Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions.

BACKGROUND: Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults. METHODS: Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT. ELIGIBILITY CRITERIA: Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care). INFORMATION SOURCES: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020. OUTCOME MEASURES: Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate. DATA SYNTHESIS: We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data. RESULTS: We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%). CONCLUSIONS: KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018084810.

Saving millions of lives but some resources squandered: emerging lessons from health research system pandemic achievements and challenges.

During the SARS-CoV-2 pandemic, astonishingly rapid research averted millions of deaths worldwide through new vaccines and repurposed and new drugs. Evidence use informed life-saving national policies including non-pharmaceutical interventions. Simultaneously, there was unprecedented waste, with many underpowered trials on the same drugs. We identified lessons from COVID-19 research responses by applying WHO's framework for research systems. It has four functions-governance, securing finance, capacity-building, and production and use of research-and nine components. Two linked questions focused the analysis. First, to what extent have achievements in knowledge production and evidence use built on existing structures and capacity in national health research systems? Second, did the features of such systems mitigate waste? We collated evidence on seven countries, Australia, Brazil, Canada, Germany, New Zealand, the United Kingdom and the United States, to identify examples of achievements and challenges.We used the data to develop lessons for each framework component. Research coordination, prioritization and expedited ethics approval contributed to rapid identification of new therapies, including dexamethasone in the United Kingdom and Brazil. Accelerated vaccines depended on extensive funding, especially through the Operation Warp Speed initiative in the United States, and new platforms created through long-term biomedical research capacity in the United Kingdom and, for messenger ribonucleic acid (mRNA) vaccines, in Canada, Germany and the United States. Research capacity embedded in the United Kingdom's healthcare system resulted in trial acceleration and waste avoidance. Faster publication of research saved lives, but raised challenges. Public/private collaborations made major contributions to vastly accelerating new products, available worldwide, though unequally. Effective developments of living (i.e. regularly updated) reviews and guidelines, especially in Australia and Canada, extended existing expertise in meeting users' needs. Despite complexities, effective national policy responses (less evident in Brazil, the United Kingdom and the United States) also saved lives by drawing on health research system features, including collaboration among politicians, civil servants and researchers; good communications; and willingness to use evidence. Comprehensive health research strategies contributed to success in research production in the United Kingdom and in evidence use by political leadership in New Zealand. In addition to waste, challenges included equity issues, public involvement and non-COVID research. We developed recommendations, but advocate studies of further countries.

The Covid-19 Pandemic Has Exposed Opportunities To Strengthen Our Health Research Systems.

Professor Sir Mark Walport, FRS, FMed Sci, FRCP, physicianscientist, academic leader and visionary health research planner, was the recipient of the 2020 Henry G. Friesen International Prize in Health Research. He is a former Chief Executive, UK Research and Innovation (UKRI) and UK government's Chief Scientific Advisor. He continues to be a champion of fundamental science in health research, engineering, technology and innovation, and is a major spokesperson on COVID-19 pandemic trends at the global level.

Can Systems Thinking Become "The Way We Do Things?" Comment on "What Can Policy-Makers Get Out of Systems Thinking? Policy Partners' Experiences of a Systems-Focused Research Collaboration in Preventive Health".

In "What Can Policy-Makers Get Out of Systems Thinking? Policy Partners' Experiences of a Systems-Focused Research Collaboration in Preventive Health," Haynes et al glean two important insights from the policy-makers they interview. First: active promotion of systems thinking may work against its champions. Haynes and colleagues' findings support a backgrounding of systems thinking; more important for policy-makers than understanding the finer details of systems thinking is working in situations of mutual learning and shared expertise. Second: co-production may be getting short shrift in prevention research. Most participant comments were not about systems thinking, but about the benefits of working across sectors. Operationalizing the 'co' in co-production is not easy, but it may be where the pay-off will be for prevention researchers, who must understand the critical success factors of co-production and its potential pitfalls, to capitalize on its significant opportunities.

Re-imagining Research: A Bold Call, but Bold Enough? Comment on "Experience of Health Leadership in Partnering with University-Based Researchers in Canada: A Call to 'Re-Imagine' Research".

Many articles over the last two decades have enumerated barriers to and facilitators for evidence use in health systems. Bowen et al's article "Response to Experience of Health Leadership in Partnering with University-Based Researchers: A Call to 'Re-imagine Research'" furthers the debate by focusing on an under-explored research area (health system design and health service organization) with an under-studied stakeholder group (health system leaders), by undertaking a broad program of research on partnerships, and, based on participant responses, by calling for re-imagining of research itself. In response to the claim that the research community is not providing expertise to this pressing issue in the health system, I provide four high level reasons: partnerships mean different things to different people, our language does not reflect the reality we want, our health systems have yet to fully embrace evidence use, and complexity is easier to talk about than act within. Bowen et al's study, and their broader program of research, is well-placed to explore these issues further, helping identify appropriate researcher-health system leader partnership models for various health system change projects. Given the positive shifts identified in this study, and the knowledge that participants demonstrate about what needs to change, the time is right for bold action, re-imagining not only research, but healthcare, such that the production and use of evidence for better health is embraced and supported.

Evaluation of the "Foundations in Knowledge Translation" training initiative: preparing end users to practice KT.

BACKGROUND: Current knowledge translation (KT) training initiatives are primarily focused on preparing researchers to conduct KT research rather than on teaching KT practice to end users. Furthermore, training initiatives that focus on KT practice have not been rigorously evaluated and have focused on assessing short-term outcomes and participant satisfaction only. Thus, there is a need for longitudinal training evaluations that assess the sustainability of training outcomes and contextual factors that may influence outcomes. METHODS: We evaluated the KT training initiative "Foundations in KT" using a mixed-methods longitudinal design. "Foundations in KT" provided training in KT practice and included three tailored in-person workshops, coaching, and an online platform for training materials and knowledge exchange. Two cohorts were included in the study (62 participants, including 46 "Foundations in KT" participants from 16 project teams and 16 decision-maker partners). Participants completed self-report questionnaires, focus groups, and interviews at baseline and at 6, 12, 18, and 24 months after the first workshop. RESULTS: Participant-level outcomes include survey results which indicated that participants' self-efficacy in evidence-based practice (F(1,8.9) = 23.7, p = 0.001, n = 45), KT activities (F(1,23.9) = 43.2, p < 0.001, n = 45), and using evidence to inform practice increased over time (F(1,11.0) = 6.0, p = 0.03, n = 45). Interviews and focus groups illustrated that participants' understanding of and confidence in using KT increased from baseline to 24 months after the workshop. Interviews and focus groups suggested that the training initiative helped participants achieve their KT project objectives, plan their projects, and solve problems over time. Contextual factors include teams with high self-reported organizational capacity and commitment to implement at the start of their project had buy-in from upper management that resulted in secured funding and resources for their project. Training initiative outcomes include participants who applied the KT knowledge and skills they learned to other projects by sharing their knowledge informally with coworkers. Sustained spread of KT practice was observed with five teams at 24 months. CONCLUSIONS: We completed a longitudinal evaluation of a KT training initiative. Positive participant outcomes were sustained until 24 months after the initial workshop. Given the emphasis on implementing evidence and the need to train implementers, these findings are promising for future KT training.

Engaging patients as partners in health research: Lessons from BC, Canada.

Canada is seeing increased interest in engaging patients in health research, recognizing the potential to improve its relevance and quality. The momentum is promising, but there may be a tendency to ignore the challenges inherent when lay people and professionals collaborate. We address some of these challenges as they relate to recruitment, training, and support for patients at the British Columbia (BC) Support for People and Patient-Oriented Research Unit, part of Canada's Strategy for Patient-Oriented Research. A retrospective review of a telehealth project demonstrates that, as well as the practical elements of recruitment, training, and support, attention must be paid to issues of credibility, legitimacy, and power when engaging patients. We propose that all patient-oriented research projects would benefit from using a similar framework to guide patient engagement planning and implementation, helping to anticipate and mitigate challenges from the outset. Projects would ideally also include the study of patient engagement methods, to add to this important body of knowledge.

Reviewer training to assess knowledge translation in funding applications is long overdue.

BACKGROUND: Health research funding agencies are placing a growing focus on knowledge translation (KT) plans, also known as dissemination and implementation (D&I) plans, in grant applications to decrease the gap between what we know from research and what we do in practice, policy, and further research. Historically, review panels have focused on the scientific excellence of applications to determine which should be funded; however, relevance to societal health priorities, the facilitation of evidence-informed practice and policy, or realizing commercialization opportunities all require a different lens. DISCUSSION: While experts in their respective fields, grant reviewers may lack the competencies to rigorously assess the KT components of applications. Funders of health research-including health charities, non-profit agencies, governments, and foundations-have an obligation to ensure that these components of funding applications are as rigorously evaluated as the scientific components. In this paper, we discuss the need for a more rigorous evaluation of knowledge translation potential by review panels and propose how this may be addressed. CONCLUSION: We propose that reviewer training supported in various ways including guidelines and KT expertise on review panels and modalities such as online and face-to-face training will result in the rigorous assessment of all components of funding applications, thus increasing the relevance and use of funded research evidence. An unintended but highly welcome consequence of such training could be higher quality D&I or KT plans in subsequent funding applications from trained reviewers.

Time to shift from systems thinking-talking to systems thinking-action: Comment on "Constraints to applying systems thinking concepts in health systems: A regional perspective from surveying stakeholders in Eastern Mediterranean countries".

A recent International Journal of Health Policy and Management (IJHPM) article by Fadi El-Jardali and colleagues makes an important contribution to the literature on health system strengthening by reporting on a survey of healthcare stakeholders in Low- and Middle-Income Countries (LMICs) about Systems Thinking (ST). The study's main contributions are its confirmation that healthcare stakeholders understand the importance of ST but do not know how to act on that understanding, and the call for collective action by the global community of systems thinkers committed to healthcare improvement. We offer three basic considerations for next steps by this community, derived from our recent work in ST and the related field of Knowledge Translation (KT): resist the temptation to adopt a reductionist approach; recognize not everyone needs to understand ST; and do not wait for everything to be in place before getting started.

How funding agencies can support research use in healthcare: an online province-wide survey to determine knowledge translation training needs.

BACKGROUND: Health research funding agencies are increasingly promoting evidence use in health practice and policy. Building on work suggesting how agencies can support such knowledge translation (KT), this paper discusses an online survey to assess KT training needs of researchers and research users as part of a Canadian provincial capacity-building effort. METHODS: The survey comprised 24 multiple choice and open-ended questions including demographics, interest in learning KT skills, likelihood of participating in training, and barriers and facilitators to doing KT at work. More than 1,200 people completed the survey. The high number of responses is attributed to an engagement strategy involving partner organizations (health authorities, research institutes, universities) in survey development and distribution. SPSS was used to analyze quantitative results according to respondents' primary role, geographic region, and work setting. Qualitative results were analyzed in NVivo. RESULTS: Over 85 percent of respondents are interested in learning more about the top KT skills identified. Research producers have higher interest in disseminating research results; research users are more interested in the application of research results. About one-half of respondents require beginner-level training in KT skills; one-quarter need advanced training. Time and cost constraints are the biggest barriers to participating in KT training. More than one-half of respondents have no financial support for travel and almost one-half lack support for registration fees. Time is the biggest challenge to integrating KT into work. CONCLUSIONS: Online surveys are useful for determining knowledge translation training needs of researchers, research users and ultimately organizations. In this case, findings suggest the importance of considering all aspects of KT in training opportunities, while taking into account different stakeholder interests. Funders can play a role in developing new training opportunities as part of a broad effort, with partners, to build capacity for the use of health research evidence. Survey results would ideally be complemented with an objective needs assessment based on core competencies, and should be acted on in a way that acknowledges the complexity of knowledge translation in healthcare, existing training activities, and the expertise stakeholders already have but may not refer to as knowledge translation.