Stroke best practice: KT in
At the Cochrane Symposium in
Ottawa last month, Dr Grace Warner, a Dalhousie
epidemiologist and occupational therapy professor,
presented a paper that set out to examine the
effectiveness of an interactive workshop style
of knowledge transfer (KT) in promoting best practices
in secondary stroke prevention in a rural setting.
When she heard patients in the
rural South West Nova health district weren't
always receiving recommended stroke prevention
measures, Dr Warner and her colleague Dr Gord
Gubitz set up dialogue-based workshops with family
physicians in the area. The workshops presented
best practices guidelines for stroke prevention
and put the data in context using case studies.
Based on info they obtained from questionnaires
and follow-up interviews with participants, they
came to a surprising conclusion: "The health authority
thought FPs were not aware [of best practices],
but the FPs were concerned about patient compliance,"
says Dr Warner. For example, a doc might not refer
to a specialist if they know the patient won't
make the long journey for the appointment. The
question that arose, she explains, is not just
how to get the evidence to the clinicians, but
rather how to get the evidence to the clinicians
in a way that helps them implement it according
to their practice's needs.
"There's a mountain of clinical
practice guidelines and recommendations out there,"
says Dr Eddy Lang. "Unfortunately, they're collecting
dust on shelves."
Dr Lang, an emergency doc and assistant
professor of medicine at McGill, should know. A longtime
disciple of evidence-based medicine, Dr Lang works in
the fast-growing and relatively new area of medical
research known as knowledge transfer, or KT for short.
The holy grail of KT is getting medical research results
to make the leap into clinical practice. The Canadian
Cochrane Network held a symposium in Ottawa in February
devoted to this question.
Despite (or perhaps because of)
the boggling array of communication tools at doctors'
disposal, too often the info simply isn't getting through.
This was starkly illustrated in a seminal 2003 NEJM
study that examined the standard of basic treatment
given to 6,700 American patients. The results may surprise
even the most cynical clinician: fully 45% weren't receiving
"Current methods for improving
practice are unfortunately problematic," laments Dr
Lang. "They don't work." But tackling KT is no walk
in the park when almost half of patients aren't getting
care that corresponds to best practices. This is what's
often called "the evidence-to-practice gap," or, in
the more despondent tone of the US Institute of Medicine,
"the quality chasm."
Why is KT proving to be so difficult? "One of the major
obstacles is that when researchers study new treatment
strategies or diagnostic strategies, their projects
are there to prove that A is better than B," explains
Dr Lang. "But they rarely go that extra step to say
that if A is better than B, then how does A get implemented
into practice?" What clinicians need, he says, are concrete,
clear and concise answers to their questions and concerns
about the research: direct instructions rather than
just a bunch of data.
Dr Lang cites the Ottawa Ankle
Rules as a case study in KT failure and a mistake
to be learned from. The Rules were developed in the
early 90s to reduce the number of unnecessary x-rays
ordered for ankle injuries. After a number of studies
and a randomized trial showed their effectiveness, the
guidelines were adopted across Canada and the US. But
the results have been discouraging: 90% of US and Canadian
doctors know the rules, but less than half actually
Dr Lang decided to study some of
the places where the Ottawa Ankle Rules were successfully
adopted to figure out why. The solution, he discovered,
was to incorporate the guidelines into the decision-making
and test-ordering processes themselves. X-ray order
forms for ankles were updated to include a box where
a doctor ordering an ankle scan has to "indicate the
aspect of the Rules that's present."
"We don't want to tie physicians'
hands and make it a fascist system," Dr Lang adds, "but
for the most part, physicians wish they had the tools
at their disposal to apply the guidelines."
BY CASE BASIS
"Another major obstacle [in KT] is that we've set up
a pattern of continuing professional development that's
very passive, very didactic and lecture-based," Dr Lang
says. "It's not engaging physicians, it doesn't ask
them to reflect on practice and to change." Interactive
workshops, like Dr Warner's described in the box to
the right, have proven to be far superior to traditional
lectures. Asking physicians to participate in case-based
problem-solving exercises seems to yield better results.
The answers to KT's challenges
are still in the works, but the field is growing exponentially,
says Dr Lang, and is poised to change the way that medicine
is learned, practised and understood. "It's the way
of the future," he says.