidence from systematic reviews on KT among physicians, nurses, and allied health professionals are presented and applied to O&P practice.

Knowledge Translation Barriers in O&P

Research published by Cabana et al. in 1999 describes over 290 barriers to physician adherence to CPGs, which the authors classified into seven categories (Table 1).³ KT requires changes in knowledge, attitudes, and behaviors, and barriers in each of these areas can be observed in O&P practice. In addition, some unique features of O&P practice compared with other medical professions result in even more barriers to the use of research. These unique features include the nature of O&P research evidence, reactions to reimbursement pressure, and rapid technological advancement.

The Nature of the Evidence

Published research is not accessible to many practitioners because of its cost, limitations in their research training, and the time required to read and synthesize information. It is unreasonable to expect that most practitioners have the time, training, or resources to perform independent searches of the literature and summarize the findings. An even more challenging barrier in O&P is that the research process is often designed to answer highly specific questions and provides information that cannot be easily translated into specific clinical decisions. Additionally, results from well-designed studies on O&P subjects often cannot be generalized because of the inherent limitations of the small sample sizes and homogeneity of the subject pools.

The inability to reach decisive conclusions based on much of the O&P literature results in a lack of confidence in research and a lack of universally accepted guidelines. If, as Strauss et al. report, "high-quality evidence is not being consistently applied" in the practice of medicine in general, it is understandable that the lower levels of evidence common in rehabilitation research may be regarded as irrelevant by clinicians. Practitioners may question whether patient outcomes will be improved as a consequence of implementing practices supported by low levels of evidence.

Reactions to Reimbursement Pressure

It could be argued that reimbursement pressure from payers, including Medicare's prepayment audits, has been the primary motivation for large-scale changes in clinical practice in recent years. A common KT strategy called audit and feedback involves a review of clinical performance (often based on a review of information found in the patient records) intended to guide practitioners in changing their performance to conform to a particular standard. However, a proactive clinical audit and feedback process is very different from the changes in assessment and documentation procedures that many practitioners have made to comply with third-party payer policies.

Problems arise when reimbursement pressure drives modifications in clinical practice. First, it puts payers in the position of determining what constitutes appropriate medical care. While payers may selectively use evidence in developing their policies, a more concerning reality is that the lack of conclusive evidence regarding the benefits of specific treatment options may be used as a rationale for denying coverage for that intervention under any circumstance. The larger problem is that this motivation for change is primarily economic: Claims that do not contain the required information are not paid. Since claims are only submitted after a significant financial investment in components, salaries, and other costs of doing business, claim denials result in reduced profitability and, in some cases, may make the business unsustainable. This type of reactive approach puts the practice at a disadvantage that is difficult to overcome.

A positive effect of payer policies and reimbursement pressure is that many practices are improving their assessment and documentation procedures. However, a proactive approach based on the interests of the patient is preferred to a reactive approach of implementing new clinical practices simply to ensure payment. Increasingly, clinics are recognizing the value of implementing outcome measurements and other evidence-based practices (EBPs) because they improve patient care. Improvements in clinical practice, such as the routine collection and aggregation of outcomes data, may help discourage future reductions in reimbursement by establishing a more relevant evidence base that can be used to demonstrate the value of O&P interventions. A focus on responding to reimbursement pressure may direct valuable time and resources away from the proactive development of EBPs.

Rapid Technological Advancement

In many cases, O&P technology has developed so rapidly that there is not enough time to generate research evidence supporting its implementation. In his 2016 article, "Mobilizing Knowledge: The Evidence Gap for Assistive Devices," Edward Lemaire, PhD, writes, "the knowledge mobilization process is challenged in sectors where the pace of change outpaces the ability to complete high-quality research methodologies." Using the example of the proliferation of carbon fiber AFOs, Lemaire says, "typical medical research methods are insufficient to generate timely evidence to guide assistive device prescription and consumer/clinician decision making and enable effective knowledge mobilization." He notes that clinicians can choose from 68 different carbon fiber AFOs, with little evidence to guide their decisions. He reports that 29 research articles related to this type of orthosis were published in a ten-year period (2006-16), yet "the level of evidence remains insufficient to support clinical decisions when choosing between the many designs available in the marketplace."⁴

In cases involving rapidly advancing technology, practitioners are often required to make decisions without the benefit of supporting research. In those cases, reliance on clinical experience and patient feedback, which are also part of EBP, can result in an appropriate decision. Lemaire recommends using evidence "in forms other than peer-reviewed academic publications." This includes an appreciation of the value of single-participant reports, even though this type of evidence is generally not viewed to be sufficient quality to dictate clinical practice.

Knowledge Tools are Not Enough

After researching KT in public health settings, LaRocca et al. note, "the availability of a systematic review alone does not ensure that decision makers know it is available to them or can interpret the findings or use the evidence in service delivery decisions," and "simply having access to an online registry of research evidence appeared to have no impact on evidence-informed decision making."⁵ LaRocca et al. mention the work of other researchers who "demonstrated that simply having access to a resource that repackaged review contents into a short summary of key findings, assessment of the methodological quality, and recommendations, was not enough to influence evidence-informed decision making among public health practitioners."

There are reasons to be optimistic about the creation and dissemination of O&P knowledge, since significant progress has been made in these areas over the past few decades. Additionally, students are graduating from O&P educational institutions with a better grasp of how to understand and apply research in a clinical setting, resulting in a growing population of research-savvy practitioners. However, knowledge does not automatically result in behavior change. As efforts to build the research base and dissemination strategies are increasingly successful, it is important to consider how that evidence can be translated into specific improvements in clinical practice.

Knowledge Translation Strategies

Novel teaching and KT strategies have been developed to address the reality that traditional education methods do not always result in behavior changes. In 2016, De Angelis et al. published a systematic review of research related to "health professionals' perceived behavior when using information and communication technology [ICT] to disseminate clinical practice guidelines."⁶ Technology included in the research they reviewed encompassed websites, computer software, web-based workshops, computerized decision-support systems, electronic educational games, and email. The study concludes that "it remains unclear whether one ICT is more effective than another."⁶ Interestingly, De Angelis et al. found no trends regarding the efficacy of older ICTs, such as email or websites, versus newer, emerging ICT interventions, like web-based workshops, etc.

LaRocca et al. performed a systematic review, published in 2012, that was designed to evaluate the effectiveness of KT strategies in public health settings.⁵ They found that passive strategies, such as collections of evidence or printed materials, were not as effective as active strategies. They also report that internet-based strategies and traditional methods of instruction have comparable beneficial effects. Strategies such as "tutorials, longer-duration courses, and online peer discussion" result in statistically significant improvements in KT, perhaps because of the increased level of interaction.⁵ LaRocca et al. conclude that "no singular KT strategy was shown to be effective in all contexts."

Yost et al.'s research review relates to the effectiveness of KT translation among nurses.⁷ They report that "active interventions such as alerts, educational outreach, opinion leaders, audit and feedback, and point-of-care computer reminders" result in "small to moderate improvements in EIDM [evidence-informed decision-making] behaviours...." However, they state that "no definitive conclusions could be made about the relative effectiveness of the KT interventions...."⁷

After reviewing KT strategies in the allied health professions, Scott et al. are unable to recommend one KT strategy over another based on the evidence.⁸ Their findings "reveal an over-reliance on educational strategies," and the most common KT strategy is "educational meetings." They point out that while education strategies are "intended to increase knowledge and skills with the expectation that new information will facilitate behaviour change," education on its own does not result in changes in practice.⁸

Putting Knowledge to Use

According to Harrison et al., "uptake of knowledge...usually requires a substantive, proactive effort to encourage use at the point of decision making." LaRocca identifies accessibility and tailoring KT efforts to the needs of decision makers as important factors contributing to changes in clinical knowledge and practice.⁵ Scott et al.maintain "provider behaviour change requires persuasion at multiple levels (e.g., healthcare professional, department decision makers...) and the allocation of significant resources to support the change."

The research by Yost et al. into KT among nurses reveals that organization leadership impacts KT in important ways. Leaders can support the implementation of EBPs in a variety of ways, such as creating a positive environment, making implementation of EBPs a priority, modelling commitment, reinforcing goals related to implementation, and applying their influence to organizational structure and processes. This support occurs in practical ways when workloads are adjusted and other resources provided to allow clinicians time to develop new practice habits.

Yost et al.'s 2015 research demonstrates that the support of managers, colleagues, and referral sources positively impacts the use of research following an education program. On the other hand, fear of criticism by colleagues who view EBP as not real work, and who resent the added time required to perform EBPs negatively impacts these practice changes.⁷

Conclusion

Researchers have demonstrated that some type of KT intervention is better than no intervention.6,7 According to De Angelis et al.'s research on the use of communication technology, clinical guidelines were followed more closely when some sort of education effort was made compared to no intervention. As obvious as this may seem, it highlights that while there is no perfect KT intervention, efforts in that direction are likely to improve clinical practice more than simply maintaining the status quo.

The proliferation of knowledge creation and dissemination within O&P presents many opportunities for individual practitioners to improve patient care by modifying their practices based on that knowledge. Practitioners can update their knowledge base by taking advantage of education offered by reputable sources and in a variety of formats. Business owners, practice managers, and residency supervisors can facilitate the process of turning that knowledge into action and improving clinical decision making by providing adequate resources to support those efforts.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.

References

1. Straus, S. E., J. M. Tetroe, and I.D. Graham. 2011. Knowledge translation is the use of knowledge in health care decision making. Journal of Clinical Epidemiology 64 (1):6-10.
2. Harrison, M. B., F. Légaré, I. D. Graham, and B. Fervers. 2010. Adapting clinical practice guidelines to local context and assessing barriers to their use. CMAJ 182 (2):E78-84.
3. Cabana, M. D., C. S. Rand, N. R. Powe, et al. 1999. Why don't physicians follow clinical practice guidelines?: A framework for improvement. JAMA 282 (15):1458-65.
4. Lemaire, E. D. 2016. Mobilizing knowledge: The evidence gap for assistive devices. Technology Innovation Management Review 6 (9):39-45.
5. LaRocca, R., J. Yost, M. Dobbins, D. Ciliska, and M. Butt. 2012. The effectiveness of knowledge translation strategies used in public health: A systematic review. BMC Public Health 12:751.
6. De Angelis, G., B. Davies, J. King, et al. 2016. Information and communication technologies for the dissemination of clinical practice guidelines to health professionals: A systematic review. JMIR Medical Education 2 (2):e16.
7. Yost, J., R. Ganann, D. Thompson, et al. 2015. The effectiveness of knowledge translation interventions for promoting evidence-informed decision-making among nurses in tertiary care: A systematic review and meta-analysis. Implementation Science 10:98.
8. Scott, S. D., L. Albrecht, K. O'Leary, et al. 2012. Systematic review of knowledge translation strategies in the allied health professions. Implementation Science 7:70.