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Family Practice Advance Access originally published online on November 12, 2008
Family Practice 2008 25(Supplement 1):i38-i43; doi:10.1093/fampra/cmn080
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© The Author 2008. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.

This article appears in the following Family Practice issue: Creating Supportive Environments for Nutrition Guidance: Towards a Synergy Between Primary Care and Public Health. Proceedings of the Fifth Heelsum International Workshop 10-12 December 2007. [View the issue table of contents]

Bringing important research evidence into practice: Canadian developments

Walter Rosser

Department of Family Medicine, Queen's University, 220 Bagot Street, Kingston, Ontario K7L 5E9, Canada

Correspondence to Walter Rosser, Department of Family Medicine, Queen's University, 220 Bagot Street, Kingston, Ontario K7L 5E9, Canada; Email: rosserw{at}post.queensu.ca

Received 26 May 2008; Revised 22 September 2008; Accepted 28 September 2008.


   Abstract
Top
 Abstract
Introduction
 Finding the evidence
 Applying the evidence
 Evaluation
 Practice-based research networks
 Conclusion
 Declaration
 References
 
Background. The transfer of evidence from research into clinical practice is made almost impossible by enormous volume of literature on any topic. Consolidated evidence into guidelines is not very helpful as there are usually 50 guidelines existing on common clinical topics. Clinicians need assistance in identifying the best available evidence. This paper describes two strategies to transfer research evidence into clinical practice.

Methods. The Guideline Advisory Committee (GAC) in Ontario has assessed all available guidelines on 70 clinical topics using a validated and transparent process involving community-based physicians as assessors. A single best guideline is selected and a summary of its evidence-based recommendations are produced for easy use by practitioners (http://www.gacguidelines.ca). The Critically Appraised Practice Reflection Exercise (CAPRE) programme takes the best available evidence on 40 common practice problems, presents a summary for clinician and patient, has a strategy for physician and patient to find common ground in applying the evidence and has the practitioner to carry out a reflection exercise to gain continuing education credits (http://www.capre.ca). Distribution of these strategies in practice-based research networks is a further step in making research more relevant to practice.

Results. The GAC website has more than 100 000 ‘hits’ per month and 4500 identified regular users from Canada and the world. The numbers are steadily increasing. The CAPRE programme has not been formally evaluated but over 150 clinicians have used the programme with patients. With a national launch, the programme there between 60 000 and 80 000 hits per week with 100 physicians completing the programme for continuing medical education (CME) credits in the first month. Physicians report that their patients are very pleased with their physician using the latest evidence to address their problem. This is true even if the patient does not agree to follow the evidence-based recommendations. Using these programmes in practice-based research, networks should further promote making research more relevant to practice.

Conclusions. Transferring research-based evidence into clinical practice has many challenges. Two programmes developed to address these challenges are described. Although not fully evaluated, there is some evidence of success.

Keywords. Clinical practice, research-based evidence, transfer.


   Introduction
Top
 Abstract
 Introduction
Finding the evidence
 Applying the evidence
 Evaluation
 Practice-based research networks
 Conclusion
 Declaration
 References
 
Most research currently used to influence patterns of practice and guidelines that are followed has been carried out in highly selected populations, usually assembled in research or teaching facilities that are highly specialized.1 The conclusions, directives and guidelines produced from most of these studies may or may not apply to individuals who are seen in the average community practice.2 The guidelines and materials used by the clinician to make decisions on what should be recommended to patients have passed through the very extensive filtering process outlined by Larry Green.3

A very important part of the role of the community-based practitioner is to determine if the recommendations that reach the practitioner are applicable to the individual patient in the surgery.

A further step in the process of adopting research evidence into practice is the patient’s decision whether or not to accept and actually use the recommended therapy. All recommendations should be congruent with the beliefs, values and wishes of each individual. Given the number of steps in this translational process, it is not surprising that it seems very difficult to move evidence derived from carefully complete research to people in the community and to the further step of measurably improving their health.4,5

Given the complexity of these processes, it is not surprising that several strategies designed to move research evidence into practice show little effect. However, a growing body of evidence supports a ‘patient-centred’ approach to delivering evidence-based knowledge to patients that is outlined in more detail in Evelyn van Weel Baumgarten’s manuscript.6–8

The more ‘patient centered’ a physician–patient encounter the better outcomes when the physician and patient in partnership agree on therapeutic goals. There is some evidence that addressing the ‘translation problem’ using a patient-centred approach and in addition using online web-based strategies will improve patient outcomes. Although no specific studies have been reported on weight control and increasing exercise, one would expect similar benefit.9 This paper describes two strategies to transfer research evidence into clinical practice.


   Finding the evidence
Top
 Abstract
 Introduction
 Finding the evidence
Applying the evidence
 Evaluation
 Practice-based research networks
 Conclusion
 Declaration
 References
 
If we follow the steps involved in knowledge translation, the first problem the practitioner encounters is finding the evidence. If you chose almost any topic from clinical practice at a primary care level and do a literature search you are likely to find thousands of papers and on average at least 50 guidelines (Table 1). Table 1 illustrates the enormous volume of medical literature as well as the dramatic increase in publications over the past decades. This overwhelming volume of information makes it impossible for the practitioner to do all the sorting and critical appraisal assessment required for one topic, let alone the many dealt within practice. The fact that on average there are 50 guidelines on any common clinical topic has rendered the use of most guidelines impractical. The only solution is to have an objective and trusted third party do the sorting work. To be credible, this organization or group must use transparent and evidence-based methods to develop recommendations. This information must be provided to the practitioner in a format that the practitioner can quickly access and use when the patient is in the surgery.


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  		TABLE 1 Finding the right evidence (PubMed citations)

 
The Ontario Guideline Advisory Committee (GAC) is one of several organizations that review the literature and using a rigorous methodology attempt to determine which is the best available guideline and then summarize the recommendations for the practitioner.

Topics reviewed by the GAC are chosen on the basis of relevance to practice, requests from users and practitioners and requests from the Government of Ontario as well as the Ontario Medical Association. Guidelines found in an extensive literature search are initially assessed for their quality on the basis of transparency of process in developing the guidelines as well as the use of evidence in making recommendations. More details about the process are available on the GAC website.

When the GAC review process was conducted for the topic of obesity, more than 50 documents said to be guidelines were found on literature search for adult and child obesity. Nineteen of these guidelines were considered to meet basic quality criteria that meant further review was justified. Four of these guidelines rose to the top after being scored for quality of guideline development and the use and support of recommendations by high-quality evidence. Each guideline was reviewed by four community-based physicians who had been trained to use the AGREE scoring system which is a validated instrument.10 The AGREE instrument assess 26 different aspects of guideline production to determine the quality of the guideline and how evidence was used to support recommendations. The four scores for each guideline as well as comments from the reviewers were assembled on an evidence table. The two or three highest scoring guidelines are reviewed by a committee (GAC) and the best guideline selected using a number of criteria outlined on the website.

The committee applies an ‘Apple Score rating’ that is based on the quality of guideline production, the quality of evidence used in the guideline supporting the topic and the currency of the guideline. This rating takes into account the fact that the best available guideline may not meet all the criteria of excellence of a ‘4 Apple Guideline’. The following guideline for Adult Obesity was endorsed by the GAC with a 4 apple rating (the highest).11

Each selected guideline has both the date of selection and the stale date when it must be reviewed again by the GAC. A summary of the chosen guideline is produced by our medical advisors. The summary is organized according to the strength of evidence supporting each of the recommendations (Table 2). Once this process is completed, every step in the process is posted on our website including the full copy of the selected guideline http://www.gacguidelines.ca. Clinicians are encouraged to download guideline summaries onto their handheld computers. We are aware of several hundred users downloading some part of the material on the website each month. Clinicians are encouraged on the website as well as in continuing medical education programmes to use the material in their practice when patients are in their office. They can print out summaries of recommendations to give to patients to promote the concept of partnership between physician and patient. The summaries are used by University Continuing Professional Education programmes as well as a number of organizations to promote the practice of evidence-based medicine.


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  		TABLE 2 Summary of GAC chosen obesity guideline

 

   Applying the evidence
Top
 Abstract
 Introduction
 Finding the evidence
 Applying the evidence
Evaluation
 Practice-based research networks
 Conclusion
 Declaration
 References
 
Finding the best available evidence through the GAC guideline selection and summary process is only one of many steps in transferring evidence into practice and ultimately to improve patient outcomes.12

Lawrence Green in his paper decries the amount of ‘filtering’ that takes place through these many steps. He argues that what actually influences patient choice may not reflect the science that discovered best medical practice.3 He sees the GAC process as yet another filter that risks altering the pure messages that emerge from clinical trials. However, the filtering process provided by the GAC and other groups provides the only practical way that clinicians can deal with the massive amounts of literature that are present on any clinical topic. Lawrence Green’s example of changing population behaviour in a positive way through smoking cessation and uptake prevention involved campaigns at every level of social structure and primarily focussed on gaining public support. To cause the level of societal change needed to reverse the alarming rise in overweight and obese adults and children, an intervention similar to that against smoking will be required. However, as in the anti-smoking campaign, there is a role for the physician–patient encounter providing a significant element to a successful campaign.13

One such structured strategy to bring evidence-based information to the physician in a way that is likely to influence the physician’s behaviour in providing evidence to the patient is found in the Critically Appraised Practice Reflection Exercise (CAPRE) programme. The programme is available in both French and English. There are four steps in the CAPRE programme which is a web-based programme on an open website found at http://www.capre.ca:

(i)  The bottom line: this provides a brief one-paragraph summary of the core critically appraised recommendations for managing the problem. The bottom line can be easily downloaded to a handheld computer and may be used by the clinician as guidance when actually with a patient (Table 3).
(ii)  A critically appraised discussion of the best available evidence from the literature on the topic. Because written information on clinical topics can rapidly go out of date, there is provided an automated literature search. Librarians have designed a search to bring up only high-quality papers (randomized controlled trials or meta-analysis) from PubMed to bring information on the topic up to the time the user clicks on the icon to do the search. If new trials on the topic are found, the user has to decide whether the most recent literature is up to standard and whether new findings will alter the information provided to the patient.
(iii)  A document for patients outlining the evidence and recommendations written in language that most patients can understand. This is usually on one sheet of paper that the clinician can print and give to the patient. Also included is a form (physician patient partnership paper) that may be used optionally by the physician (Table 4). This form includes some information about the patient’s medical history that may impact on the problem. There is a list of the risks and benefit of the recommendations, a section where the patient states how their own beliefs, values, fears and experiences may influence their decision and finally a space where the physician and patient find ‘common ground’ to decide what the best application of evidence is for that individual. It is optional for the physician and patient to formalize this step by signing the form and each keeping a copy or to carry out these informally with the physician recording the agreement in the medical record.
(iv)  A reflection exercise for the physician to answer five questions on how the steps were followed and whether the agreement reached was in the physician's opinion best for the patient. The physician is asked to reflect on whether the information might be presented or the discussion conducted differently in the future (Table 5).


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  		TABLE 3 The bottom line for obesity in adults

 


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  		TABLE 4 The physician patient partnership paper

 


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  		TABLE 5 The physician reflection exercise

 
By going through these steps, the physician can be rewarded for up to 4 hours of study credit by the College of Family Physicians of Canada. Presently in Canada, every Family Physician is required to gain 50 hours a year of study credits.


   Evaluation
Top
 Abstract
 Introduction
 Finding the evidence
 Applying the evidence
 Evaluation
Practice-based research networks
 Conclusion
 Declaration
 References
 
More than 150 physicians who have participated in this programme have provided qualitative evaluation of their experience and their perception of the patient’s reaction to the process. This evaluation was reported as part of a course in which clinicians used the CAPRE programme to transfer evidence to their patients. Physicians found that presenting patients with the information and then discussing the benefits and difficulties implementing the recommendations strengthen patient’s trust in the physician–patient relationship. Patients were appreciative of their physician seeking the best available evidence supporting their treatment even if they did not agree to follow the recommendations. Physicians believed that there was a strong likelihood of patients following the common ground recommendations; however, the actual outcomes have not been evaluated. A focus group session with seven clinicians in a rural area resulted in a number of modifications to improve acceptance of CAPRE. A national launch of the CAPRE in April 2008 found between 60 000 and 80 000 website hits per week suggesting good acceptance across the country. Within 4 weeks, more than 100 physicians had applied for CME credits demonstrating completion of the five steps. Physicians reported finding the critical appraisal of the literature with key references both credible and helpful. They particularly appreciate the automated literature search.


   Practice-based research networks
Top
 Abstract
 Introduction
 Finding the evidence
 Applying the evidence
 Evaluation
 Practice-based research networks
Conclusion
 Declaration
 References
 
The concept of practice-based research networks is not new. There have been networks in Holland for at least 25 years. And there are many in the US, UK and Australia.14,15 Canada has been very slow to support these networks but the national public health agency is now establishing networks for research in nine centres across the country. Each of the nine networks has between 20 and 80 practitioners who have electronic medical records and collect data from their practice in a standardized way. By submitting data daily, patterns of management of chronic diseases, detecting acute infectious outbreaks and monitoring any significant changes in patterns of health-care delivery becomes possible with central pooling of anonymous data. While much data can be collected from practices, it is important to maintain the interest of the practitioners to provide practices with useful clinical information. Unfortunately, it may take months or years to obtain and analyse interpretable data from the ongoing data collection. Thus, providing practices CAPRE modules prompted by diagnosis occurring on their medical records will allow participants to incorporate evidence into their practice while earning CME credits. This strategy is in the planning and pilot testing phase and will be functional in 1–2 years and be in a position to provide evaluation of outcomes from the CAPRE programme in several years.


   Conclusion
Top
 Abstract
 Introduction
 Finding the evidence
 Applying the evidence
 Evaluation
 Practice-based research networks
 Conclusion
Declaration
 References
 
It is a complex and difficult process to identify and transfer the best available evidence to clinicians and their patients.

The GAC using a transparent methodology assists clinicians in finding the best available guidelines to use in their practice. Given the volume of users, the programme provides this support but its impact on patients requires further evaluation.

The CAPRE programme provides clinicians with a method of applying the evidence in their practice. Qualitative feedback from 150 physicians about their comfort with using the strategy and their perceptions of patient reaction suggest as good acceptance of the programme. High volumes of use across Canada after a formal launch in April 2008 support acceptance of the strategy. Proper evaluation of both of these programmes on patient behaviour and outcomes is required.

Practice-based research networks could benefit from their participants using both strategies in their practice allowing for evaluation of the impact on patient outcomes.


   Declaration
Top
 Abstract
 Introduction
 Finding the evidence
 Applying the evidence
 Evaluation
 Practice-based research networks
 Conclusion
 Declaration
References
 
Funding: Center for Effective Practice.

Ethical approval: None.

Conflicts of interest: None.


   Notes
 
Rosser W. Bringing important research evidence into practice: Canadian developments. Family Practice 2008; 25: i38–i43.


   References
Top
 Abstract
 Introduction
 Finding the evidence
 Applying the evidence
 Evaluation
 Practice-based research networks
 Conclusion
 Declaration
 References
 
1 Rosser WW. Application of evidence from randomised controlled trials to general practice. Lancet (1999) 353:661–664.[CrossRef][Web of Science][Medline]

2 Rosser WW. Aspirin for primary prevention of cardiovascular events. Lancet (2001) 357:84–85.[CrossRef][Web of Science][Medline]

3 Green L. If it is an evidence-based practice, where's the practice-based evidence? Fam Prac (2008) 25(suppl 1). i20–i24.

4 Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. CMAJ (1997) 156:1705–1712.[Abstract]

5 Young JM, Leong DC, Armstrong K, et al. Concordance with national guidelines for colorectal cancer care in New South Wales: a population-based patterns of care study. Med J Aust (2007) 186:292–295.[Web of Science][Medline]

6 Stewart M, Brown JB, Donner J, et al. The impact of patient-centered care on outcomes. J Fam Pract (2000) 49:796–804.[Web of Science][Medline]

7 Stewart M, Brown JB, Hammerton J, et al. Improving communication between doctors and breast cancer patients. Ann Fam Med (2007) 5:387–394.[Abstract/Free Full Text]

8 van Weel-Baumgarten E. The Patient Centered Information and Interventions: Tools for Life Style Change? Consequences for Medical Education. Fam Pract (2008) 25(suppl 1). i67–i70.

9 Stewart M, Marshall JN, Østbye T, et al. Effectiveness of case-based on-line learning of evidence-based practice guidelines. Fam Med (2005) 37:131–138.[Web of Science][Medline]

10 Cluzeau FA, Littlejohns P, Grimshaw JM, Feder G, Moran SE. Development and application of a generic methodology to assess the quality of clinical guidelines [Review]. Int J Qual Health Care (1999) 11:21–28.[Abstract/Free Full Text]

11 Lau DCW, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, Ur E, for members of the Obesity Canada Clinical Practice Guidelines Expert Panel. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. Can Med Assoc J (2007) 176(8 suppl). http://www.cmaj.ca/cgi/data/176/8/S1/DC1/1 (accessed on 18 October 2007).

12 Green LW, Mercer SL, Rosenthal AC, Dietz WH, Husten CG. Possible lessons for physician counselling on obesity from the progress in smoking cessation in primary care [Review]. Forum Nutr (2003) 56:191–194.[Medline]

13 Green LW. Public health asks of systems science: to advance our evidence-based practice, can you help us get more practice-based evidence? Am J Public Health (2006) 96:406–409.[Abstract/Free Full Text]

14 Tierney WM, Oppenheimer CC, Hudson BL, et al. A national survey of primary care practice-based research networks. Ann Fam Med (2007) 5:242–250.[Abstract/Free Full Text]

15 van Weel C, de Grauw W. Family practices registration networks contributed to primary care research. J Clin Epidemiol (2006) 59:779–783.[CrossRef][Web of Science][Medline]


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