Translating Research into Practice: A United States Perspective

1. Translating Research into Practice: A United States Perspective Marita G. Titler, PhD, RN, FAAN Director of Research, Quality and Outcomes Management Department of Nursing Services and Patient University of Iowa Hospitals and Clinics and Clinical Professor University of Iowa College of Nursing Iowa City, IA

2. Focus of this Paper • Overview the state of the science of translation research in the United States • Stimulate a discussion about translation science from various world perspectives • Stimulate discussions of possible international collaborative research

3. Definition of Translation Research • Testing the effect of interventions aimed at promoting the rate and extent of adoption of evidence-based practices by nurses, physicians, and other healthcare providers (Titler & Everett, 2001) • Describing organizational, unit, and individual variables that effect the use of evidence in clinical and operational decision-making

4. Healthcare System in the U.S. • Private not-for-profit • Private for profit • Public • Third party reimbursement (private, governmental) • Uninsured • Veteran Healthcare • CMS (Medicare reimbursement)

5. “Between the healthcare we have and the care we could have lies not just a gap but a chasm”.

6. The Dilemma and Challenge “The stark reality [is] that we invest billions in research to find appropriate treatments, we spend more than $1 trillion on healthcare annually, we have extraordinary capacity to deliver the best care in the world, but we repeatedly fail to translate that knowledge and capacity into clinical practice” (IOM, 2003 “Priority Areas for National Action”; Berg et al, 1997; Dickersin & Manheimer, 1998; Kamerow, 1997)

7. Examples • Fewer than half of adults >50 years of age received recommended screening tests for colorectal cancer. • Inadequate care after a heart attack results in 18,000 unnecessary deaths per year. • 17 million people were informed by their pharmacist that the drugs that were prescribed could cause an interaction IOM, 2003

8. The Harkin “Question” “There is a reason it’s the ‘National Institutes of Health’ and not the ‘National Institutes of Science’. We expect the NIH to be actively involved in translational research. Yes, you get the basic science done, but we want to know, how does that help us lead healthier lives?” (Brainard J., The Chronicle of Higher Education, Feb. 6, 2004)

9. NIH Roadmap “These initiatives are integrated to accelerate our knowledge into effective prevention and treatment strategies, and in many ways transform the way we conduct research and the way we accelerate the translation of that research to the bedside and eventually to clinical practice.” (Zerhouni quotation in The Scientist, October 1, 2003).

10. Big Message – It’s Important • Translation of research findings is critical in the NIH agenda/roadmap. • AHRQ - translating research into practice (TRIP I and II studies; Partnership Studies) • Magnet Designation • JCAHO Accreditation Criteria • CMS • Specialty Nursing Organizations (e.g. ONS, AWHONN, AACN)

11. Funding Agencies in the U.S.- Translation Science • Agency for Healthcare Research and Quality • Veterans Health Administration is the largest healthcare delivery system in the U.S. • CMS • RWJ • NIH (fairly new area)

12. Design/Methods • Electronic search strategies • Manual search strategies • Federal agency web-sites • Limited to research and U.S. • Major search terms

13. Purpose of Studies • Describe barriers and facilitators of evidence-based practice/research use (Baessler et al, 1994; Barta, 1995; Carroll et al, 1997; Charles , 2000; Funk et al, 1991, 1995; Katz, 1999; Pettemgill et al, 1994) • Assess research use/levels of adoption of certain evidence-based practices (e.g. pressure ulcer prevention)(Brett et al, 1987; Coyle & Sokop, 1990; Morin et al, 1999; Omery & Williams, 1999; Rutledge et al, 1995; Wells & Baggs, 1994)

14. Purpose of Studies • Demonstration projects (1970s-90s) – to implement evidence-based practices. • Multiple case reports of evidence-based practice projects to improve patient care • Describe factors that influence adoption of evidence in practices. • Testing the effect of interventions designed to translate research into practice. • Improve quality of care – based on evidence – in multiple sites (e.g. CalNoc project on falls).

15. Methods Used • Descriptive cross-sectional designs • Qualitative methods • Randomized designs • Case reports • Partnership models

16. Findings Across Studies • Most focused on clinical topics • Most nonexperimental/paucity of randomized clinical trials • Most acute care focused, primary care, and then long-term care • A variety of single and multifaceted TRIP interventions were investigated

17. Dufault et al Sales et al Donaldson et al Jones et al Watson et al Titler et al Feldman et al Fifield Kovner Resnick Selected U.S. Studies

18. Methodological Challenges • Single and multifaceted strategies • Metric of TRIP intervention • Selection/measurement of dependent measures • Multi-site studies • Level of engagement (individuals and organization) • Statistical analysis (clustering/nesting)

19. Sustainability • Where is the boundary between the downstream effect of the TRIP intervention as compared to evidence that the improvement is being sustained over time. • What type and dose of TRIP interventions are needed to keep/sustain the adherence to the EBPs? Are sustainability interventions necessary?

20. “Sustainability”

21. Summary • More experimental studies to test the effect of TRIP interventions • Address measurement issues • Multi-site and international studies • Take advantage of the natural experiments by studying what works and what does not work (e.g. Magnet status; VA; AHRQ Partnership grants)

22. Closing Thoughts • American healthcare could benefit greatly from the establishment by the federal government of a Health Care Extension Service modeled on the Agricultural Extension Service (Berwick, 2003) • To create a future different from its past, healthcare needs leaders and scientists who understand innovation and how it spreads, who respect the diversity of change itself, and who will design and conduct research to hasten the transfer of knowledge into care delivery.