Translating evidence into practice

Patient care and outcomes could be significantly improved if the knowledge gained from health research was better translated into practice. This is the message from studies suggesting that 30%–40% of patients do not receive treatments of proven effectiveness and that 20%–25% have treatments that are unnecessary or potentially harmful.1,2

Three years ago, the Australian Government established the National Institute of Clinical Studies (NICS)3 to improve healthcare by helping to close important gaps between the best available evidence and current clinical practice. The NICS aims to do this by working with clinicians to support evidence uptake, helping to increase knowledge about the science of evidence uptake in clinical care, building national capacity for evidence uptake, and advocating for systemic change that will improve the use of evidence in clinical practice.

The Institute was initially chaired, before his untimely death, by Chris Silagy, a world leader in promoting better use of evidence in healthcare. In its first years it has worked with a range of partners to identify important gaps between evidence and practice and to develop and test approaches for assisting clinicians to improve evidence uptake in these areas. Priority areas for initial work were chosen to reflect a range of disciplines, issues and settings, and to develop methods and tools that could be used in other clinical areas or settings with similar barriers to evidence uptake. Current projects focus on improving emergency care, heart failure management, pain management in cancer care, and prevention of deep vein thrombosis.

In 2002, the NICS funded a targeted grants program for investigators seeking to improve appropriate use of interventions over a broader range of areas. Since then, the Institute has invested in a longer-term capacity-building program by developing evidence implementation fellowships.

The NICS has also been identifying which measures are known to improve evidence uptake and which are seemingly ineffective, and is seeking advice on ways this knowledge might be best applied in Australia. In November 2003, the Institute held a meeting in Hobart at which a wide range of healthcare professionals, social scientists, policymakers and consumers met to discuss possible approaches to improving evidence uptake across the Australian healthcare system. Two working groups convened by the NICS, one chaired by Jeffrey Robinson and one by Chris del Mar, developed initial proposals for the meeting participants to discuss. The meeting was addressed by two overseas experts in knowledge translation approaches — Martin Eccles, from the United Kingdom, and Jeremy Grimshaw, from Canada. These acknowledged experts are the first visitors brought to Australia by the Institute to help inform its work program.

This Supplement presents a report of this meeting.4 It also draws together a number of articles on ways to promote clinical change from people who contributed to the strategies discussed at the meeting and from other experts who will be visiting and providing advice to the NICS in the coming year. Many of these articles highlight the limitations of current studies and emphasise the need to learn more about the ways to promote and sustain behavioural, organisational and system change in healthcare.

Research that builds understanding about diffusion of innovation and factors influencing knowledge uptake comes from a broad range of disciplines, many of which lie outside the traditional areas of focus for healthcare research. Grol and Wensing (page S57) outline theories and models of change and emphasise the need to address barriers at different levels when complex changes are required to improve care.5 They illustrate their argument with an analysis of the lessons for improving diabetes care, but the same principles could be applied in other areas. The article by Eccles and Grimshaw6 (page S52) focuses on the quality of guidelines and on features that might enhance their use. The article by Davis and colleagues (page S68) on the work of the Ontario Guidelines Advisory Committee7 shows the way one group supports clinicians by finding and appraising the quality of available guidelines and by developing practical implementation strategies. Factors influencing the adoption of innovations, and the difficulties and potential facilitators of sustainable change, are discussed in contributions from Australian experts in the field of behavioural change (see pages S55, S66).8,9

Other issues relevant to achieving successful change are discussed in articles by the Chairs of the working groups that developed strategies for the workshop participants to consider (see pages S63, S61).10,11

Grol and Grimshaw have commented elsewhere that, while sometimes the step from best evidence to best practice is simple, most of the time it is not12 — research so far shows that none of the many different approaches to changing practice is superior for all changes in all situations.

The potential strategies for evidence implementation suggested at the Hobart meeting incorporate a variety of features and approaches. The “bare bones” of these strategies will be developed for consideration by the NICS Board. Further discussion with stakeholders will examine the feasibility of various approaches, leading to a decision about which strategies might be developed further, tested, and taken forward in 2004.