MARCH 15, 2007
VOLUME 4 NO. 5

PATIENTS & PRACTICE

Patient cases catalyse knowledge transfer

Interactive learning gets evidence out of the journals
and into doctors' hands


Stroke best practice: KT in action

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 recommended care.

"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."

FOLLOW THE RULES
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 use them.

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."

CASE 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.

 

 

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