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If We Want More Evidence-based Practice, We Need More Practice-Based Evidence

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Title: If We Want More Evidence-based Practice, We Need More Practice-Based Evidence


1
If We Want More Evidence-based Practice, We Need
More Practice-Based Evidence
The Shifting Context for Dissemination
Evaluation in Translational Research
  • UCSF Translation-2 Course, Oct 30, 2008
  • Lawrence W. Green
  • University of California at San Francisco

2
NIH Roadmap Initiative--translating discoveries
into health
The roadmap less traveled?
The Roadmap identifies the most compelling
opportunities in three arenas new pathways to
discovery, research teams of the future, and
reengineering the clinical research enterprise
(Zerhouni, p. 63).
Green LW. Am J Prev Med., 2007 33(2)137-38,
after K. Grumbach.
Zerhouni E. Science 2003, Oct 3302(5642)63-72
.
3
"Blue Highways" on the NIH Roadmap
Program Evaluation, CQI, Policy Analysis, TA in
EBP adaptation. Systems research.
Westfall, J. M. et al. JAMA 2007297403-406.
4
Evolution of the Model, Bangladesh
  • Correlates of family planning in Pakistan, 1960s
  • Green LW., Krotki KJ. Proximity and other
    geographical factors in the utilization of family
    planning clinics in Pakistan. Pakistan Dev. Rev.
    680-104, 1966.
  • Green LW. Validity in family planning surveys
    Disavowed knowledge and use of contraceptives in
    a panel study in Dacca, East Pakistan. Public
    Opin. Q. 32504, 1968.
  • Green LW., Krotki KJ. Class and parity biases in
    family planning programs The case of Karachi.
    Soc. Biol.15235-251, 1968.
  • Green LW. East Pakistan Knowledge and use of
    contraceptives. Stud. Fam. Planning 19-14,
    1969.
  • Cluster trial of interventions in Dhaka
  • Green, L.W. Identifying and overcoming barriers
    to the diffusion of knowledge about family
    planning. Adv. Fertil. Control 521-29, 1970.
  • Green, L.W., et al. Field experiment comparing
    family planning education programs directed at
    males and females. Int. J. Health Educ.
    16242-259, 1973.

5
Evolution The Hopkins Trials
  • Asthma the diffusion concept of homophily
  • Green LW. Toward cost-benefit evaluations of
    health education Some concepts, methods and
    examples. Health Educ. Monogr. 2 (supp.2)34-64,
    1974.
  • Maiman L, Green LW, Gibson G, Mackenzie EJ.
    Education for self-treatment by adult asthmatics.
    J. Am. Med. Assoc. 2411919-1922, 1979.
  • Hypertension the concept of comprehensiveness
  • Green LW., Levine DM, Deeds SG. Clinical trials
    of health education for hypertensive outpatients
    Design and baseline data. Prev. Med. 4417-425,
    1975.
  • Green, L.W., et al. Development of randomized
    patient education experiments with urban poor
    hypertensives. Patient Couns. Health Educ.
    1106-111, 1979.
  • Levine DM, Green LW, Deeds SG, et al. Health
    education for hypertension patients. J. Am. Med.
    Assoc. 2411700-1703, 1979.
  • Morisky DE, Levine DM, Green LW, et al. Five-year
    blood-pressure control and mortality following
    health education for hypertensive patients. Am J
    Public Health 73153-162, 1983.

6
Where Have All the Data Gone? Longtime Passing

17 yrs
It takes 17 years to turn 14 per cent of
original research to the benefit of patient
care
Original research
Submission
Unknown
0.3 year
6. 0 - 13.0 years
0.6 year
0.5 year
9.3 years
Poyer, 1982
Antman, 1992
Kumar, 1992
Kumar, 1992
Publication
Acceptance
Bibliographic databases
Reviews, guidelines, textbooks
Implementation
50
35
Negative results
18
46
Lack of numbers, Design issues
Lack of numbers, Design issues
Inconsistent indexing
Balas, 1995
Poynard, 1985
Dickersin, 1987
Koren, 1989
7
R
The Pipeline Fallacy of Producing
Vetting Research to Get Evidence-Based Practice
The 17-year odyssey
Practice
-
Guidelines for Evidence-Based Practice
Funding patient needs, demands local
practice circumstances professional discretion
credibility fit of the evidence.
Research Synthesis
Publication Priorities Peer Review
Peer Review Of Grants
Priorities for Research Funding
Evidence-based Medicine movement
Academic appointments, promotion, tenure
criteria
Blame the practitioner or blame dissemination
Based on Green, L.W. From research to best
practices in other settings and populations. Am
J Health Behavior 25165-178, April-May 2001.
Full text www.ajhb.org/25-3.htm
8
The research indicates that we really should do
something with all this research.
Diffusion Adoption Quality EBP
Bridging the gap
9
5 Ways of Making Research More Relevant for
Practice
  • Making research more theory-based
  • Setting research evaluation priorities
  • Making research findings actionable, usable,
    relevant (to whom?)
  • Disseminating translating (adapting) research
    to local circumstances, cultures, and personnel
  • Making evidence more practice-based

10
Filling the Chasm, as Conceived by the U.S.
Translation Agency
Practice is
We want it to here be here
Innovation
Implementation
Reminiscent of the Fallacy of the Empty Vessel
from early health education
Adoption
Education
Diffusion
TRIP
Carolyn Clancy. Agency for Healthcare Research
Quality 2003.
11
R
The Pipeline Fallacy of Producing
Vetting Research to Get Evidence-Based Practice
The 17-year odyssey
Practice
-
Guidelines for Evidence-Based Practice
Funding patient needs, demands local
practice circumstances professional discretion
credibility fit of the evidence.
Research Synthesis
Publication Priorities Peer Review
Peer Review Of Grants
Priorities for Research Funding
Evidence-based Medicine movement
Academic appointments, promotion, tenure
criteria
Blame the practitioner or blame dissemination
Based on Green, L.W. From research to best
practices in other settings and populations. Am
J Health Behavior 25165-178, April-May 2001.
Full text www.ajhb.org/25-3.htm
12
RFA (PAR) from NIH, 2006
  • Applications to identify, develop, and refine
    effective and efficient methods, structures, and
    strategies that test models to disseminate and
    implement research-tested health behavior change
    interventions and evidence-based prevention,
    early detection, diagnostic, treatment, and
    quality of life improvement services into public
    health and clinical practice settings.
  • Two problems with these framings of the issue
  • Are the research-tested interventions adequate?
  • Are they appropriate to other settings,
    populations?
  • To illustrate the first problem

13
Canadian Cancer Society RFP for a Review to
Answer 4 Questions
  • Are group counseling programs for smoking
    cessation effective?
  • If so, what is the optimal content of the
    sessions?
  • What is the optimum number and frequency of
    sessions that should be offered?
  • What are the characteristics of the most
    effective facilitators?

14
University of Waterloo Results
  • A comprehensive literature review of over 40
    years of published and unpublished studies
  • Deficiencies in purpose, design and reporting
  • Research could answer only the first of 4
    questions that group programs for smoking
    cessation are effective.

Manske SR, Miller S, Moyer C, Phaneuf MR,
Cameron RC. Best practice in group- based smoking
cessation Results of a literature review. AJHP
18409-23, 2004.
15
Evidence-Based Medicine and Patient-Centered
Medicine
Information of importance to patient choice that
is not even potentially of evidence-based type.
Area where there is currently good
evidence-based information of importance to
patients in making choices.
C
A
A Good evidence B Potential for good
evidence C Information of potential importance
to patients in making health care choices
Information of importance to patient choice that
is potentially of evidence- based type.
B
In A.L. Cochrane, from T. Hope. Evidence-based
patient choice and the doctor-patient
relationship. In But Will It Work, Doctor? Kings
Fund, London, 1997, 20-24.
16
Issues for Evidence-Based Practice and
Translating Research to Practice
  • Making practice more theory-based
  • Setting research priorities
  • Making research findings actionable, usable,
    relevant within settings
  • Translating research from outside to local
    circumstances, cultures, personnel
  • Making evidence more practice-based

17
Priority-Setting for Health Research
Population Level
Program Evaluation
CDC
Community Statewide Effectiveness Trials
Surveillance
PBRNs, CQI
Applied Research Development
Clinical Trials
Basic Research
Demonstration Education Research
Clinical Investigations
NIH
Molecular Level
T2
T1
Knowledge Acquisition
Knowledge Transfer
Knowledge Translation
Knowledge Validation
Green LW, Popovic T, et al. CDC Futures
Workgroup on Research. Atlanta, 2004.
18
The Internal Validity Drift of Health Sciences
Evidence Lost in Translation
  • Evidence-based medicine movement taken to scale
    in general practice health promotion
  • The peer review preferences for experimental
    control and certainty of causation
  • The publishing preferences for RCTs and positive
    results
  • The limitations of print space driving out richer
    description of interventions, protocols,
    procedural lessons, subgroup variations
  • But a more natural type of practice-based
    evidence has greater influence on multi-level
    program planning, practice policy

19
Change in Per Capita Cigarette ConsumptionCalifor
nia Massachusetts vs Other 48 States, 1984-1996
5
0
-5
Percent Reduction
-10
-15
-20
-25
Other 48 States
California
Massachusetts
1984-1988
1990-1992
1992-1996
20
Issues for Evidence-Based Practice and
Translating Research to Practice
  • Making practice more theory-based
  • Setting research priorities
  • Participatory research to make findings
    actionable, usable, relevant within settings
  • Translating research from outside to local
    circumstances, cultures, personnel
  • Making evidence more practice-based

21
Some Benefits of Participatory Research in
Practice-Based Evidence
  • Results are relevant to interests, circumstances,
    and needs of those who would apply them
  • Results are more immediately actionable in local
    situations for people and/or practitioners
  • Generalizable findings more credible to people,
    practitioners and policy makers elsewhere because
    they were generated in partnership with people
    like themselves
  • Helps to reframe issues from health behavior of
    individuals to encompass system and structural
    issues.
  • Green LW, Mercer SL. Am J Public Health Dec.
    2001.

22
Definition and Standards of Participatory
Research for Health
  • Systematic investigation
  • Actively involving people in a co-learning
    process
  • For the purpose of action conducive to health
  • --not just involving people more intensively as
    subjects of research or evaluation

Green, George, Daniel, et al., Participatory
ResearchOttawa Royal Society of Canada, 1997.
www.lgreen.net/guidelines.html
23
Caption adapted from Bizarro, Universal Press,
1997.
I want you to quit smoking and lose 35 pounds.
Then I want you to come back and tell me how the
hell you did it.
24
The Lenses of Scientists, Health Professionals
and Lay People
Subjective Indicators of Health
Professional, Scientific
Layperson
Objective Indicators of Health
25
Issues for Evidence-Based Practice and
Translating Research to Practice
  • Making practice more theory-based
  • Setting research priorities
  • Making research findings actionable, usable,
    relevant participatory research
  • Translating research to local cultures
    circumstances External validity fidelity vs
    adaptation
  • Making evidence more practice-based

26
Building Policy and Practice from Evidence
Theory
  • Not starting with theory and looking for problems
    on which to test them, but starting with problems
    and looking for theories to help us solve them
  • Evidence on solutions generalizes to other
    circumstances, settings, populations in the
    form of either replication or theory
  • Replication is limited by the infinite number of
    context-population combinations
  • "In theory, theory and practice are the same
    thing. In practice they're not.. -Jan L.A. van
    de Snepscheut
  • All models are wrong. Some are useful --Box

Green LW. Public health asks of systems science
Amer J Public Health 96, March 2006.
27
Fidelity vs Adaptation
  • Researchers test an intervention for its efficacy
  • Rigorous test (efficacy) qualifies it for
    official lists of evidence-based practices and
    guidelines
  • Practitioners try to incorporate it into their
    programs in other populations, circumstances
  • Poor fit produces failure of program
  • Practitioners are blamed for not implementing
    with fidelity
  • Now buy the producers training program

Green LW, Glasgow RE, external
validityEvaluation the Health Professions,
Mar. 2006.
28
Efficacy vs. Effectiveness
  • Efficacy. The tested impact of an intervention
    under highly controlled circumstances.
  • Effectiveness. The tested impact of an
    intervention under more normal circumstances
    (relatively less controlled, real-time, typical
    setting, population, and conditions).
  • Broad Program Evaluation. The tested impact of a
    blended set of interventions on larger systems
    and populations. Natural Experiments with
    minimal control, maximum variability.

29
The Trade-offs
  • Efficacy. Maximizes internal validity, i.e., the
    degree to which one can conclude with confidence
    that the intervention caused the result.
  • Effectiveness. Maximizes external validity,
    i.e., the degree to which one can generalize from
    the test to other times, places, or populations.
  • Program Evaluation. Maximizes reality testing in
    particular settings, with the combination of
    interventions at multiple levels required for
    public health effect.

Green LW, Glasgow RE, external
validityEvaluation the Health Professions,
Mar. 2006.
30
Issues for Evidence-Based Practice and
Translating Research to Practice
  • Blending evidence-based practice with
    theory-based practice
  • Setting research priorities
  • Making research findings actionable, usable,
    relevant Participatory Research
  • Translating research to local circumstances
  • Making evidence more practice-based the
    centrality of evaluation and continuous quality
    improvement research

31
Mediating and Moderating Variables



Mediator
Intervention
Outcome
or Program

Variable(s)




Mediator

Moderators
Moderators

Green Kreuter, Health Program Planning An
Educational and Ecological Approach. 4th ed. New
York McGraw-Hill, 2005. Green Glasgow, EHP,
2006.
32
Aligning Evidence with (and deriving it from)
Practice Matching, Mapping, Pooling and Patching
  • Matching ecological levels of a system or
    community with evidence of efficacy for
    interventions at those levels
  • Mapping theory to the causal chain to fill gaps
    in the evidence for effectiveness of
    interventions
  • Pooling experience to blend interventions to fill
    gaps in evidence for the effectiveness of
    programs in similar situations
  • Patching pooled interventions with indigenous
    wisdom and professional judgment about plausible
    interventions to fill gaps in the program for the
    specific population

Green Kreuter, Health Program Planning An
Educational and Ecological Approach. 4th ed. NY
McGraw-Hill, 2005, Chapter 5. Green Glasgow,
2006.
33
3 Conceptualizations of the Gap Between Research
Practice
  • Practitioners need to receive the lessons of
    research and put them into practice.
  • Research and practice are entirely separate
    disciplines and each must develop their own
    answers to their own problems
  • Research and practice have complementary
    perspectives and skills that need to be used
    together to address the real need, collaborative
    knowledge production.
  • Add to this the need to include the patients
    perspective. Whose perspective prevails?

Van De Ven A, Johnson P. Knowledge for theory and
practice. Academy of Management Review.
200631(4).
34
The Bridge (not the Pipeline) from Research to
Practice and Back
  • If we want more evidence-based practice, we need
    more practice-based evidence.
  • The importance of practitioners and policy-makers
    in shaping the research questions.
  • Practitioners and their organizations represent
    the structural links (and barriers) to addressing
    the important determinants of health behavior at
    each level. Engage them, not at passive
    recipients, but as partners

Green, L.W. From research to best practices in
other settings and populations. Am J Health
Behavior 25165-178, April-May 2001. Full text
www.ajhb.org/25-3.htm.
35
The Vision for Translation 2
  • A future in which we would not need to ask how to
    get more evidence-based practice, rather
  • How to sustain the engagement of students,
    practitioners, patients and communities in a
    participatory process of practice-based research
    and program evaluation?
  • How to adapt the best practices guidelines
    through best processes of collecting data to
    diagnose the biopsychosocial needs of their
    patients and communities

36
Translation 2 Vision (expanded)
  • How to match the proposed evidence-based
    interventions to those needs, filling gaps in the
    evidence-based interventions with the use of
    theory and mutual consultation, and prospective
    testing of complementary interventions
  • The cumulative, building-block tradition of
    evidence-based medicine from RCTs would be
    complemented by a parallel strengthening and
    support of a tradition of participatory research
    and evaluation conducted in practice settings.

37
6 Conclusions (Remedies)
  • Adapt the research funding priorities
  • Adapt publication criteria
  • Adapt the criteria for inclusion and weighting of
    studies into systematic reviews and research
    syntheses
  • Adapt the derivation and qualification of
    practice guidelines from the systematic reviews
  • Adapt the academic promotion and tenure criteria
    and weights given to community- practice-based
    research
  • Adapt the research training of students and
    fellows in methods of practice-based and
    participatory research
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