Identifying the Knowledge-to-Action Gaps

Alison Kitson
Templeton College, University of Oxford, Oxford, UK

Sharon E. Straus
Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and Department of Medicine, University of Toronto,
Toronto, ON, Canada

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What is a “gap”?

There are many examples of underuse and overuse of evidence in decision making and clinical care
1/3 patients do not get treatments of proven effectiveness
1/4 patients get care that is not needed or potentially harmful
Up to 3/4 of patients don’t get the information they need for decision making
Up to 1/2 of physicians don’t get the evidence they need for decision making
Policy makers often don’t use evidence from systematic reviews to inform policies, despite its availability

This process starts with identifying outcomes of interest
Quality indicators can be considered
- These are measures that monitor, assess and improve quality of care and organizational functions that affect patient outcomes

Quality indicators should include:
descriptive statement

list of necessary data elements necessary for constructing and reporting the measure
detailed specifications on how data elements are to be collected
population on whom the indicator is constructed
timing of data collection and reporting
analytic models used to construct model
format in which the results will be presented
evidence in support of its use
should be valid, reliable and feasible

Little agreement on optimal quality indicators across countries

Requires careful consideration of best available evidence such as that from systematic reviews and use of an appropriate rating process
- RAND Health advocates use of modified Delphi method to develop quality indicators:
  - Rounds of anonymous ratings on a risk-benefit scale and in-person discussions between rounds
  - Includes all relevant stakeholders
  - Testing of indicator in real practice settings
Could also consider using indicators developed from high-quality evidence-based guidelines

Needs assessments
- systematic processes determine size and nature of gap between current and more desirable knowledge, skills, attitudes, behaviours and outcomes
- Strategies depends on purpose of the assessment, type of data, and resources that are available
- Can be subjective or objectively measured
Classification of needs:
- Felt needs (what people say they need)
- Expressed needs (expressed through action)
- Normative needs (defined by experts)
- Comparative needs (group comparisons)
When assessing needs, must also consider and specify the stakeholder’s perspective i.e. the population, provider organizations or health care providers

Can be done using epidemiological data from administrative databases
- E.g. diagnosis, procedures, laboratory investigations, billing information
- Databases can range from regional to national
- Examples include Ontario MOH LTC database of OHIP billings, CIHI data on hospital admissions

All strategies for needs assessments have limitations
Administrative databases have limitations including:
- They were not developed for research so may not contain all the information (such as socioeconomic status)
- Coding may be incomplete for co morbid conditions etc
- Only records event for which there are codes
- May not include the entire population (e.g. prescription database may only contain information on patients who are aged 65 and older because their prescriptions are paid for by the health plan)

These include registries of patients who have undergone specific procedures/have certain diagnoses
- Examples include databases of people who received a CABG in a health region or who participated in colorectal cancer screening
They may complement administrative data because they may have additional data such as information on patient comorbidities
Limitations of these databases include inaccurate information and challenges integrating across databases

Multiple strategies can be used including
- Data abstraction from paper health records and electronic health records
- Extraction of data from organisational databases (such as those used for hospital accreditation)
Chart abstraction should use valid abstraction tools
Challenges in use of health records include lack of detail, illegibility (often a challenge in paper records), inability to easily capture data from electronic records

Most individuals are efficient processors of routine tasks
Do not concentrate on repetitive tasks once they master them
Skills for performing repetitive tasks are repressed, allowing us to pay attention to other things
Consequently, tasks individuals do most frequently, they think about the least
They do not have ways of evaluating the impact of these routine tasks
This may result in a “drift” in performance
People stop searching for improved conditions when they find a satisfactory result
Individuals adapt to slowly changing environments leading them to tolerate extreme variations without becoming aware they are doing so.
Opportunities for new ideas or introduction of new knowledge are not recognized
Problems become critical situations and catastrophes can result as the system drifts away from its ability to get feedback on routine tasks
Most people operate on “automatic pilot”
Most individuals will unconsciously adapt to worsening conditions
Active strategies must be put into place to counter these natural trends

Testing how routine data can stimulate identification of gaps in service delivery, monitoring changes to practice, and introducing new practices in a reliable and valid way
Understanding how local teams can become more autonomous and self-directing to keep vigilant over routine matters
Being clearer about how we identify knowledge-to-action gaps in the health care system

Identifying gaps in care is the starting point for knowledge implementation
When people are given more freedom to get involved, they more actively engage in finding creative solutions to routine problems and implementing them