Background
Patient-oriented health outcomes are key to assessing health care in chronic illness. Chronic disability, as a result of adult musculoskeletal or childhood disorders, is profound and comprises a large component of practice for a variety of health care providers. Musculoskeletal diseases of adulthood are the leading cause of long-term disability in Canada, accounting for roughly one-third of the country's long-term disability costs [
1]. Childhood disorders also account for a large percentage of disability treatment costs with 1 in 12 children now considered disabled; increasing rates are attributable to improvements in medical care that save more compromised children, broader definitions of disability, and a greater willingness to report handicaps [
2]. Due to the chronic nature of these disorders, treatment is focused on minimizing disability and improving quality of life. Standardized measurement of the impact of interventions on these health outcomes is fundamental to advancing clinical practice and research.
The current use of patient-oriented outcome measures in research and practice is deficient, despite the fact that health care professionals recognize the importance of measuring health outcomes and efforts have been made to transfer available knowledge into practice. These efforts include national initiatives by the professional associations of both occupational therapists (OT) and physical therapists (PT), traditional workshops [
3], published editorials [
4], scientific articles [
5‐
16], textbooks [
17], professional association endorsements, and promotion of an outcomes database. While agreement with the need for outcome measures is consistently high, utilization remains low across professional groups dealing with these chronic problems, such as Rehabilitation [
18], Rheumatology [
7,
19], and Orthopaedic Surgery [
20]. Rehabilitation is commonly performed by PTs and OTs in a variety of practice settings. As few knowledge transfer studies have included these providers, we decided to focus on PTs and OTs for this study. The needs have been well established in this area, and the investigators have established partnerships with the associated national professional associations who will facilitate the current project and arising national KT initiatives.
The deficiency in current practice indicates a failure to implement effective knowledge transfer, and systematic reviews confirm that KT is based on inadequate evidence. The current failure to implement health status measures into practice is not unexpected; reviews of available evidence suggest that traditional dissemination/continuing education has little substantive impact on clinical behavior. A large body of evidence has been developed on the impact of continuing education. Studies of high quality have been synthesized in systematic reviews [
21‐
23]. These reviews have focused on physician behavior, in particular, concrete medical outcomes such as prescription practices that are quite different from rehabilitative interventions. Nevertheless, they do provide some indication of KT approaches that might be used in other areas where evidence is lacking.
Separate reviews have addressed printed education materials, educational outreach visits, local opinion leaders, and continuing education workshops/meetings [
21,
22,
24‐
27]. Each strategy was shown to lead to a measurable change, although the impact of printed materials was small and of uncertain clinical significance [
27]. Neither audit and feedback [
28‐
30] nor conferences [
31] made substantial change in practice, with larger effects occurring through occasional outreach visits and use of opinion leaders [
32]. Educational outreach visits were investigated in 18 randomized trials that were independently reviewed by two researchers [
26] and shows that outreach with supporting materials was more effective than no intervention. Again, physician-prescribing practices were the most common target behaviour. In five separate trials, it was shown that outreach visits with social marketing were most effective when high prescribers were targeted [
33‐
35]. However, little evidence addresses the optimal timing or frequency of outreach or whether changes in practice are maintained over time. A single study [
36] included 2-year follow-up and demonstrated that new prescribing behaviours were maintained over time.
Continuing education meetings and workshops were addressed in 32 studies that were judged to be of moderate to high quality and included 2995 health professionals, usually physicians [
22]. Interactive workshops were shown to have moderate to large effects in six studies and small effects in four. Combinations of workshop and didactic presentation also were effective, showing moderate or large effects in 12 studies and small effects in seven [
22]. Seven studies addressing didactic presentations showed no significant impact. It was suggested that didactic presentations might improve knowledge without impacting on practice, whereas small group discussion and practice might improve skills/behavior. Unfortunately, only a single trial made this comparison and it had inconclusive results. Cochrane reviewers suggested that further (high-quality) studies are required, and they should focus on interactive workshops. They also suggested that future studies should use qualitative processes to clarify how specific attributes of workshops contribute to effects on professional practice [
22].
There is a specific lack of knowledge on the impact of knowledge transfer on complex clinical decision-making. The majority of intervention trials attempting to change clinical behavior have focused on the prescribing practices of physicians, limiting the generalizability to clinical practices used to manage chronic musculoskeletal or childhood disability problems. Management of chronic conditions requires that health care professional deal with multi-factorial disability issues by selecting multi-level customized interventions. It is more difficult to assess how KT impacts on clinical decision-making in this situation, as compared to monitoring adherence to prescription recommendations. Beggs and Sumison [
37] presented a model that incorporated multi-level evaluation of the long-term benefits of continuing education within a Northern Outreach Program for PT and OT. They proposed a 4-stage model of evaluation. Stage 1 involves participant evaluation of the event. Stage 2 evaluates the affective, cognitive, and psychomotor changes that participants experience as a result of the event; this typically requires a pre-test and post-test of attitudes, knowledge, or specific skills. In Stages 3 and 4, higher levels of evaluation are incorporated. Stage 3 evaluates the extent to which programs change the behavior of the clinician within their practice and requires chart audits and observations. Stage 4 focuses on the client and requires evaluation of the efficiency, effectiveness, adequacy and appropriateness of care and its impact on resultant health outcomes.
We know from surveys of orthopedic practice [
18] that the use of standardized health outcome measures is low. Conversely, within pediatric rehabilitation utilization levels are higher, but therapists reported difficulty in selecting and applying available outcome measures appropriately (pilot work, publication under review). It is clear that evaluation of knowledge transfer should measure changes in knowledge, intent, and behavior, but also determine how new knowledge is incorporated into clinical decision-making.
Systematic reviews have highlighted the need to better understand the mediators of knowledge transfer, and previous work has established that a variety of factors may influence the effects of KT [
38,
39]. However, the mediators are usually only addressed as secondary issues, and few high-quality studies or literature synthesis have been conducted. Prior knowledge, education, and age have been considered as demographic predictors. We will evaluate the role of these previously studied predictors. However, we also wish to identify unknown predictors. To fully address KT mediators, it is important to have an in-depth understanding of responses to knowledge transfer; this requires qualitative research that identifies and characterizes the elements that facilitate or obstruct KT. It is our belief that it is important to identify mediators that could be used to maximize KT effectiveness using a proactive approach. 'Readiness to Change,' also called the Transtheoretical Model, incorporates features of a variety of behavior models to describe the stages of change. It has been used in addiction, health promotion, organizational change, and professional practice literature, most commonly health behavior applications [
40,
41]. More recently, some have suggested that Readiness to Change may provide a greater depth of understanding of how participants respond to knowledge transfer [
42]. Specifically, these investigators used a Readiness to Change questionnaire to evaluate how KT affected intent and action to a short course on knowledge transfer. The Readiness to Change model suggests that change in behavior is modulated by a person's readiness to make changes at the time the information is provided [
40,
41,
43]. In other words, "
the right information and the right process – at the right time." The stages are:
Precontemplation (uninformed about the need for change, uninterested in changing behavior),
Contemplation (thinking about change in the near future),
Preparation (ready to make a change in the next month),
Action (implementing a specific action plan), and
Maintenance (continuation of desirable actions). The model developers [
44‐
46] and subsequent studies [
40,
43,
47‐
51] suggest that categorizing people in stages allows one to customize messages and strategies specific to the participant's stage. This concept has not been applied to KT, but if we demonstrate that readiness to change mediates responses in this study, it will provide a promising approach to customize knowledge transfer to users. We will use the qualitative component of the study to understand the decisional balance inherent in the Transtheoretical Model.
Knowledge transfer interventions should bring knowledge into action. Constructivist principles recognize that knowledge is, "not a thing to be sent, but a fluid set of understandings shaped by both those who originate it and by those who use it" [
52]. The user is seen as an active problem solver and a constructor of his/her own knowledge rather than a receptacle of information [
52]. Clinicians must be able to use outcome measures within a valid and practical framework. Knowledge transfer strategies that engage researchers and clinicians to resolve these competing requirements may be more successful in facilitating the use of outcome measures. The possession of knowledge does not mean that it will be used. The need to go beyond dissemination that simply reflects successful distribution towards effective dissemination that requires use of the information has been emphasized [
53]. Huberman [
52] differentiated
conceptual use of knowledge, which is characterized by changes in knowledge, understanding or attitude, from
instrumental use that includes changes in behavior and practice. Practice surveys indicate both conceptual and instrumental knowledge deficits exist in musculoskeletal and pediatric practice [
54]. Knowledge transfer interventions must target and assess both.
McMaster University has a worldwide reputation for educational innovation and problem-based learning (PBL). PBL is an ideal pedagogical strategy for facilitating knowledge transfer. Research on memory suggests memory and learning can be enhanced by: maximizing the positive effects of context by closely matching the learning and clinical environments, enhancing meaning by activating relevant prior knowledge, using educational activities that require the participants to elaborate on their information, and ensuring that new knowledge is used repeatedly in a number of different contexts [
55]. The elaboration of information that occurs in tutorial discussion, the use of problems to match new knowledge to the clinical context, and the activation of prior knowledge have been recognized as active components of PBL [
56]. Therefore PBL helps in the contextualization of knowledge and in the application of knowledge, which are key components of the CIHR knowledge transfer model (listed as KT3 and KT5 by CIHR).
The rationale for a PBL approach to knowledge transfer is based on solid evidence of adult learning and the effects of PBL [
58,
59]. This work has shown that PBL is not more effective in acquiring knowledge, but
is more effective in generating a life-long learning approach where learners become more self-directed in fulfilling their personal learning issues and applying acquired knowledge to problems [
58]. This may be the critical component needed in KT, where users must incorporate new knowledge into clinical practice and resolve inherent barriers before implementing change.
Research on KT strategies suggests that the strategy must be tailored to the types of decisions that clinicians face and to the environments in which they work [
60]. It is important to consider organizational and political factors that may influence decisions to incorporate new knowledge [
60]. Therefore, the curricular design of both knowledge transfer strategies will incorporate contextual learning principles within a PBL framework. Research on both adult education and on effective knowledge transfer suggests that passive learning is ineffective and that interactive strategies are necessary to be successful [
60]. While both the interventions will be problem-based and involve interaction, the strategies will differ in the delivery mode. One strategy will incorporate face-to-face PBL, whereas the other will be internet-based. Hence, the nature of interaction will be quite different between delivery modes.
Traditionally, PBL is highly dependent on face-to-face interaction. Effective knowledge transfer is supported through these types of interactions, particularly if associated with an opinion leader [
32]. The opportunity for meaningful engagement between researchers developing outcome measures and clinicians using them through a traditional PBL process should augment KT that supports "instrumental use." There is a strong body of evidence supporting the effectiveness of traditional face-to-face PBL education that suggests it will assist clinicians to acquire higher level reasoning, incorporate newly acquired information, and address barriers to implementing new outcome measures [
56,
59,
61]. It is unclear whether the inherent value of face-to-face interaction with developers outweighs the time constraints of this form of knowledge transfer. Research on PBL indicates that learners are initially inefficient and stressed with this new approach to learning [
62]. While the learning curve is steep, it is not unattainable. Participants in our pilot study reported that the PBL was time-consuming, but valued.
A rapidly evolving mode of accessing information and continuing education is through the use of the Internet. Online course work has proliferated at a pace well beyond the capacity of educational/KT researchers to study its effectiveness or implications. While theoretical papers on online learning have laid out the pedagogical issues, few high-quality research studies have addressed learning outcomes in a quantitative way. A recent study reviewed all studies indexed on Medline that addressed Internet-based medical education [
63] to determine the extent of formal evaluation. Of 85 studies, 55 merely described the program and provided no evaluation. Of the remaining 31 studies, 81% evaluated participant satisfaction, 52% evaluated learning outcomes, and only 6% evaluated change in clinical practice behaviors.
Despite the low level of evidence surrounding online professional education, there is a rationale for this approach. One potential benefit is that participants can access information/course work asynchronously. If participation in face-to-face PBL is a significant barrier to busy clinicians, online interaction might be preferable. There are advantages to online learning that may promote knowledge transfer. For example, online learning allows for increased time for reflection and synthesis [
64,
65] and provides increased time to develop the ability to organize thoughts when problem-solving collaboratively [
64]. Online learning and online forums also are thought to promote critical thinking and problem-solving in a collaborative environment [
66]. Despite these potential benefits, few studies have specifically examined online PBL. Dennis [
67] compared online PBL and face-to-face PBL and found there was no difference in learning outcomes. However, the online groups spent more time on learning, suggesting that this process was less efficient. Chan et al. [
68] randomized family physicians to either Internet-based PBL or a control group (Internet content without PBL) and found no difference in knowledge. However, the sample was small (n = 23). In a qualitative study, Valaitis et al. (2005) examined health science students' perceptions of online PBL. The results showed that students valued the flexibility of online learning and felt it enhanced their ability to deeply process content, but they had initial difficulties adapting to an online environment and perceived a heavy workload. Given the current state of practice and knowledge, we propose to evaluate two KT approaches to implanting knowledge on outcome measures.