Advancing knowledge translation in primary care

Primary care: a unique practice setting

Compared with other health care settings, primary care is unique in the breadth of its scope, being concerned with a range of patient health issues and human needs. Primary care providers respond to physical and emotional health concerns of diverse populations, providing and coordinating care across the lifespan. Many patients present with multiple health concerns and other psychosocial, family, or cultural issues requiring attention.¹³

This broad scope of practice contrasts with what some see as the highly specialized nature of medical and intervention research, driven by a focus on single, tightly defined diseases or clinical situations.¹⁴ Clinical trials, for instance, have strict eligibility criteria and typically exclude people with comorbid conditions, which can limit the generalizability of the findings to primary care patients.¹⁵ Similarly, clinical practice guidelines and educational programs are often developed with single diseases in mind and sometimes overlook socioeconomic and cultural differences in populations.^16–18 This disconnect forces primary care providers to assess the applicability of research findings and interventions to the “real-world” patients in their own practice settings, a challenging process of “shaping the square peg of the evidence to fit the round hole of the patient’s life.”¹⁹ Unsurprisingly, the success of researchers in trying to close the gap between what we know and what is done in primary care has also been limited.²⁰ For KT practice to be more effective, knowledge inquiry needs to be more responsive to the knowledge needs of family physicians and other primary care providers. Steps in this direction include the growing interest in pragmatic clinical trials, which seek to assess the benefits of different care options in routine clinical settings,²¹ and recent research on multimorbidity.^13,22 Continued efforts to increase the responsiveness of PHC research should allow providers to more easily achieve care that is both patient centred and evidence based.

Importance of integrated KT

Despite the volume of research evidence available, relatively little is taken up and applied in clinical practice.²³ Family physicians in particular have been shown to be more cautious than other specialists in applying new research knowledge and more apprehensive of evidence produced in settings that differ from their own (eg, specialized clinical settings).^24,25 As researchers we can increase the relevance and uptake of our research findings by actively engaging family physicians and other partners throughout the entire research process to coproduce knowledge in their contexts. The CIHR describes this collaborative, action-oriented approach to research as integrated KT.²⁶ With integrated KT, researchers and providers share control of the research process and together identify problems, shape research objectives, decide on methodologies, collect and interpret data, and disseminate and apply findings.

While the benefits of participatory research approaches are recognized,²⁷ including increased validity of research and greater exchange and commitment between partners, in practice a variety of barriers (eg, competing demands, time or funding pressures) often hinder active collaborations.²⁸ At the Summer Institute we learned how primary care practice-based research networks (PBRNs) can help to overcome these barriers. Practice-based research networks bring researchers and primary care providers into collaborative learning communities to address the challenges faced in daily practice.²⁹ Although not developed as extensively as in other countries, PBRNs do exist in Canada³⁰ and are key sites for the production and translation of PHC research. Furthermore, when research activities within PBRNs actively engage patients and community members, such networks not only hasten the knowledge-to-action process but can also help to identify solutions that are acceptable and equitable within a wider audience.³¹

Communication and exchange

In primary care systems, family physicians are just one among many professional groups and other stakeholders who play a role in care delivery. During exchanges at the Summer Institute, participants noted that stakeholders often differed with respect to the value they placed on certain types of scientific evidence (eg, systematic reviews, randomized controlled trials, observational studies, qualitative research) the weight given to various types of information (eg, scientific, experiential, contextual, patient or peer opinions) when making decisions, and the knowledge sources (eg, scientific journals, lay magazines, practice guidelines, opinion leaders) they considered credible.

When engaged in KT it is thus important to be sensitive to these issues. As researchers, we can facilitate access to our research findings by using the specific communication channels that are trusted by our target users and we can help remove barriers that stakeholders face when attempting to access and use evidence (eg, time constraints, lack of research skills, insufficient resources or infrastructure). Researchers can further support the application of knowledge by engaging patients and embedding research within the relationships that providers develop across time with patients, such as through the development of patient-mediated KT interventions (eg, patient decision aids) tailored to patients’ clinical risk profiles.³² We must also recognize that even when scientific evidence seems solid and incontestable, some stakeholders might interpret and act on it differently. Indeed, researchers and primary care providers would mutually benefit from establishing forums where clinical practice can be reflected upon, knowledge can be exchanged, use of knowledge can be monitored, and concerns over findings can be voiced and resolved.³³ For instance, Baumbusch and colleagues used 3 approaches to promote exchanges between researchers and clinicians: they involved clinical leaders in the research project and its meetings; they created roles for doctoral students with clinical backgrounds to act as consultants who could meet individually or in small groups with clinicians and support KT activities in their practice settings; and they established face-to-face meetings between researchers and clinicians over breakfast where researchers shared emerging findings, received feedback, and, together with these clinicians, considered how to address issues of common concern.³³ Studies suggest that few primary care practices have such forums in place,^20,34 yet they might be critical to promoting shared understandings and actions affecting everyday practice.

Advancing KT research for primary care

Knowledge translation is an emerging and increasingly diverse field of science. It includes work to^35,36

• develop theory about how knowledge is best generated, shared, and used, and the various factors involved in this process;

• assess gaps in knowledge that affect health decision making and identify determinants and conditions of knowledge use;

• better understand how to accelerate moving evidence to action and the factors that make KT interventions in different contexts effective and sustainable; and

• measure the success and effects of KT interventions.

Put simply, KT research is about making the knowledge-to-action process more effective. Such research has already led to many insights, including the complex, nonlinear nature of the process, the limits of passive dissemination strategies, the importance of practice contexts and facilitating practice changes, and the challenge of scaling up innovations and sustaining change.^37–39 There remain many gaps in our knowledge of the KT process in primary care. Advances to KT research are thus needed to guide effective KT practice in this unique setting. Our discussions led us to identify 4 broad strategies for achieving this goal: supporting research, building capacity, developing infrastructure, and promoting the visibility of both PHC and KT research. These strategies have relevance for both primary care providers and researchers, although the ways in which each group engages with these strategies might occasionally be different (Table 1).^40–42 Often, however, joint actions will be needed to build the science of KT in primary care, such as support for research and the development of primary care PBRNs, linked electronic medical records, and forums for knowledge exchange and translation.