The number of biomedical publications available for medical consumers increased dramatically in the late 20th century to over 5000 manuscripts per day. Not surprisingly, even astute clinicians find it difficult to maintain up-to-date proficiency with the latest research. The result is a substantial delay (6-13 years) from the publication of results to the inclusion of the highest quality evidence in guidelines, reviews, and textbooks to facilitate the transfer of knowledge to bedside care. One analysis, published in the New England Journal of Medicine, looked at a dozen hospitals, over 400 quality indicators and 6,700 patients and found that 45% of patients do not receive recommended care. These findings have been echoed in the Institute of Medicine’s landmark paper “Crossing the Quality Chasm: A New Health System for the 21st Century”. Some would argue that this delay is appropriate because today’s miracle cure often turns into tomorrow’s medical catastrophe. Understand that no one is advocating the routine utilization of a single, methodologically challenged paper in clinical practice. But should medical evidence obtained from well-conducted, replicated randomized trials or compilations of trials in systematic reviews which have been analyzed by specialty specific experts take 6-13 years to become the standard of care?
Knowledge Translation (KT) is the science of moving from evidence to action. In the past, KT has been labeled many things including evidence translation and research uptake. The name is less important than the concept. Basically, KT consists of two components: getting the evidence straight and getting the evidence used. The first portion of KT is obviously a key. Who will decide what constitutes “best-evidence”? Likely suitors include insurers such as the federal government, key specialty opinion leaders, biomedical companies with profit margins to maintain, patient advocate groups, and organized medicine. Emergency Medicine KT leaders have suggested a hierarchy for obtaining best-evidence in order of decreasing validity: systems, synopses, systematic reviews, and studies. Systems remain largely science fiction consisting of frequently updated computerized reminders and order prompts integrated seamlessly into physician electronic health care records which guide diagnostic testing and therapeutic interventions based upon the most recent, highest quality evidence without any extra effort from the clinician real-time during the patient encounter. Synopses consist of searchable databases of clinically relevant high-quality evidence. An example of such a review includes the American College of Physicians’ ACP Journal Club (www.acpjc.org). EM relevant Systematic Reviews, highlighted in several recent issues of EP Monthly, are increasingly available in peer-reviewed print journals and in the Cochrane Database (see December 2007 issue “Who Is this Cochrane Guy?”). Individual studies remain the cornerstone of evolving evidence with randomized controlled trials generally less biased than observational studies which themselves are more applicable for physicians than non-clinical lab-based research reports.
Once the highest quality evidence has been identified, ensuring widespread clinical application remains problematic. In one study, cardiologists reviewed thirty randomized trials with proven effectiveness in North America, Australia, and Europe. They surveyed the original authors of these trials noting that only 2/15 US trials (versus 7/13 trials in other countries) continued their published management recommendations at their own institutions! As illustrated below, the leakage of information from publication to routine clinical care is multi-factorial, flowing from basic awareness of research findings by health care providers to patient compliance. The theoretical framework of a “KT Pipeline” may serve useful in designing and implementing plugs for the wasted knowledge leaks contributing to the quality chasm.
The 2007 Academic Emergency Medicine Clinical Consensus Conference brought together experts from around the world to evaluate the young science of KT and suggest a research agenda. Their conclusions, along with several real-life example of KT in the management of TIA, sepsis, and other common ED clinical problems are available for free at (www.aemj.org). The success of KT, though, depends upon each of you who will decide which sources will define “best-evidence” EM for your patients. Should you remain disengaged, governmental funding sources, third-party payers, and industry will undoubtedly define these quality standards for us. Active participation in this process will include the identification of knowledgeable, unbiased sources with a demonstrated ability to weed through the ever-expanding biomedical literature to locate, appraise, and disseminate user-friendly, newsworthy, clinically relevant EM updates in diagnostic, prognostic, therapeutic, and cost-effectiveness fields. At EPMonthly and Best Evidence in Emergency Medicine (www.beemcourse.com
) we will endeavor to be one source of such information for your pipeline to clinical expertise.
For a high-res version of this flow chart, click the image below
Illustration by Kai Choummanivong and Alex Lee.
This graphic was published in Academic Emergency Medicine, Volume 14, Diner BM, Carpenter CR, O’Connell T, et al. Graduate Medical Education and Knowledge Translation: Role Models, Information Pipelines, and Practice Change Thresholds, pages 1008-1014, copyright Elsevier 2007” Originally reprinted with permission with modifications from ACP Journal Club