Definitions and framework for knowledge translation to continue to evolve

      Turning research into action should be a major aspect of any researcher’s livelihood. In this month’s issue of the Journal of Clinical Epidemiology, we start with an extremely interesting and relevant series on knowledge translation. We begin with a commentary by Beverly Shea who states that there is no one agreed-upon definition for knowledge translation – she indicates that there are in fact over 90 synonyms for knowledge translation, each with a myriad of definitions. The article by Straus et al. provides an overview of the science and practice of knowledge translation, including a framework for its use. The framework, adapted from the Canadian Institutes of Health Research (CIHR), provides an approach that clearly links knowledge generation and synthesis to knowledge translation and practice. As indicated in the CIHR knowledge to action cycle, knowledge syntheses are central to knowledge translation. The first article in this series by Tricco et al. provides a very useful step-by-step guide for conducting knowledge syntheses in the form of systematic reviews; other knowledge synthesis methods such as realist reviews and narrative reviews are also discussed. Majumdar examines three case studies with the intention of demonstrating high-quality and successful knowledge-to-action processes. The three case studies all share the following features; they evaluate well-designed interventions, have adequate sample sizes, use reasonable and robust analytic plans without any unit-of-analysis errors, deliver valid results, and were published in high-impact mainstream general medical journals. As indicated in the CIHR knowledge to action framework, once the evidence has been synthesized it must undergo a process of dissemination and exchange with the affected parties to ensure the ethically sound application of knowledge. Gagnon presents and discusses approaches to knowledge dissemination and exchange and provides a summary of factors that appear to influence the effectiveness of these processes. In addition, they offer practical advice for researchers and knowledge users on what to include in the dissemination and exchange plans developed as part of grant applications. As with any intervention, it is important that the implementation process is monitored and evaluated for both impact and cost. Battacharyya et al. provide an overview of the useful and relevant resources that are available to guide the evaluation process. In addition, they discuss how study designs can focus on establishing internal validity or applicability and how the choice of focus affects the study design. The articles in this series are meant to examine various aspects of knowledge translation in detail including; theoretical frameworks, types of interventions, implementation methods, and issues related to measurement, evaluation of processes, outcomes of care, and the strengths and limitations of various study designs.
      The commentaries by Weiss and the response by Ramsay and Etzioni discuss the use of case-control studies to measure the efficacy of screening for cancer recurrence. Within the cancer field, it has been observed that patients who seem to have been cured from cancer later sustain a recurrence that can prove fatal. This could be avoided if recurrences were diagnosed earlier, through surveillance mechanisms.
      Three papers address clinical diagnosis, care, and patient values: Diagnosis of osteoporosis and osteoporotic fractures has relied on a history of fragility fractures and low bone mineral density. Determining anatomic sites and circumstances under which a fracture may be a consequence of osteoporosis has been a topic of ongoing controversy. Without an evidence-based consensus on what constitutes an osteoporosis-related fracture, the epidemiology and public health burden of osteoporosis cannot be accurately determined. Warriner et al. conducted a systematic literature review and formal group consensus process to generate an evidence report on fracture risk based on specific anatomic bone sites and fracture diagnosis codes. The results were consistent with clinical experience and indicate that fractures rated most likely because of osteoporosis were the femoral neck, pathologic fractures of the vertebrae, and lumbar and thoracic vertebral fractures. This approach is challenged in the Commentary by Mackey. Clinical prediction rules have become a very popular with administrators, but clinicians are always looking for ways to reduce their length. Dionne et al. sought to determine whether a back pain prediction rule could be improved by shortening the original version, while maintaining its predictive validity. They found that a five-item clinical prediction rule of long-term back-related functional limitations was superior to physicians prediction and its’ predictive validity was greater than that of the original 17-item version. Patient priorities, values, and preferences should always be taken into account for any treatment plan or medical decision that involves their health. Sharma et al. highlight this issue in their article comparing caesarean birth to vaginal birth for women who have previously had a caesarean section.
      Research methodology and participation is addressed in four papers. Critical appraisal tools (CAT) provide transparent methods with which to assess data in a systematic review. Crowe et al. has conducted a review of CATs that have been through a peer-reviewed development process. They found that many of these tools had been developed for a specific systematic review and that they are designed ignoring basic validity and reliability principles. They propose a structure based on the review of 44 critical appraisal tools that could guide the development of future tools. China and India have become major producers of randomized clinical trial research. However, the quality of trials conducted within these countries is questionable. Zhang et al. conducted a review of trials that have been conducted within these two countries and compared them to ‘gold standard’ trials conducted in high income countries such as Canada, the European Union, and the United States. In addition, their quality was assessed against a subset of criteria from the CONSORT statement. Overall, this research found that trials conducted in China and India were not as rigorous as trials published from high-income countries. Efforts such as the International Clinical Epidemiology Network, which the Journal of Clinical Epidemiology has recently partnered with, could be beneficial in improving the research standards of countries such as India and China. The reporting of inter-rater and intra-rater reliability is often vague and inadequate. Kottner et al. have developed guidelines for reporting of reliability and agreement of studies. They propose 15 issues that should be addressed; these correspond to the heading usually used in publications. This is a proposed first draft and the authors welcome comments and feedback from our readers. Participant’s willingness to be involved in research will ultimately affect the dropout rate (and validity) of a study. It is therefore in the best interests of researchers to adhere to factors that will improve a participant’s willingness to participate in research. Agoritsas et al. conducted a study wherein they asked all patients discharged from a hospital whether they would participate in one of four hypothetical scenarios. They found that patients valued safety, convenience, oversight, and open communication in research studies. In addition, they were often deterred by some aspects that are valued by health care professionals, such as use of placebo and random allocation of patients.