An integrated knowledge translation strategy is a key factor in fostering the implementation of practice changes. Building on a 15-year history of projects that include close collaboration between researchers and decision-makers in the Saguenay region of Quebec (Canada), the authors identify several key elements that resulted in practice changes in primary care and improved outcomes for patients with multimorbidity.
Health system researchers and decision-makers typically deal with very different work contexts. As a result, they often have different perspectives on how to most effectively use research findings to improve health services despite the use of rigorous processes to ensure that recommendations are evidence-based (WHO 2004). Developing research projects and generating evidence requires significant effort as well as considerable human and financial resources. Therefore, finding ways to ensure that relevant evidence is used by decision-makers is important. However, decision-makers have to consider a range of factors when creating policies aimed at improving health. These include the following:
- Ensuring the feasibility of programs while balancing economic, political and technical aspects.
- Questioning the sustainability of tested innovations against the context in which they will be implemented.
- Attempting to satisfy competing demands and recommendations for healthcare improvement from diverse stakeholder groups.
We know that decision-makers pay more attention to evidence when they already have invested funds and time to develop it (Martens and Roos 2005). They often turn to internal research support services or to researchers with whom they already have a good working relationship (Wilson et al. 2015). They may also turn to special advisers, experts, opinion formers and even to lobbyists or pressure groups (Greenhalgh and Russell 2006).
Knowledge of effective researcher–decision-maker collaborations is important for both sides. As an example of a long-term collaboration, we will describe the engagement of decision-makers and researchers of the Saguenay-Lac-Saint-Jean (SLSJ) region of Quebec (Canada) in introducing integrated chronic disease prevention and management (CDPM) services to the region.
The Context of the Story
In the SLSJ region, CDPM services were implemented in 2001 under the leadership of the regional health authority. These CDPM services, including integrated and evidence-based interventions (Agence de la santé et de services sociaux du Saguenay-Lac-Saint-Jean 2006; CSSS de Chicoutimi 2004), were grouped into a program called Programme régional de la Trajectoire de services de réadaptation intégrés pour les maladies chroniques (referred to as the Trajectoire in the following text). The Trajectoire addressed a number of different chronic diseases (CD) in silo: cardiovascular disease (CVD), heart failure, chronic obstructive pulmonary disease (COPD), asthma and diabetes. The Trajectoire's objectives were threefold: (1) to reduce modifiable risk factors; (2) to support patient self-efficacy and self-management; and (3) to improve patient functional autonomy and biopsychological and social balance (CSSS de Chicoutimi 2004). Services were delivered by various professionals, including nurses, nutritionists, pharmacists, psychologists, and medical specialists. (CSSS de Chicoutimi 2004). The original intent was for patients to be referred to the program by their healthcare providers; however, the majority of referrals followed an acute episode of care or hospitalization. The Trajectoire program is still ongoing and has not been evaluated since its implementation.
In 2007, the Université de Sherbrooke created the Research Chair on Chronic Diseases in Primary Care in collaboration with key decision-makers from the healthcare organizations of the SLSJ region (Guyatt et al. 2013). The Chair aimed to develop and disseminate knowledge to help primary healthcare (PHC) professionals of all disciplines interact efficiently with patients with CD, to train researchers in applied studies on PHC services, to support the alliance between researchers and decision-makers and to promote knowledge translation. The work of the Chair was also supported by a research award (Research Chair on Health Services and Policy Research) from the Canadian Institutes of Health Research (CIHR) and the Canadian Health Services Research Foundation from 2009 to 2014.
In 2010, a collaboration between researchers associated with the Chair and local decision-makers resulted in a regional CIHR-funded dissemination meeting, bringing together more than one hundred stakeholders (Chouinard et al. 2011). Patients from the Trajectoire were involved in this process. The goal of the meeting was to appraise existing regional CDPM services and to suggest potential improvements. Several areas for health system improvement were identified, among which were (1) coordination of patient navigation in the healthcare system; (2) integration of CDPM services into primary care practices; (3) better communication and collaboration between PHC professionals and family physicians to maintain patient motivation; (4) dissemination of clinical guidelines; (5) focus on multimorbidity; and (6) linking CDPM services to community resources.
The 2010 meeting motivated researchers and decision-makers, in collaboration with healthcare professionals, to apply to the Fond de Recherche du Québec – Santé (FRQ-S) in response to a request for proposals targeting innovations in chronic disease management in primary care.
In December 2010, the Programme de réadaptation intégré en première ligne pour les maladies chroniques (PR1MaC) received funding from the FRQ-S. The clinical components and the implementation of the program consisted of many steps articulated in a logic model. The first step consisted of a needs assessment conducted with primary care professionals. The second step consisted of adapting and implementing CDPM services into the participating practices. The third step was the implementation of a support mechanism by the research team, along with a follow-up with the participating clinics, to ensure a seamless integration.
In many aspects, PR1MaC could be considered as a pilot. The effectiveness of the intervention was measured using mixed pragmatic methods. The complete protocol is described elsewhere (Fortin et al. 2013). After three months, the intervention showed benefits in improving various patient self-reported outcomes (self-management, fruit and vegetable consumption, physical activity and quality of life). Improvements continued even after one year (Fortin et al 2016).
The PR1MaC study also demonstrated that it was possible to implement an intervention integrating CDPM services for several chronic conditions in primary care settings. The recommendations from the 2010 meeting had been successfully acted upon. The development of the proposal and the implementation of the intervention created synergistic interactions and successful relationships among all stakeholders, particularly decision-makers and researchers who played a central role. Their commitment went beyond the usual boundaries. Without this successful relationship, the story could have ended there with an effective pilot intervention but no scaling up and long-term implementation.
The Next Step of the Story
In 2015, the Quebec Ministry of Health and Social Services invited all regional health authorities to apply for funding for the implementation of CDPM services in primary care practices. Strengthened by the successful relationship developed previously, the team of decision-makers and researchers submitted a proposal to implement, on a permanent basis, CDPM services in the 11 Family Medicine Groups (FMGs) of the SLSJ region. The Démarche Intégrée en Maladies Chroniques de la région 02 (DIMAC02) was born. Much of this initiative built on the PR1MaC experience and results with some inspiration from other clinical and research projects that also have generated evidence in the SLSJ region (Chouinard et al. 2013). There was also an opportunity at this time for the FMGs to welcome professionals other than primary care physicians and nurses into their organizations (nutritionists, kinesiologists, pharmacists, etc.). The resulting submission was an operationalization of the Chronic Care Model, along with training for health professionals in motivational interviewing, self-management support, case management, interprofessional collaboration and patient-centred approaches, with a special focus on patients with multimorbidity who are so prevalent in primary care (Barnett et al. 2012; Fortin et al 2005, 2012). To strengthen the proposal, DIMAC02 included an innovative evaluation framework developed as part of a CIHR-funded team grant from the Community-Based Primary Health Care Signature Initiative: "Patient Centered Innovation for Persons with Multimorbidity" (PACE in MM) (Angold et al. 1999; Cornell et al. 2007). PACE in MM involves researchers and decision-makers from six Canadian provinces but is mostly a Quebec–Ontario research program. The main goal of PACE in MM is to change primary healthcare and community-based chronic disease prevention and management programs in order to move from a single-disease focus to a multiple disease focus, to centre not only on disease but on the patient and to realign the healthcare system from separate silos into coordinated collaborations in care. In this respect, there was a good synergy with the DIMAC02.
DIMAC02 was one of the three initiatives funded by the Quebec Ministry of Health and Social Services and as such acknowledged the good relationship between decision-makers and researchers in the SLSJ region. The implementation of DIMAC02 started gradually in June 2015 and included the training of 70 non-physician primary care providers. The project was closely monitored by an executive committee, including managers of each participating FMG. The evaluation process is ongoing since the regional ethics board approval.
With this story of collaboration between researchers and decision-makers in the SLSJ region, we describe in this section the key elements that helped us (researchers and decision-makers) to overcome the challenges of participating in the development and use of evidence while working in a real-life environment.
Trust takes years to build, and a moment to destroy
Honesty and loyalty are vital ingredients in all relationships, including the one between researchers and decision-makers. Such a relationship takes time and commitment to build and needs to be preserved from any harm through misconduct or miscommunication.
Involving all stakeholders at early stages
Partners in general and decision-makers in particular are more devoted to projects and ideas they own or with/in which they are integrally involved. When the partners are invited to participate in a study, they want to know exactly what their roles are and what their contribution looks like in terms of time and effort. They also want to create innovations that are well-aligned with their policies. Sometimes, partners feel intimidated by the strange world of research. Similarly, researchers are often unaware of the equally strange (to them) world of healthcare policy (Lomas 1997).
Relationships create opportunities
Sustainable and successful relationships between researchers and decision-makers multiply the potential for collaboration. Most of the funding agencies highly value the existing collaborations that have led to results.
Keep the partner close to the research
Researchers need to make an effort to ensure that the research becomes part of the decision-makers' world. The worst scenario is to involve decision-makers only when their support is needed, such as at the funding stage and later when the research is over. They need to be involved at every step to allow evidence to be integrated seamlessly and to prepare for scale-up of successful innovations. The best scenario is when a sustainable relationship that goes beyond a single project is created.
Get to know the partner's entourage
The healthcare system imposes frequent changes in governmental and non-governmental positions. The best way to ensure continuity of the work and to bridge a potential gap between the clinical world, the research world and the governing world is to invest in communication within and between different levels and persons. People change and new relationships have to be built!
Researchers need to adapt the agenda, timelines and deadlines to the partners and expect the same from them
Researchers and decision-makers look at the same things from different angles. They allocate time and resources according to their own point of view. If they have to adapt to other partners, at least they should be aware of such different realities.
Rigor and flexibility are not contradictory concepts
When researchers are in charge of the clinical application of the evidence they generated, they may, naturally, act as gatekeepers because they are those who know in what context and conditions an intervention led to a given outcome. This rigor is important to make evidence-based changes. However, the real world of clinical practice and decision-making may require some adjustment. Flexibility has to be introduced early in the research process to allow for a later implementation in a real-world environment. Pragmatic interventions offer an alternative that bridges rigor and flexibility.
Researchers have to think, talk and write like decision-makers to communicate effectively with decision-makers
To succeed in knowledge translation, researchers have to adapt the message to each target audience. Lengthy reports are unlikely to be read unless they are preceded by a short executive summary that highlights the key findings and their meaning. The message from the researchers should take into account the world of the decision-makers and the policies in place or to be implemented and be coherent with them in order to have an impact (Grimshaw et al. 2012).
After generating evidence, and working on its translation, researchers may be disappointed if their recommendations do not lead to real and rapid changes in the system. Researchers should live with high ambitions and moderate expectations. Change involves usually more effort than generating evidence. Researchers have to learn to be patient when engaging in the translation of evidence into action. They have to consider this as a learning process that will affect their future research and inspire new research ideas and new challenges.
Considering the successes as well as the failures
Decision-makers and researchers build on previous successes. Researchers need to learn how to capitalize on each success and think of it as a pilot experience for the next bigger one. However, there is usually much to learn from less successful experiences, and all partners should openly try to learn from them by identifying factors that led to undesired results as well as desired ones.
Agreements are more efficient when they are clear, understood and followed by all partners
Once all partners invest the necessary effort and time to reach agreements, mechanisms should be set to ensure that decisions, tasks and timelines are equally understood by all partners. If necessary, written conclusions could be used to guarantee the engagement of everyone over time.
This paper describes a retrospective overview of a local longitudinal experience of collaboration over 15 years. This case study may not reflect all facets or all the ups and downs of interactions between the moving planets of decision-makers and researchers. Little is known about the real place of research in decision-making. Consequently, every experience could represent a significant addition to fill the gaps in knowledge on the effectiveness of the process of translation of research evidence into decisions and on-the-ground change. This paper is co-authored by researchers and decision-makers who have succeeded in a building a relationship of personal trust. Among the authors, two (MC and EL) are alumni of the EXTRA: Executive Training Program for Research Application from the Canadian Foundation for Healthcare Improvement (see: https://www.cfhi-fcass.ca/whatwedo/extra). One can assume that the ideas in this paper reflect different points of view that make this paper relevant for researchers and decision-makers who are looking for an effective process to make research relevant for decision-making.
The Tango Metaphor
In the tango of researchers and decision-makers, there are quick changes in direction indicating flexibility of the process within a rigorous structure. Each partner scans the 360-degree horizon with head movements bringing observation to the process. Most importantly, the partners alternate being the lead to create a harmonious flow of exchanges of information, interpretations, feedback and continuous adjustments. Good tango dancers are skilled communicators. Researchers and decision-makers who learn how to tango can really make a difference.
About the Author(s)
Martin Fortin, MD, MSc, CMFC, is professor in the Family Medicine Department at the Université de Sherbrooke, Sherbrooke, QC. He also holds an appointment at the Centre intégré universitaire de santé et de services sociaux du Saguenay–Lac-Saint-Jean, QC.
Martine Couture, BSc Inf, MAP, is présidente-directrice générale of the Centre intégré universitaire de santé et de services sociaux du Saguenay–Lac-Saint-Jean, QC.
Tarek Bouhali, MSc, is adjunct professor in the Family Medicine Department at the Université de Sherbrooke, Sherbrooke, QC. He also holds an appointment at the Centre intégré universitaire de santé et de services sociaux du Saguenay–Lac-Saint-Jean, QC.
Esther Leclerc, BSc inf, MSc, MEd, is directeur général adjoint à la retraite – Affaires cliniques, CHUM, QC.
Moira Stewart, PhD, is distinguished university professor in the Centre for Studies in Family Medicine, Department of Family Medicine, and Department of Epidemiology and Biostatistics in the Schulich School of Medicine and Dentistry at Western University in London, ON.
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