Implementation Science - Latest Comments

About the use of GADS as outcome measure

Enric Aragonès — 2012-01-25T10:50:55Z

The Goldberg¿s Anxiety and Depression Scales (GADS) are heteroapplied questionnaires that were derived by latent trait analysis from a standardized psychiatric research interview. They were designed and calibrated to aid general practitioners and other non-psychiatrists in the better recognition of anxiety and depression [1].
These scales were translated and validated as screening tool in Spanish primary care patients by Monton et al. [2] Afterward, these scales were recommended as a screening test by the Program of Preventive Activities and Health Promotion (PAPPS) of the Spanish Society of Family and Community Medicine (semFYC) and they became widely known among Spanish GPs [3].
However, in this research protocol the GADS anxiety sub-scale is proposed to use not as a tool for detection, but as a primary outcome measure by means of monitoring changes in anxiety severity.
As far as we know, this questionnaire is not designed for this purpose and there are no studies examining its operability as an instrument to monitor the symptomatic progression of anxiety or depression symptoms. We have reviewed some systematic reviews of therapeutic interventions for anxiety disorders [4,5,6] and we have seen that there are no clinical trials using the GADS as an outcome measurement.
We advocate using a well validated test to measure the clinical outcomes with reliability. Otherwise, this methodological error may cause difficulties to properly interpret the results of the evaluation, and also difficulties to pass the filters of editors and peer-reviewers when the authors want to publish their report.

1. Goldberg D, Bridges K, Duncan-Jones P, Grayson D. Detecting anxiety and depressionin general medical settings. Br Med J 1988; 297:897-9.
2. Montón C, Pérez-Echevarría MJ, Campos R, et al. Escalas de ansiedad y depresión de Goldberg: una guía de entrevista eficaz para la detección del malestar psíquico. Aten Primaria 1993; 12: 345-9.
3. Tizón García JL, Buitrago Ramírez F, Ciurana Misol R, Chocrón Bentata L, Fernández Alonso C, García Campayo J, Montón Franco C, Redondo Granado MJ. Prevención de los trastornos de salud mental desde la atención primaria. Aten Primaria 2003;32(Supl 2):77-101.
4. Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;(1):CD001848.
5. Kapczinski F, Lima MS, Souza JS, Schmitt R. Antidepressants for generalized anxiety disorder. Cochrane Database Syst Rev. 2003;(2):CD003592.
6. Depping A, Komossa K, Kissling W, Leucht S. Second-generation antipsychotics for anxiety disorders. Cochrane Database Syst Rev. 2010;(12):CD008120.

in support of KT training

David Phipps — 2012-01-25T10:16:56Z

Having recently presented at a knowledge brokers forum in the UK there is international interest in capacity building for knowledge brokering, more than we usually do through individual peer sessions and one off workshops. As valuable as these are for supporting and sustaining knowledge brokering there is a need for accredited knowledge brokering training. 30 years into technology transfer that industry has established a series of accredited training courses for tech transfer. We need the same degree of rigour in training for knowledge brokering. The KTPC session described in the previous comment by Melanie Barwick has been accredited by Univ. Toronto. We need more KTPC across Canada

CPD for KT in Canada

Melanie Barwick — 2012-01-06T09:54:19Z

Interesting to learn how KT Canada is working to expand KT training in Canada. Similar efforts have been undertaken coast to coast since 2004, in KT training for health scientists through the Scientist Knowledge Translation Training course http://tinyurl.com/3uaqob7 (966 people researchers trained to incorporate KT practices into their programs of research) and more recently, the Knowledge Translation Professional Certificate - targeted to KT practitioners http://tinyurl.com/7m7hlux. There is great demand for supports in this area, and this work is very important for building KT capacity.

Clear guidance for researchers is to be welcomed

Philip Preshaw — 2011-08-17T14:15:15Z

I read the editorial by Eccles et al, "Requirements for ethics committee review for studies submitted to Implementation Science", with great interest.

As the Chair of an NHS Research Ethics Committee in the UK, I receive a steady stream of requests for 'retrospective approval' by researchers who, upon submitting their completed research to a journal, suddenly find that before the journal will consider their paper, they are required to either have ethical approval in place, or to obtain a letter from an ethics committee saying that ethical approval would not have been needed. Clearly, this is a very unsatisfactory situation, and can arise for all sorts of reasons. Most usually, researchers feel that their research would not have required ethical approval in the first place, for example, they might consider their project to have been an audit, or a service evaluation. However, when it comes to publication, then suddenly, most authors seem to prefer that their work is regarded as research!

I am also a researcher, so I am familiar with both sides of the system. I also feel that sense of mild dread when starting the process of obtaining all the permissions and approvals necessary to commence a research project. Filling in ethics application forms can be a daunting and laborious process, and the work involved can sometimes seem out of kilter with the ethical issues posed by a particular research project. Having read the comments in this editorial about the hope that ethics committees would have an expedited process for reviewing low risk studies, it may interest readers to learn that in the UK, a system of "Proportionate Review" is currently being piloted by the National Research Ethics Service (NRES). This system is targeted at studies which pose no material ethical issues (e.g. low risk questionnaire studies). These studies are not reviewed by the full ethics committee, but are reviewed by a Proportionate Review (PR) Committee comprised of 3 members of the main ethics committee, usually virtually (i.e. by email), with any questions that are raised by the PR committee being forwarded to the researchers who can then give a quick response by email so that a decision can be made very rapidly. The decisions are made within 14 days of receipt of the application from the researchers.

The editorial by Eccles et al gives very clear guidance to researchers about the requirements for ethics committee approval for those studies that need it, and provides a framework for researchers to adhere to as they plan their research projects. I also echo the expectation that ethics committees make balanced and objective decisions, and support the implementation of expedited processes for low risk studies to reduce the burden on both researchers and ethics committees.

Funding for this project

Elizabeth Staton — 2011-08-17T14:14:42Z

This project was funded by the Agency for Healthcare Research and Quality: AHRQ - 5 R18 HS017886-03 PI: PACE, WILSON

Communities of Practice: Development and Prospects in CLAHRC-NDL

Justine Schneider — 2011-07-07T10:06:23Z

Roman Kislov, Gill Harvey and Kieran Walshe (6:64) draw attention to the fruitful application of the concept of communities of practice in Collaborations for Leadership in Applied Health Research and Care (CLAHRCs).

In the CLAHRC spanning Nottinghamshire, Lincolnshire and Derbyshire (CLAHRC-NDL), communities of practice were embraced as the theoretical framework for our engagement activities from the outset. Setting ourselves the objective of self-sustaining communities of practice linking service users, applied health researchers and professionals within the five-year lifespan of the CLAHRC, we have utilised both analytical and instrumental approaches to communities of practice.

As a small team (~4 wte) of professionals with the explicit purpose of developing communities of practice, we perform a range of roles designed to span academic-clinical boundaries, service user-research boundaries and others. We set about promoting the four characteristic activities identified by Linda Li and others in their systematic review (2009): social interaction among members, knowledge sharing, knowledge creation, and identity building.

To this end, the fact that, in its early years, the CLAHRC had little to offer in the way of hard research results enabled us to run events where knowledge exchange was genuinely reciprocal. At these CLAHRC-NDL 'development opportunities', communities of practice have been helped to form, storm and norm while we explored what clinicans need to know about researchers, what commissioners do, and how to network. We now have about 700 Associates registered, each linked to one or more of our 16 implementation research projects, and we aspire to manage these relationships more proactively as the CLAHRC matures.

A substantial number of our Associates ¿ stakeholders of all descriptions, are actively involved in knowledge production through collaboration in implementation research. Others are more detached observers, and some are critics of the whole process. We have sought to engage particularly with health care commissioners ¿ whom we see as our future funders, and with the third sector - with its potential to increase the scope of communities of practice and its growing significance in health care delivery.

Community of practice theory recognises that all of these activities ¿ the outreach, the communications, the engendering of communities and their maintenance, require vision, leadership, time and resources. Paradoxically, however, the work described is by its nature self-effacing; as communities of practice grow in size the part played by facilitators can become less obvious, if no less important. Unless this contribution is formally acknowledged and supported, for example by embedding it in the essential functions of the CLAHRC, the potential and promise of communities of practice in CLAHRCs will not be realised.

More details about the audit and feedback system, please.

Sylvia Hysong — 2011-04-27T10:02:17Z

The authors present an interesting protocol; and although the intervention of interest is the decision support system, not the audit
and feedback (since it is being used as a control), research shows that how feedback is delivered greatly affects how effective it is (see for example, Hysong, 2009; Jamtvedt et al., 2006, Kluger & DeNisi, 1996). What data will be presented to participants? Verbally or in writing? How often? Will suggestions for improvement be provided? Details like this have an impact on how effective the feedback is, and are needed in the protocol in order to determine how strong of a control "intervention" the authors have designed (see Michie et al. 2009).

References:

Hysong, S. J. (2009). Meta-Analysis: Audit & Feedback Features Impact
Effectiveness on Care Quality. Medical Care, 47, 356-363.

Jamtvedt, G., Young, J. M., Kristoffersen, D. T., O'Brien, M. A., &
Oxman, A. D. (2006). Audit and feedback: effects on professional
practice and health care outcomes. Cochrane Database Syst Rev.,
CD000259.

Kluger, A. N. & DeNisi, A. (1996). The effects of feedback interventions
on performance: A historical review, a meta-analysis, and a preliminary
feedback intervention theory. Psychological Bulletin, 119, 254-284.

Susan Michie, Dean Fixsen, Jeremy M Grimshaw, Martin P Eccles (2009).
Specifying and reporting complex behaviour change interventions: the
need for a scientific method.
Implementation Science 2009, 4:40 (16 July 2009)

Disseminating research findings: What should universities do?

Christian Dagenais — 2011-03-30T09:38:17Z

The question of what role researchers should play in the dissemination of research findings is crucial to promoting the use of such knowledge. However, there is relatively little data available on the manner in which researchers are or should be involved in these activities, and thus on how to address ¿deficiencies in the dissemination and transfer of research-based knowledge to routine clinical practice.¿ As such, this scoping review makes a significant contribution to the knowledge transfer (KT) field. Wilson and his colleagues conclude by suggesting that research funding agencies should make any grant conditional, in part, on applicants adopting a theoretically-informed approach to their KT activities.
Exerting pressure on researchers is of course likely to improve the quality of their involvement in KT. However, until universities explicitly recognize the value of KT activities and provide adequate support for their implementation, researcher involvement will remain limited. There is a consensus in the literature on KT that one of the most significant obstacles to knowledge transfer by researchers exists at the level of the university institutions themselves, which fail to recognize the relevance of KT activities and do not explicitly include them among the criteria for tenure and promotion. Instead, the existing organizational structure of academia, with its tenure and promotion policies, resources and practices, is one that privileges members who meet disciplinary standards while disadvantaging those interested in knowledge transfer.
In order to identify initiatives on the part of university institutions that explicitly acknowledge the value of KT activities and encourage researcher involvement, my team and I conducted a survey of the KT policies and practices of 21 academic institutions in four countries: Australia, Canada, the US and the UK. Our examination was based on documentation and narratives available on university web pages. Accordingly, I make no claims to presenting an argument based on practical research.
Despite the rich and omnipresent rhetoric around knowledge transfer, there is still little movement beyond ¿lip service¿ to the real action of re-orienting core university activities around knowledge transfer in various forms. Our overview of university policies on faculty career advancement shows that the recognition of achievement in knowledge transfer is slowly but gradually becoming a legitimate option for academic promotion, alongside the traditional triad of excellence in teaching, research and service to the academic community. Nonetheless, despite attempts to qualify faculty excellence in knowledge transfer, institutions have yet to quantify this criterion, with the notable exception of the University of Melbourne (Australia). In fact, this institution is the only one of those we surveyed to have quantified the criterion of knowledge transfer in relationship to the three other parameters. According to policy guidelines, knowledge transfer, along with community service, may account for as much as half of the evaluated effort distribution. Specifically, the weight given to knowledge transfer and service may, in aggregate, range from 20% to 50%, as compared to the aggregate maximum of 80% assigned to traditional scholarly outputs such as teaching and research.
It seems that openings are being created to integrate knowledge transfer activities into the traditional triad of assessment parameters. However, given the virtual absence of schemes to quantify the relationship between knowledge transfer and the traditional triad of excellence in teaching, research and service to the academic community, the application of this criterion remains highly problematic.

Researchers shouldn't be the ones to have to translate knowledge

Lynne Garner — 2010-08-17T12:56:46Z

As a US funder of medical research, and one that focuses on getting the benefit of research put into action, I agree with much of what Wilson, et al describe in their discussion of the survey’s findings. Funders need to be clearer about their knowledge translation expectations and create funding opportunities that mirror them. However, the overall implication that researchers must be in the forefront of the knowledge translation endeavor is misguided. University reward structures are focused on faculty members getting new grants and on reporting “high impact” findings, both of which impede translation activities. Funders - working with public health agencies, health care businesses and researchers - need to develop new translation pathways to increase the impact of their investment and not rely primarily on researchers and universities to do so.

Importance of reflective capacity

Donald Nease — 2010-08-17T12:55:55Z

Excellent in depth work examining the challenges of delivering quality care for depression in primary care. The findings related to reflexive monitoring parallel our own and others' work in the US that has sought to increase reflective capacity to implement and sustain change in care processes.(1) It is worth noting the similarities despite the clear differences in how medical care is funded in our respective countries.

The suggestion regarding Balint groups as a means to introduce reflexive monitoring is an interesting one. Within the American Balint Society we are just beginning to examine this potential application, having piloted it once at a Society of Teachers of Family Medicine workshop. We too are intrigued by the possibilities for applying it within our own context of Patient Centered Medical Homes.

1. Nease et al. Inducing sustainable improvement in depression care in primary care practices. Joint Commission journal on quality and patient safety / Joint Commission Resources (2008) vol. 34 (5) pp. 247-55