- Email: [email protected]
Translating research into practice—a three-paper series
COMMENTARY
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Rights were not granted to include this image in electronic media. Please refer to the printed journal.
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http://www.assemblee-nat.fr/12/cr-cafc/02-03/c0203058.asp (accessed Oct 7, 2003). BBC News. Italy heat killed ‘4,000’. Sept 11, 2003: http://news. bbc.co.uk/1/hi/world/europe/3099878.stm (accessed Oct 7, 2003). E Klinenberg. Heat wave: a social autopsy of disaster in Chicago. Chicago: Chicago University Press, 2002. Weisskopf MG, Anderson HA, Foldy S, et al. Heat wave morbidity and mortality, Milwaukee, Wis, 1999 vs 1995: an improved response? Am J Public Health 2002; 92: 830–33. Naughton MP, Henderson A, Mirabelli MC, et al. Heat-related mortality during a 1999 heat wave in Chicago. Am J Prev Med 2002; 22: 221–27.
PA Photos
Translating research into practice—a three-paper series
Paris plage Beach on River Seine—too hot in August, 2003.
a new public-health law will be debated in Parliament in the coming months. The Government presents these as first steps in an extensive programme of reforms. The discussion for the moment focuses mainly on the need for more financial and human resources to improve geriatric care, and for a warning system and emergency response plan to cope with extreme heat. Welcome as these reforms are, they should not distract attention from the need to design preventive measures targeted specifically at heatwaves. Such programmes are effective at reducing heat-related mortality.7,8 These programmes usually involve predictive models tailored to local conditions, extensive broadcasting of preventive information, and the identification of people at risk and of airconditioned places where they can cool off, as well as the allocation of social and medical resources. The saddest lesson from this crisis may be that knowledge about heatwaves is not easily disseminated. Information about emerging infectious diseases tends to spread quickly, whereas heatwaves seem to induce bewilderment and inadequate reactions. Often medical and public attention focuses on intervention rather than prevention. However, a heatwave is different in nature from a very hot summer and requires a different approach. Doctors will know how to rehydrate patients but may not think about systematically providing practical tips to prevent heatstrokes. This is a lesson that up to now seems to be relearned with each new crisis. One can only hope that the magnitude of this summer’s death toll will ensure that such lessons are not forgotten or ignored. Delphine Grynszpan The Lancet, London NW1 7BY, UK 1
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Institut de veille sanitaire. Impact sanitaire de la vague de chaleur en France survenue en août 2003. Rapport d'étape. Saint Maurice: InVS, Aug 29, 2003: http://www.invs.sante.fr/publications/default. htm (accessed Oct 7, 2003). D Hémon, E Jougla. Surmortalité liée à la canicule d’août 2003— rapport d’étape. Paris: INSERM, Ministère de la Santé, de la Famille et des Personnes Handicapées, Sept 25, 2003: http://www. sante.gouv.fr/htm/actu/surmort_canicule/sommaire.htm (accessed Oct 7, 2003). F Lalande, S Legrain, AJ Vallleron, D Meyniel, M Fourcade. Mission d’expertise et d’évaluation du système de santé pendant la canicule 2003. Paris: Ministère de la Santé, de la Famille et des Personnes Handicapées, Sept 8, 2003: http://www.sante.gouv.fr/ htm/actu/canicule/sommaire.htm (accessed Oct 7, 2003). Commission des affaires culturelles, familiales et socials de l’Assemblée nationale. Compte rendu no 58, Sept 24, 2003:
1170
See page 1225 Research shapes innovations for doctors and patients. Yet transfer of new knowledge into practice is less selfevident than expected. A series of three papers starting in The Lancet today explores this gap between research and clinical practice, from three different angles: promotion of quality of care, clinical (primary) care, and health-care policy. Quality of care has developed into a research field in itself, providing sophisticated methods to change clinical practice, and the first paper in the series (by Richard Grol and Jeremy Grimshaw) comes from this background. Their paper explores hand hygiene—an example that goes back more than a century, to Semmelweiss.1 Most clinicians must have come across this classic story, and unawareness of the implications of hand hygiene for clinical care is unlikely. It is a sobering thought that even this knowledge does not dictate physicians’ behaviour, unless supervised by planned actions. The concept of evidence-based medicine emphasises the application of best available research for the care of patients. The devil of evidence-based medicine is in the transition between research and practice—from study to clinical problem, from study participant to patient, and back. This transition requires a dialogue between practitioners and researchers and evidence-based medicine has implications for clinical research as much as for clinical practice. Understanding where research is missing is critically important and this lack is often the case in general practice. The second paper of the series addresses how research can better serve the needs of primary care. Maynard2 showed that what is best for the individual patient is not necessarily best from a public-health perspective. The third paper in the series highlights problems in health-care policy, with three case studies from the UK, the USA, and the Netherlands. Evidencebased health-care policy is in its early stages and it still has to be practised in a non-evidence-based health-care system. Although it is not possible to define the best model of health care, obvious progress is being made. As the series highlights, the translation of research into practice is very much an ongoing process. I acted as an adviser to The Lancet on this series.
Chris van Weel Department of General Practice, University Medical Centre Nijmegen, 6500 HB Nijmegen, Netherlands (e-mail: [email protected]) 1 2
Watton J, Barondess J, Lock S, eds. The Oxford medical companion. Oxford: Oxford University Press, 1994. Maynard A. Evidence-based medicine: an incomplete method for informing treatment choices. Lancet 1997; 349: 126–28.
THE LANCET • Vol 362 • October 11, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.
5 6 7
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
8
http://www.assemblee-nat.fr/12/cr-cafc/02-03/c0203058.asp (accessed Oct 7, 2003). BBC News. Italy heat killed ‘4,000’. Sept 11, 2003: http://news. bbc.co.uk/1/hi/world/europe/3099878.stm (accessed Oct 7, 2003). E Klinenberg. Heat wave: a social autopsy of disaster in Chicago. Chicago: Chicago University Press, 2002. Weisskopf MG, Anderson HA, Foldy S, et al. Heat wave morbidity and mortality, Milwaukee, Wis, 1999 vs 1995: an improved response? Am J Public Health 2002; 92: 830–33. Naughton MP, Henderson A, Mirabelli MC, et al. Heat-related mortality during a 1999 heat wave in Chicago. Am J Prev Med 2002; 22: 221–27.
PA Photos
Translating research into practice—a three-paper series
Paris plage Beach on River Seine—too hot in August, 2003.
a new public-health law will be debated in Parliament in the coming months. The Government presents these as first steps in an extensive programme of reforms. The discussion for the moment focuses mainly on the need for more financial and human resources to improve geriatric care, and for a warning system and emergency response plan to cope with extreme heat. Welcome as these reforms are, they should not distract attention from the need to design preventive measures targeted specifically at heatwaves. Such programmes are effective at reducing heat-related mortality.7,8 These programmes usually involve predictive models tailored to local conditions, extensive broadcasting of preventive information, and the identification of people at risk and of airconditioned places where they can cool off, as well as the allocation of social and medical resources. The saddest lesson from this crisis may be that knowledge about heatwaves is not easily disseminated. Information about emerging infectious diseases tends to spread quickly, whereas heatwaves seem to induce bewilderment and inadequate reactions. Often medical and public attention focuses on intervention rather than prevention. However, a heatwave is different in nature from a very hot summer and requires a different approach. Doctors will know how to rehydrate patients but may not think about systematically providing practical tips to prevent heatstrokes. This is a lesson that up to now seems to be relearned with each new crisis. One can only hope that the magnitude of this summer’s death toll will ensure that such lessons are not forgotten or ignored. Delphine Grynszpan The Lancet, London NW1 7BY, UK 1
2
3
4
Institut de veille sanitaire. Impact sanitaire de la vague de chaleur en France survenue en août 2003. Rapport d'étape. Saint Maurice: InVS, Aug 29, 2003: http://www.invs.sante.fr/publications/default. htm (accessed Oct 7, 2003). D Hémon, E Jougla. Surmortalité liée à la canicule d’août 2003— rapport d’étape. Paris: INSERM, Ministère de la Santé, de la Famille et des Personnes Handicapées, Sept 25, 2003: http://www. sante.gouv.fr/htm/actu/surmort_canicule/sommaire.htm (accessed Oct 7, 2003). F Lalande, S Legrain, AJ Vallleron, D Meyniel, M Fourcade. Mission d’expertise et d’évaluation du système de santé pendant la canicule 2003. Paris: Ministère de la Santé, de la Famille et des Personnes Handicapées, Sept 8, 2003: http://www.sante.gouv.fr/ htm/actu/canicule/sommaire.htm (accessed Oct 7, 2003). Commission des affaires culturelles, familiales et socials de l’Assemblée nationale. Compte rendu no 58, Sept 24, 2003:
1170
See page 1225 Research shapes innovations for doctors and patients. Yet transfer of new knowledge into practice is less selfevident than expected. A series of three papers starting in The Lancet today explores this gap between research and clinical practice, from three different angles: promotion of quality of care, clinical (primary) care, and health-care policy. Quality of care has developed into a research field in itself, providing sophisticated methods to change clinical practice, and the first paper in the series (by Richard Grol and Jeremy Grimshaw) comes from this background. Their paper explores hand hygiene—an example that goes back more than a century, to Semmelweiss.1 Most clinicians must have come across this classic story, and unawareness of the implications of hand hygiene for clinical care is unlikely. It is a sobering thought that even this knowledge does not dictate physicians’ behaviour, unless supervised by planned actions. The concept of evidence-based medicine emphasises the application of best available research for the care of patients. The devil of evidence-based medicine is in the transition between research and practice—from study to clinical problem, from study participant to patient, and back. This transition requires a dialogue between practitioners and researchers and evidence-based medicine has implications for clinical research as much as for clinical practice. Understanding where research is missing is critically important and this lack is often the case in general practice. The second paper of the series addresses how research can better serve the needs of primary care. Maynard2 showed that what is best for the individual patient is not necessarily best from a public-health perspective. The third paper in the series highlights problems in health-care policy, with three case studies from the UK, the USA, and the Netherlands. Evidencebased health-care policy is in its early stages and it still has to be practised in a non-evidence-based health-care system. Although it is not possible to define the best model of health care, obvious progress is being made. As the series highlights, the translation of research into practice is very much an ongoing process. I acted as an adviser to The Lancet on this series.
Chris van Weel Department of General Practice, University Medical Centre Nijmegen, 6500 HB Nijmegen, Netherlands (e-mail: [email protected]) 1 2
Watton J, Barondess J, Lock S, eds. The Oxford medical companion. Oxford: Oxford University Press, 1994. Maynard A. Evidence-based medicine: an incomplete method for informing treatment choices. Lancet 1997; 349: 126–28.
THE LANCET • Vol 362 • October 11, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.