What Do We Know About Knowledge Translation in the Care of Older Adults? A Scoping Review

JAMDA 13 (2012) 210e219

JAMDA journal homepage: www.jamda.com

Review

What Do We Know About Knowledge Translation in the Care of Older Adults? A Scoping Review Anne-Marie Boström RN, PhD a, *, Susan E. Slaughter RN, PhD b, Dagmara Chojecki MLIS b, c, Carole A. Estabrooks RN, PhD b a

Karolinska Institutet, Huddinge, Sweden University of Alberta, Edmonton, Canada c Institute of Health Economics, Edmonton, Canada b

a b s t r a c t Keywords: Evidence-based practice quality of care geriatrics

Objectives: The recent emphasis on knowledge translation (KT) in health care is based on the premise that quality of care improves when research findings are translated into practice. This study aimed to identify the extent, nature, and settings of KT research pertaining to the care of older adults. Design and Methods: We searched Medline, CINAHL, The Cochrane Library, and EMBASE for systematic reviews related to KT using the terms knowledge translation, research use, evidence-based practice, clinical practice guidelines, or diffusion of innovations. Then we searched the systematic reviews to identify included articles related to older adults. We used quantitative content analysis to summarize the information. Results: Two of the 53 systematic reviews about KT focused on the care of older adults. One examined the impact of quality systems on care processes and outcomes for long term care residents. The other studied the effectiveness of active-mode learning programs on physician behavior. Sixty-one of the 1709 primary research articles (3.6%) pertained to the care of older adults. Thirty of these were conducted in long term care facilities, 26 in outpatient clinics, 2 in hospitals, and 3 in multiple settings. Most studies focused on KT interventions targeting professionals (eg, prescribing medications). Organizational interventions (eg, modifying roles) were few; financial and regulatory interventions were rare. Conclusion: We identified a gap in KT research pertaining to the care of older adults. KT intervention research focusing on organizational, financial, and regulatory areas is warranted. The connection between geriatrics and KT is fertile ground for future research. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.

The recent emphasis on knowledge translation (KT) is based on the premise that the quality of care and the health of the population improves when research findings are translated into practical

The postdoctoral fellowships of the first two authors were supported by the Canadian Institutes of Health Research, CapitalCare Foundation (AMB), the Alberta Heritage Foundation for Medical Research, and the Faculty of Nursing at the University of Alberta. The last author holds a Canada Research Chair funded by the Canadian Institutes of Health Research and the Faculty of Nursing, University of Alberta. The sponsors had no role in any aspect of the study, including data collection and analysis, manuscript preparation, or authorization for publication. Some preliminary findings were presented during workshops at the Annual Meeting of National Initiative for the Care of the Elderly in Toronto, in May 2009. We are grateful for the comments and questions of the participants in our workshops. In June 2010 some of the findings were presented as a poster at the Knowledge Utilization Colloquium 2010 in Halifax, Canada. We also appreciate the insightful comments offered by our colleague Sandy Cobban on an earlier draft of the manuscript. * Address correspondence to Anne-Marie Boström, RN, PhD, Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Alfred Nobels Allé 23, 23300, 141 83 Huddinge, Sweden. E-mail address: [email protected] (A.-M. Boström).

applications.1 It is also based on an increasing emphasis on researchers’ accountability to the public for research that is supported through public funds.2,3 As early as 1985, Nelson and Mullins4 questioned how the findings from gerontological research had been applied and if gerontological research was influencing government policy. To our knowledge, the extent to which geriatric clinicians have used KT research to inform methods of increasing the adoption of promising evidence-based interventions into clinical practice has not been studied. Nor do we know the extent to which KT researchers have conducted research that could be useful in the care of older adults. The aim of this scoping review was to describe the extent, nature, and settings of KT research pertaining to the care of older adults. We begin with a brief overview of the development of KT research, followed by an overview of the state of KT in the care of older adults and a summary of why KT research is important to clinical practice. Then we present our method of conducting the scoping review; the extent, nature, and clinical settings where KT research has been completed; and finally, the implications of the findings for the care of older adults and for future research.

1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. doi:10.1016/j.jamda.2010.12.004

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The field of KT research in health care encompasses methods to promote the uptake of clinical research findings and other evidencebased practices into clinical settings.5 KT research includes the study of influences on individual, group, and organizational capacity to use evidence in decision making. Rogers6 traced its origins date back at least to the early 1900s and the work of sociologist Gabriel Tardé. Knowledge translation, or as it was known in this period diffusion of innovation research, had a resurgence with the agricultural extension model in the United States. This resurgence was heralded by the study of the spread in use of hybrid corn by Iowa farmers.6 Public health practitioners and medical sociologists adopted the innovation diffusion model in the 1960s;7 the knowledge utilization and technology transfer fields developed in the 1970s.8 In 1992, Guyatt and colleagues9 published the landmark paper on evidence-based medicine. The Cochrane collaboration was founded in 1993 to support well-informed decisions about health care by preparing, maintaining, and ensuring the accessibility of systematic reviews on the effects of health care interventions. This has expanded into a global movement.10 In 1994, the Cochrane Effective Practice and Organization of Care Review group (Cochrane EPOC group) was established to review interventions designed to improve professional practice and the delivery of effective health services.11 Most recently, funding agencies in the United States and internationally are promoting and supporting implementation research,12 and new health science publications such as Implementation Science and International Journal of Evidence-Based Healthcare are emerging. Two articles provide a comprehensive historical overview of the development of knowledge translation field.7,8 The State of Knowledge Translation in the Care of Older Adults The transfer of new knowledge into practice is slow, if it happens at all. Some estimates suggest that 30% to 45% of patients across sectors are not receiving care based on current evidence.13,14 According to Grol and Grimshaw,13 changing clinical practice is complex for several reasons. The ever-increasing volume of knowledge being produced (eg, more than 10,000 new published trials are indexed in MEDLINE every year) makes it difficult for individual practitioners to keep up to date. To overcome this barrier, many systematic reviews (such as Cochrane reviews) and clinical practice guidelines are being developed; however, guidelines are representations of the best available evidence and their existence does not ensure use. Once they are developed they must be effectively disseminated. Once disseminated, they must be adopted and their recommendations implemented into practice. These latter steps are the crux of the KT problem; how is it that we get evidence accepted and used by busy clinicians functioning in complex organizations for the improvement of care? Health care organizations are complex adaptive systems composed of many and sometimes competing groups and subject to multiple internal and external pressures. The implementation of evidence demands multifaceted changes in practice, such as increased collaboration between groups and changes in the systems within which clinicians and managers work and patients receive care, making the uptake of evidence both challenging and potentially time-consuming. The state of KT research in the care of older adults is less well understood; however, findings from a few studies suggest that it is no better developed than the field generally and may, in fact, be less developed. In a sample of community-dwelling older Americans, the authors estimated that only a third of recommended care is provided for a subset of geriatric conditions such as mobility disorders or cognitive impairment.15 In the Canadian province of Ontario, 306 long term care (LTC) facilities completed a survey about the awareness and application of evidence-based guidelines.16 Forty percent were aware of these guidelines and 20.6%

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applied them. The slow transfer of new research findings (evidence) into the care of older people has been attributed to a lack of knowledge and understanding of the complex and dynamic mechanisms of the social processes that support and hinder this transfer.17,18As the proportion of older adults in populations around the world rises over the next decades; it is imperative that we accompany this rise with more effective ways to apply relevant research findings at both health policy levels and in clinical practice settings where older adults receive care. We know from previous reports that the quality of care for older adults living in LTC is suboptimal.19 Furthermore, the cost for health care is increasing, in particular in the last years or months of life.20,21 Thus, there is a need to understand the process of implementing new research evidence in practice, including KT interventions, which could lead to a better quality of care and quality of life for the older population. Internationally, the location where health care is provided to older adults has shifted from acute care to seniors’ own homes, assisted living facilities, and LTC facilities.22 Much of the KT research has, however, been conducted in acute and primary care settings.23 This work may not then, be applicable to home care, supportive living environments, or LTC facilities. These settings differ from hospitals with respect to (1) the characteristics of the population served, (2) the staff member skill-mix (eg, professional groups and education levels), (3) the resources available, and (4) the physical environment. The extent and nature of KT research that has been conducted in settings where older adults receive health care is unclear. Understanding the differences in research implementation across settings is important because there is a growing body of evidence to suggest that research uptake is not only associated with individual factors of the care provider but also associated with contextual, environmental, and organizational factors where care is provided, and in fact, these factors are likely more important than individual characteristics.6,24e26 For medical directors and managers working in LTC facilities, assisted living facilities, and home care, the development of this knowledge will be crucial. Their quality improvement efforts will benefit from a better understanding of the individual and organizational factors that influence research uptake. The aim of this scoping review was to describe the extent, nature, and settings of KT research pertaining to the care of older adults. The following questions guided this study: 1) What is the extent of KT research in the care of older adults? 2) What is the nature of KT research in the care of older adults? 3) How does the extent and nature of KT research in the care of older adults vary across clinical settings?

Methods We conducted a scoping review to systematically explore and characterize the extent and nature of the combined gerontology/ geriatrics and KT literature. Although there are numerous definitions of approaches to summarizing and/or synthesizing the literature, we define a scoping review as a systematic, transparent, and replicable review of literature using an exploratory approach.27 Search Strategies A proliferation of terminology and definitions, often leading to confusion, have accompanied the evolution of KT research.28,29 Terms have emerged based on various understandings of what constitutes knowledge or evidence (eg, patient experience, clinical experience, information from local contexts, research graded by consensus, research synthesized in systematic reviews) and the

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Table 1 Key Terms in Knowledge Translation Term

Definition

Reference

Diffusion of innovations

The process by which an innovation is communicated through certain channels over time among members of a social system The process by which specific research-based knowledge (science) is implemented in practice

Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press, 2003. Estabrooks CA, Floyd JA, Scott-Findlay S, et al. Individual determinants of research utilization: A systematic review. J Adv Nurs 2003;43:506e520. Canadian Institutes of Health Research. 2009. About Knowledge Translation. Available at: http://www.cihr-irsc.gc.ca/e/29418. html (Accessed June 9, 2009)

Research utilization

Knowledge translation

Evidence-based practice

Implementation of clinical practice guidelines

A dynamic and iterative process that includes synthesis, dissemination, exchange, and ethically sound application of knowledge, to improve the health ., provide more effective health services and products, and strengthen the health care system The conscious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients The implementation of systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances

forms in which knowledge is conveyed (eg, experiences exchanged, ideas diffused through social networks, recommendations published, guidelines implemented).30e32 Five terms broadly encompass this research field: diffusion of innovations, research utilization, knowledge translation, evidence-based practice, and implementation of clinical practice guidelines. Definitions of these terms are presented in Table 1. The health science librarian on our team developed the search strategy using a combination of subject headings (MeSH terms) and keywords. To cover the broad KT field, the following terms were included along with their synonyms: diffusion of innovation, research use, research utilis(z)ation, research dissemination, research implementation, knowledge utilis(z)ation, knowledge translation, knowledge transfer, knowledge exchange, evidence-based practice/ nursing/medicine, and best practice guidelines. We searched for systematic reviews and meta-analyses because these reviews summarize the “state of the science” and enabled us to efficiently identify primary research studies pertaining to KT and the care of older adults. A filter was added to the search strategy to focus the search on systematic reviews and meta-analyses. Scoping reviews generally only utilize a few main health research databases for literature;27 we searched Medline, CINAHL, The Cochrane Library, and EMBASE on April 16, 2009. To pick up the entire body of KT literature there were no language, publication date, or publication status restrictions placed on the initial electronic search. Neither did we limit the search strategy to any type of setting. The complete search strategies can be viewed by contacting the authors. Subsequently the reference lists and tables of identified reviews were also hand searched and screened. Inclusion and Exclusion Criteria The screening process was guided by 3 inclusion criteria: (1) research involving all populations except children and pregnant women, (2) research reported in English, and (3) systematic reviews. The exclusion criteria were systematic reviews published before 1998 (older than 10 years at the time of the search) and published outside the peer-reviewed literature. Data Extraction Two authors completed independent screening and data extraction in 4 steps. Disagreements were resolved by consensus. First, based on the inclusion and exclusion criteria described

Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence-based medicine: What it is and what it isn’t. BMJ 1996;312:71e72. Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press, 1990.

previously, we retrieved relevant review articles from the electronic search. Second, we extracted data including country of the first author, focus of the review, years searched, total number of included articles, number of included articles pertaining to care of older adults, and settings as they were reported in the reviews (see Table 2). We identified primary research articles pertaining to the care of older adults by searching the tables and reference lists of the systematic reviews for words or phrases such as aging, older adult, senior, elder, elderly, LTC, nursing home, geriatric, or gerontological. Third, we retrieved and screened the primary research articles identified in the systematic reviews to verify that they were studies pertaining to both the care of older adults and KT. We assessed the relevance of these articles to the care of older adults by examining the characteristics of the targeted patients (we defined older persons as 65 years or older), staff, or clinical settings. We assessed the relevance of the articles to KT according to the presence of at least one of the following: KT interventions, research utilization, diffusion of innovations, evidence-based practice, or implementation of guidelines. Finally, we extracted the following data from the retrieved primary research articles: clinical settings, country of the first author, focus of the article, type of KT intervention or KT study, patient outcomes, professional groups, professional outcomes, system outcomes, and predictors and barriers to KT.

Analysis Following Arksey and O’Malley,33 we collated the extent and nature of included systematic reviews and primary research articles pertaining to the care of older adults (see Tables 2 and 3). These findings are summarized in the results section. Consistent with the exploratory approach of this study and the methods of a scoping review, we did not assess the quality of the included articles.27,33 We sorted the primary research article data according to the type of clinical setting because the services available to older people will vary across settings as their health care needs vary (see Table 3). We classified these primary research articles using the preexisting KT intervention taxonomy developed by the Cochrane EPOC group.11 This taxonomy organizes KT interventions into 4 categories: professional, organizational, financial, and regulatory. Professional interventions included the distribution of educational material, educational meetings and outreach visits, use of local opinion leaders, and audit and feedback. Organizational interventions included revision of professional roles, communication

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Table 2 Characteristics of Systematic Review Articles First Author Year, Country

Focus of Review

Years Searched

Number of Included Articles

Number of Older Care Articles

Badamgarav 2003 US Balas 2004 US Batsevani 2004 Sweden Beney* 2000 US Carlson 2008 US Dijkstra 2006 Netherlands Doumit* 2007 Canada Estabrooks 2003a Canada Estabrooks 2003b Canada Farmer* 2008 Canada Forsethlund* 2009 Norway Foxcroft* 2000 UK Frasure 2008 US Gilbody 2003 UK Godin 2008 Canada Gordon 2001 UK Greenhalgh 2004 UK Grilli* 2002 Italy Grimshaw 2004 UK Hakkennes 2008 Australia Harkness* 2009 UK Hoomans 2007 Netherlands Hulscher 1999 Netherlands Hunt 1998 Canada Innvaer 2002 Norway Jamtvedt* 2006 Norway Kaushal 2003 US Kwan* 2004 UK Lancaster* 2000 UK Lansisalmi 2006 Finland Meijers 2006 Netherlands Milner 2005 Canada Mitchell E 2001 UK Mitchell G 2002 Australia Norris 2002 US O’Brien* 2007 Canada Peach 2003 Australia Philbin 1999 US Renders* 2000 Netherlands Sandercock 2002 UK Simpson 2005 Canada Shiffman 1999 US Solomon 1998 US Stone 2002 US Thomas DC 2006 US Thomas LH 1999 UK Thompson 2007 Canada Tooher 2005 Australia Urquhart* 2008 UK Wagner 2001 Netherlands Weingarten 2002 US Wensing 1998 Netherlands Zwarenstein* 2009 Canada

Disease management for depression Computerized knowledge management for diabetes Evidence-based practice guidelines improve outcome Expanding outpatient pharmacists’ roles Barriers to research use Organizational characteristics to implement guidelines Use of local opinion leaders Individual determinants of research utilization Measurement of research use Use of printed educational materials Educational meetings Organizational infrastructure for evidence-based nursing Measurement of research use Organizational and educational interventions for depression management Individual factors influencing health professionals’ behaviors Infection control in dental care Diffusion of innovation in health service organizations Effects of mass media on the use of health services Guideline dissemination effectiveness/efficiency Guidelines implementation Mental health workers in primary care Economic evaluation of guideline implementation Interventions to improve prevention services in primary care Computer-based decision support systems for physicians Health policy-maker research use Audit and feedback Computerized support systems for MDs Stroke patient care pathways Training health professionals for smoking cessation Innovations in healthcare organizations Contextual factors and research use Clinical nurse educators and research use Impact of computers on primary care consultations Liaison of GPs with specialist service providers Disease management and case management for diabetes Educational outreach visits Research use in hospitals Multidisciplinary programs for congestive heart failure Management of diabetes Barriers to stroke guideline implementation Guideline implementation for pneumonia Computer-based guideline implementation systems MDs’ diagnostic practices Adult immunization and cancer screening Active-mode learning program Guideline implementation Interventions to increase research use in nursing Prevention guidelines for venous thromboembolism Nursing record systems Quality systems in nursing homes Adherence to chronic illness guidelines Implementation of guidelines Interventions for interprofessional collaboration

1987e2001 1976e2003 1985e2002 1966e1999 1991e2006 1966e1998 1966e2005 1993e2001 1993e2002 1966e2007 1966e2006 1966e2002 1982e2007 1966e2003 1960e2007 1980e1999 1966e2002 1966e1999 1966e1998 1966e2006 1998e2007 1998e2004 1966e1995 1992e1998 1966e2000 1966e2004 NR 1966e2003 NR NR 1966e2005 1982e2003 1980e1997 1966e2001 1966e2000 1966e2007 1997e2002 1966e1998 1966e1999 1979e2001 1966e2004 1992e1998 1966e1998 1966e1999 1966e2005 1975e1998 1982e2006 1996e2003 1856e2008 1985e1997 1987e2001 1980e1994 1966e2007

24 44 8 11 45 53 12 20 42 23 81 0 25 36 78 71 213 20 235 14 42 24 58 68 24 118 12 15 10 31 10 13 61 7 42 69 8 7 41 61 14 25 49 108 13 18 4 30 9 21 102 61 5

0 0 0 0 0 1 0 0 0 0 3 0 0 2 2 0 2 1 15 14 0 2 5 0 0 3 0 0 0 1 0 0 2 0 0 6 0 1 0 0 1 0 0 4 13 1 0 0 1 21 2 0 1

NR, not reported. *Cochrane review.

systems, or equipment availability. Financial interventions targeting both providers and patients included various methods of remuneration or payment systems. Regulatory interventions included any health service change introduced by regulation or law. For the remaining data elements of the primary research articles that did not group into one of the EPOC categories, 2 authors independently developed categories in relation to the focus of the primary research articles and the outcomes measured. Using consensus, the 2 authors agreed on a final set of categories.34,35 Then this classification system was applied to the data, data elements were counted, and percentages were calculated.

Results Study Selection Results Figure 1 provides an overview of the search and retrieval process. In total, 693 citations were identified. After removal of the duplicates, 594 citations remained. Fifty-three reviews met the broad definition for a systematic review of KT research and our inclusion and exclusion criteria (see Table 2). The 53 systematic reviews included 2249 articles. After removing the duplicates, 1709 unique articles remained. Of these 1709 articles, 90 were identified as articles relevant to the care of older adults, but only 61 (3.6%) of

First Author Year, Country

Focus of Article

Nursing Homes Articles (n [ 30) Avorn 1992, US Sedating drugs Fitzgerald 1996, US Performance measures Frenkel 2002, UK Oral health Gurwitz 1992, US H2-blocker drug use Loeb 2005, Canada & US Urinary tract infections Meador 1997, US Antipsychotic drug use Parker 1995, US Diabetes Rantz 2001, US Effects of QI using MDS-RAI on patient & process outcome Ray 1987, US Antipsychotic drug use Ray 1993, US Antipsychotic drug use Schmidt 1998, Sweden Psychotropic drug use Schnelle 1993, US Incontinence care Cherry 1993, US Ombudsman Champagne 1991, Canada Innovation implementation Effect of MDS-RAI on resident outcomes Effect of MDS RAI on process outcomes Effects of MDS RAI on system outcomes Urinary catheters Antipsychotic drug use Antipsychotic & psychotropic drug use Quality assurance procedures Facilitator of audit and feedback Falls, psychotropic drugs and stroke prevention Pneumonia Quality Oral health Hazardous mobility and constipation Seclusion and restraint Early adopter nursing homes

Werner 2001, Israel

Intention to use physical restraints

Out-patient Clinic Articles (n[26) Barton 1990, US Influenza immunization Bland 2003, US Urinary incontinence Byszewski 2003, Canada Driving and dementia Callahan 1994, US Depression Cowper 1998, US Drug prescribing Davis 2000, Canada Osteoporosis Hutchison 1989, Canada Influenza immunization Kerse 1999, New Zealand Health behaviors and wellbeing Kiefe 2001, US Diabetes care McDowell 1990, Canada Influenza immunization Pimlott 2003, Canada Benzodiazepine drug use Pond 1994, Australia Dementia and depression Schwartzberg 1997, US Home care services Van Eijk 2001, Netherlands Anticholinergic antidepressant drug use Waldorff 2003, Denmark Dementia Moore 1997, US Common geriatric problems Tilney 1998, US Heart failure Ives 1994, US Influenza immunization

Findings Knowledge Translation Interventions or Studies

Patient Outcomes

Professional Groups

Professional Outcomes

System Outcomes

Predictors and Barriers to Knowledge Translation

Professional Professional Professional Professional Professional Professional Professional Professional

B, M B, P, M No No Deaths B No B, P

MD, RN, HCA Mixed HCA MD MD, RN MD, RN, HCA RN, HCA No

T T IA T D, T A, T A, T, IA T

No No No Costs HCU No No No

No No No No No No No No

Professional Professional Professional Professional Organizational Financial

No B No B B, P No

MD MD, RN, HCA MD, RN, HCA HCA No MD, RN, Leaders

T T T A, T, Prom T A, T, IA

No No No No No No

Regulatory Regulatory Regulatory Regulatory Regulatory Regulatory Professional, Organizational Professional, Organizational Professional, Organizational Professional, Organizational Professional, Organizational Professional, Organizational Professional, Organizational Professional, Organizational Examined predictors of innovation adoption Examined predictors of using physical restraints

B, P No Deaths P B B No M B, P No No P B, P No No

No No No No MD MD RN, HCA Leaders MD MD MD, RN, HCA No Multiple HCA No

No A, D, T, Prev No T T T A, T, IA T A, T T T, Prom, Prev No A, T T No

No No HCU No No No No No No HCU, Costs No No No No No

No

RN, HCA

IA

No

No No No No No Organizational & Political factors No No No No No No No No No No No No No No Organizational & market factors Provider factors

Professional Professional Professional Professional Professional Professional Professional Professional Professional Professional Professional Professional Professional Professional Professional Organizational Organizational Financial

B B, M No B, M No No No B, M P No No No No No No No B, P No

MD MD MD MD MD MD MD, RN MD MD MD MD MD MD MD MD MD MD, Other MD

Prev T, Prev IA D, T A, D, T IA Prev T, Prom, Prev A, D, Prev Prev T D T, IA T D Prev T Prev

No No No No HCU, Costs No No No No No No No No No No No HCU, Costs No

No No No No No No No No Provider factors No No No Provider factors No No No No No

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Fries 1997, US Hawes 1997, US Mor 1997, US Moseley 1996, US Semla 1994, US Shorr 1994, US Challiner 1997, UK Chambers 1996, UK Crotty 2004, Australia Dempsey 1995, US Dickinson 1997, UK Frenkel 2001, UK Mohide 1988, Canada Richmond 1996, US Castle 2001, US

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Table 3 Characteristics of 61 Retrieved Primary Research Articles Sorted By Clinical Setting and By Type of Knowledge Translation Intervention

A, assessment; AHP, allied health professionals; B, behavior; D, diagnosis; Costs, financial outcomes; HCA, health care aides; HCU, health care utilization; M, mental health; IA, intellectual activity (knowledge, attitudes, intention); MD, physician; Multiple, article did not report specific staff groups; Other, other team members; P, physical health; Prev, prevention; Prom, promotion; RN, registered nurses; T, Treatment.

No No Provider factors No Costs No MD Multiple MD, RN, AHP Multiple Setting Articles (n[3) Maclure 1998, Canada Antihypertensive drug use Suntken 1996, US Pressure ulcers Foy 2007, UK Intention to disclose a dementia diagnosis

Professional Professional Examined predictors of disclosure of dementia

No P No

T A, T D

No Patient, provider & system factors No No D D, IA MD MD No No Professional Professional

Kouides 1993, US Influenza immunization Herman 1994, US Influenza and pneumococcal immunization Herman 1995, US Breast cancer screening Mandelblatt 1993, US Cervical cancer screening Margolis 1992, US Immunization program Mazzuca 1987, US Arthritis screening and management Nexoe 1997, Denmark Influenza vaccination Morissey 1995, US Preventive care Hospital Setting Articles (n[2) Gama 1992, UK Acute myocardial infarction Halm 2000, US Non-adherence to guidelines

Financial Professional, Organizational Professional, Organizational Professional, Organizational Professional, Organizational Professional, Organizational Professional, Financial Financial, Organizational

RN RN RN RN MD MD, MD, MD, MD, RN MD MD No No No No No No No M

Prev Prev Prev Prev Prev D, T, Prev Prev A, D, Prev

No No No No No No No HCU, Costs

Provider & context factors No No No No Barriers to referral No Patient factors

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these 1709 articles could also be classified as KT studies (Table 3). Our inclusion criteria stipulated that we only include articles pertaining to both the care of older adults and KT research. Systematic Reviews: Extent and Nature of Knowledge Translation Research Two of the 53 reviews focused exclusively on KT in the care of older adults.36,37 Wagner and colleagues36 studied the impact of “quality system activities” on care processes, satisfaction, and health outcomes of LTC residents. They reviewed 21 articles and identified the following quality system activities: implementing guidelines; providing feedback on outcomes; facilitating the assessment of resident needs to support care planning, internal audits, and training; and introducing an ombudsman for residents. The effects on care processes and the health outcomes of LTC residents were inconsistent, but there was some evidence from the 4 controlled trials that specific training and guidelines for physicians and nurses can influence patient outcomes such as a reduction in the use of psychoactive drugs, improvements in mobility, and the prevention of constipation. The second review that focused exclusively on KT in the care of older adults studied the effectiveness of interactive learning programs targeting physicians’ behaviour.37 Physician behavior change in relation to the care of older patients was inconsistent across the 13 included articles; however, the authors of the systematic review concluded that the most effective methods to change the behaviors of physicians involved multifaceted educational efforts such as written materials or toolkits combined with feedback, individual educational visits, or small group training. Primary Research Articles: Extent and Nature of Knowledge Translation Research The 61 primary research articles about KT in the care of older adults covered a broad range of topics (Table 3). We categorized these topic areas as follows: geriatric syndromes/diseases (n ¼ 15; 25%), preventive care (n ¼ 13; 21%), medication management (n ¼ 12; 19%), care processes (n ¼ 9; 15%), quality improvement (n ¼ 9; 15%), and determinants of KT (n ¼ 3; 5%). The geriatric syndromes and diseases category included mobility, falls, dementia, depression, and urinary incontinence. The preventive care category included screening and immunization. The medication management category primarily included psychotropic drugs. The care processes category included processes related to oral health, urinary catheters, and physical restraints. Quality improvement included performance measurement and the introduction of new roles and procedures. Knowledge translation interventions categorized using the Cochrane EPOC group classification system,11 revealed that the included articles primarily targeted professionals (Table 4). KT interventions targeting the organization were few, whereas financial and regulatory interventions were rare. Evaluation of the outcomes for these knowledge translation interventions focused primarily on health professionals followed by patient outcomes. Few articles reported an evaluation of system level outcomes. Most articles (n ¼ 43; 70%) included one type of KT intervention. Fifteen (25%) articles combined 2 types. Three (5%) articles did not describe any interventions but rather explored determinants of KT. Professional interventions such as the education of physicians or staff, educational outreach, and audit and feedback were described in 31 (53%) articles as a single KT intervention and in 14 (24%) articles in combination with other KT interventions. Organizational interventions such as the modification of existing professional roles or providing equipment were described in 3 (5%) articles as a single

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Fig. 1. Search and retrieval process.

KT intervention and in 14 (24%) articles combined with another KT intervention. Financial interventions such as modifying the reimbursement system for physicians, free flu shots through Medicare, or waiving user fees were reported in 3 (5%) articles as single KT intervention and in 2 articles in combination with another KT intervention. Six (10%) articles evaluated the effect of a regulatory intervention: the 1987 US Omnibus Budget Reconciliation Act. We classified patient outcomes into 4 categories: behavior, physical health, mental health, and death. The behavior category included function, mobility (including falls and restraints), agitation, and adherence to treatment. The physical health category included pain, skin condition, weight loss, oral health, immune status, and cardiovascular health. The mental health category included cognition, affect, perceived quality of life, satisfaction, and perceived well-being. The patient outcomes in Table 3 revealed 17 (28%) articles in which behavior outcomes were measured, 11 (18%) articles in which physical health outcomes were assessed, 7 (11%) articles in which mental health outcomes were measured, and 2 (3%) articles in which death was the outcome. Table 4 displays that 25 (43%) of the 58 KT intervention articles reported patient

outcomes, of which 14 (56%) reported a single outcome and 11 (44%) reported a combination of 2 or 3 patient outcome categories. Single professional groups targeted by the KT interventions included physicians (n ¼ 28; 46%), registered nurses (n ¼ 1; 2%), health care aides including nurse aides and nursing assistants 41 (n ¼ 3; 5%), and leaders including managers and administrators (n ¼ 1; 2%) (Table 3). Mixed professional groups, which were targeted in 20 (33%) articles, primarily consisted of a combination of physicians and registered nurses. Outcomes of the KT interventions targeting professional groups were reported in nearly all (n ¼ 57; 93%) primary research articles. We developed 6 categories of professional outcomes that focused on behavior or practice change of health professionals. These are “intermediate outcomes” that could be thought to influence the “final outcomes” for the older person: prevention (screening, immunization), promotion (the promotion of autonomy or reducing restraints), assessment (assessment of specific conditions such as falls or continence), diagnosis (testing, referral, and disclosure of a diagnosis), treatment (drug prescription or urinary catheterization), and intellectual activity (knowledge, attitudes, or intentions). The most frequently

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Table 4 Results from 58 Articles Organized by Type of Knowledge Translation Intervention and Type of Outcome Outcomes KT Intervention (n)

Patient Outcomes (n)

Professional Outcomes (n)

System Outcomes (n)

Professional (31)

Total (13) Behavior (4) Physical health (2) Deaths (1) Multiple (6)

Total (4) Health care use (1) Financial outcomes (2) Multiple (1)

Organizational (3)

Total (2) Multiple (2)

Financial (3)

Total (0)

Regulatory (6)

Total (5) Behavior (2) Physical health (1) Deaths (1) Multiple (1) Total (5) Physical health (1) Mental health (2) Multiple (2)

Total (31) Diagnosis (3) Treatment (10) Prevention (3) Intellectual activity (3) Multiple (12) Total (3) Treatment (2) Prevention (1) Total (3) Prevention (2) Multiple (1) Total (4) Treatment (3) Multiple (1)

Total (14) Treatment (3) Prevention (5) Multiple (6)

Total (2) Multiple (2)

Combined KT interventions (15) Professional & Organizational (13) Professional & Financial (1) Organizational & Financial (1)

Total (1) Multiple (1) Total (0)

Total (1) Health care use (1)

KT, knowledge translation; Intellectual activity, knowledge, attitudes, intentions.

reported professional outcome was treatment (n ¼ 35; 57%), followed by prevention (n ¼ 18; 30%), and the 2 outcomes assessment and diagnosis (each n ¼ 12; 20%). Promotion was the least frequently reported outcome (n ¼ 3; 5%) (Table 3). Thirty-five (60%) of the 58 KT intervention articles reported one outcome, whereas 20 (34%) reported multiple outcomes (Table 4). Eight (13%) articles reported KT studies with system outcomes that we classified into health care utilization (n ¼ 6; 75%) and financial outcome (n ¼ 6; 75%) categories (Table 3). Ten (16%) articles examined predictors or barriers to KT.

Neither of the 2 hospital studies measured patient outcomes. In outpatient clinics, professional behavior outcomes mainly targeted prevention (n ¼ 16; 62%), whereas in LTC facilities the professional behavior outcomes commonly targeted treatments (n ¼ 24; 80%). Outcomes targeting health care aides were included only in the studies based in LTC facilities but they figured prominently there with over a third (n ¼ 11) of the KT interventions targeting health care aides.

Discussion Clinical Settings of Knowledge Translation Research We categorized the systematic reviews and primary research articles by the clinical settings where older adults receive care into 4 groups: LTC facilities, outpatient clinics, hospitals, and multiple settings. It was, however, difficult to categorize the systematic reviews in this way because few reported clinical settings. For the primary research articles, these categories revealed that nearly all KT research in the care of older adults had been conducted in either LTC facilities or outpatient clinic settings; very little research was identified in hospitals or across settings. Thirty (49%) articles reported studies conducted in LTC facilities, 26 (43%) in outpatient clinics, and 2 (3%) in hospitals. Three (5%) articles reported multiple settings (Table 3). This categorization by setting also disclosed variation across settings in relation to the topics studied, types of KT interventions evaluated, professional groups targeted, and outcomes measured. Quality improvement (n ¼ 9; 100%) and medication management (n ¼ 8; 75%) were topics studied almost exclusively in LTC facilities. Preventive care (n ¼ 13; 100%) was studied exclusively in outpatient clinics. Regulatory KT interventions (n ¼ 6; 100%) were described only in LTC settings, and financial KT interventions were used mostly in outpatient clinics (n ¼ 4; 80%). Physicians (n ¼ 21; 75%) were the most targeted professional group in the outpatient clinic and hospital settings; however, 40% (n ¼ 12) of the LTC facility studies targeted mixed professional groups. Patient outcomes were assessed in 43% (n ¼ 17) of LTC facility studies, 33% (n ¼ 1) of multiple setting studies, and 27% (n ¼ 7) of outpatient clinic studies.

Despite our broad definition of KT and the growing research focus in the KT field,8 this scoping review revealed a scarcity of KT literature pertaining to the care of older adults. Just 2 of the 53 systematic reviews specifically targeted KT research relevant to elders. Furthermore, only a small proportion of the included primary research articles in the systematic reviews pertained to people older than 65 years. This was surprising in relation to the aging population worldwide. A researcher in the field of palliative care also found a dearth of research conducted with older adults. In a review of hospice, palliative care, or terminally ill adults, little distinction was observed between younger and older individuals and only 2.9% of the palliative care literature focused on those 65 years and older.38 Only 30 (1.8%) of the 1709 primary research articles were set in LTC facilities where most of the residents are older adults. This finding is consistent with Grimshaw et al’s 23 systematic review about dissemination and implementation of guidelines, which found only 3% of studies were conducted in nursing homes. There appears to be a relative lack of relevant literature to guide the implementation of research evidence in the care of older adults. There may be several reasons for this. First, few authors of systematic reviews report the clinical setting or clinical specialty even though the Cochrane EPOC checklist for extraction of data from systematic reviews does include “clinical speciality.” In fact, even if the Cochrane EPOC checklist were to be used in the extraction of data on population, it does not identify the geriatric population as a clinical specialty in its taxonomy (although the smaller pediatric population is identified). Second, older adults with multiple comorbidities are

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frequently excluded in randomized controlled trials (RCTs), which also could explain the small proportion of primary research articles pertaining to older people.39 The review by Hoomans et al40 provided an example of how to concisely summarize the contextual features of KT research in one simple table that included country, setting of care, academic status, health profession, and clinical specialty. The lack of explicit reporting of clinical settings/specialities and geriatric populations makes it difficult to compare the effectiveness of various KT interventions across health care settings, and makes it difficult to recommend specific strategies to medical directors and managers to increase the uptake of evidence in the LTC sector. The topics included in the 2 systematic reviews were activemode learning programs for physicians caring for older adults, and the effect of quality systems in LTC settings. The primary research articles yielded a much broader range of topics. Most were about the translation of evidence related to geriatric syndromes or diseases followed by medication management and preventive care; however, relatively little KT research involved care processes. It may be that there is a smaller research base for care processes related to the increased complexity of conducting robust RCTs for care processes compared with drug trials.39,41 Another explanation for the limited research on care processes may be the specific characteristics of care process innovations. Rogers’6 diffusion of innovations theory identifies the characteristics of an innovation (the evidence) that will influence the uptake of that innovation, including relative advantage, compatibility, complexity, trialability, and observability. Introducing a new medication into practice involves prescribing and administering the medication using established processes. Drug innovations are compatible with existing routines, and are therefore more likely to be adopted than a care process innovation such as promoting continence care. In contrast, continence care is a more complex intervention involving coordination of work and relationships among team members with differing educational backgrounds, degrees of professional autonomy, and work schedules.17,18 Recent studies have shown that the contextual features of health care settings influence the uptake of research findings into practice.24 Unfortunately, we found little attention to organizational context in the included systematic reviews or primary research articles. It was useful to organize the primary research studies according to clinical setting because this revealed the variation in topics covered, professional groups involved, and outcomes measured. To our knowledge, no other researchers have explored the features of KT research that have been conducted in various clinical settings. Most of the primary research articles in the current review were conducted in LTC facilities and outpatient clinics. Hospital settings and multiple settings were underrepresented possibly because of an underreporting of settings and patient populations in both the primary research articles and systematic reviews. Forty-five of the primary research articles studied KT interventions targeting professional behaviors. About a third (13) of these combined professional KT interventions with organizational KT interventions. Two studies conducted in outpatient clinics42,43 combined organizational and financial KT interventions to increase the uptake of preventive care. Wensing et al44 suggested that combining 2 or more types of KT intervention to target different levels in the organization and different professional groups may increase the uptake of knowledge. There are opportunities to explore how to combine various KT interventions and to extend these combinations of KT interventions beyond professional interventions to include organizational, regulatory, and financial interventions.

Methodological Considerations Scoping reviews are intended to broadly map existing literature. The search in the current review focused on databases judged to be the most appropriate for the aim of this review; however, some potentially useful databases such as Ageline or Web of Science were not searched. Furthermore, the indexing of the body of KT literature is still underdeveloped with little controlled vocabulary used to describe most articles.29 The variable use of terminology to describe KT could have thwarted our attempt to comprehensively search for items via keywords. It is possible, therefore, that relevant articles may have been missed, especially if gerontologists are classifying their KT research using different terms than the translation scientists. The search for systematic reviews facilitated a larger coverage of the literature and a more diverse exploration of topics than would have been identified by looking only at individual articles. This method also allowed for a more rapid examination of our topic, because the authors of these systematic reviews had already identified and assessed the quality of primary studies. One of the limitations of using reviews as the data source is the possibility of introducing selection bias. Some primary research articles extracted from the retrieved reviews were dated as far back as 1987. Only 16 of the 61 articles were published from 2000 onward. This is a concern given that KT research in general has increased in recent years.8 Furthermore, depending on quality standards or specific aims of the reviews, primary research articles pertaining to the care of older adults may have been excluded because they did not meet the inclusion criteria of the various reviews, although they could have been of interest for this scoping review. Despite these shortcomings, we succeeded in identifying 61 primary research articles with which we could assess and summarize the extent, nature, and settings of KT research in the care of older adults. We minimized threats to valid description of the literature by extracting data verbatim from the articles and reporting these in the text and in the tables whenever possible. When categorization of the data was necessary, two authors separately developed categories for the data using an inductive approach and resolved any differences by consensus. Implications In keeping with the aim of this scoping review, we did not assess the effectiveness of the KT interventions or the quality of the studies. For this reason, the findings of this scoping review cannot be used to recommend policy or practice. However, we did identify areas in which a systematic review is warranted and can make recommendations for future research. Of the primary research articles in LTC settings, 7 reported KT interventions to improve the judicious use psychotropic drugs. Of these 7 studies, 4 involved the team (physicians, nurses, and health care aides) and 3 involved physicians only. Thus, the effectiveness of different types of KT interventions targeting various health professionals in relation to psychotropic drug use is a potential topic for a systematic review. Likewise, a systematic review is indicated for KT interventions in relation to the immunization of older adults in outpatient clinics. We found few primary research articles in hospital settings focused on KT and the care of older adults. This may indicate that more research in this area is needed. We found few primary research articles about the implementation of evidence pertaining to care processes. Future research could examine which MeSH terms have been used for indexing primary research articles in these 2 areas and then conducting a more focused search for primary research articles. This approach may identify articles that the authors of previous systematic reviews did not find.

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Other areas for future research could focus on the characteristics of the evidence to be implemented, and the contextual features of the clinical setting in which it is implemented. There is reason to believe that different types of evidence have varying characteristics that will influence the uptake of evidence in varying ways.6 For example, responding to the behaviors of people with dementia using medication will be easier for physicians and nursing staff than managing it nonpharmacologically. Furthermore, there is reason to believe that contextual features such as supportive leadership or availability of resources will differ across settings and these differences will affect the extent of uptake of evidence.45 For example, managers who value and actively support their staff will be more likely to succeed in implementing evidence than less supportive managers. Conclusion This scoping review set out to study the extent, nature, and settings in which KT research has been conducted in the care of older adults. The review identified a gap in KT research pertaining to geriatrics. Most of the KT research focusing on the care of older adults was conducted in LTC facilities and outpatient clinics. Most articles about LTC facilities focused on methods of translating knowledge to physicians in the areas of medication use and the treatment of diseases and geriatric syndromes, whereas in outpatient clinics the emphasis was on immunization and screening. Nelson and Mullins4 called for gerontologists to conduct knowledge utilization research, but this scoping review reveals that 25 years later we have seen relatively little progress in the field. The connection between geriatrics and KT research is still fertile ground for future research. Studies that enhance the uptake of evidence in the care of older adults and evaluate the effectiveness of such efforts are an important component in improving quality of care and other health and quality-of-life outcomes for older adults. Supplementary Data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jamda.2010.12.004 References 1. Woolf SH. The meaning of translational research and why it matters. JAMA 2008;299:211e213. 2. Ashcroft RE. Scientific or social priorities for brain science? Making a difference. Nutr Health 2007;19:135e137. 3. Shelby R. Accountability and transparency: Public access to federally funded research data. Harvard J Legis 2000;37:369e389. 4. Nelson CE, Mullins LC. Knowledge utilization in gerontology: The example of long-term care. Gerontol Geriatr Educ 1985;5:17e27. 5. Eccles M, Mittman B. Welcome to implementation science. Implement Sci 2006;1:1. 6. Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003. 7. Valente TW, Rogers EM. The origins and development of the diffusion of innovations paradigm as an example of scientific growth. Sci Commun 1995; 16:242e273. 8. Estabrooks C, Derksen L, Winther C, et al. The intellectual structure and substance of the knowledge utilization field: A longitudinal author co-citation analysis, 1945 to 2004. Implement Sci 2008;3:49. 9. Guyatt G, Cairns J, Churchill D, et al. Evidence-based medicine: A new approach to teaching the practice of medicine. JAMA 1992;268:2420e2425. 10. The Cochrane Collaboration. The Cochrane Collaboration: Working together to provide the best evidence for health care. Available at: http://www.cochrane. org/. Accessed June 9, 2009. 11. Cochrane Effective Practice and Organisation of Care Review Group. Data Collection Checklist. Available at: http://www.epoc.cochrane.org/Files/ Website%20files/Documents/Reviewer%20Resources/datacollectionchecklist. pdf. Accessed June 9, 2009. 12. Tetroe JM, Graham ID, Foy R, et al. Health research funding agencies’ support and promotion of knowledge translation: An international study. Milbank Q 2008;86:125e155.

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