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Translating evidence into practice

Translational medicine and evidence based practice (EBP) are key principles that have guided clinical applications of research over the past two decades, helping to transform research on disease and disability. There is less evidence that clinical practice has shifted by similar dimensions. As a clinician and clinical manager turned researcher, I have seen clinicians struggle to integrate research evidence into what are often quite inflexible clinical pathways. I may also have dampened the enthusiasm of clinicians with reminders to consider cost-effective evidence; thereby unwittingly contributing to the persistence of traditional models of care. With often onerous processes of health care management, the evidence and inspiration behind proposed changes not only get diluted but critical aspects of an intervention can get lost, thus undermining the capacity to optimize care for individuals. Diane Damiano 1 has highlighted the need to move beyond group means in trying to understand the evidence and implications for clinicians, with a timely reminder of Sackett’s 1996 definition of EBP to enable clinicians to make decisions about the care of individual patients. 2 But how do clinicians marry up the evidence when confronted with an individual? In considering obstacles and facilitators to the uptake of EBP, Grimshaw et al. 3 suggest that the basic unit of knowledge translation is an up-to-date systematic review to synthesize research findings. Yet these usually include trials which inherently use group means to define treatment effects, inevitably losing the individual. This is particularly so in the case of therapies for children with neurodisability where considerable inter-individual responses to interventions have been reported. Damiano 1 has correctly identified the need for research strategies that can distinguish/predict responders in order to consider what treatment works best for whom. There remains, however, the need to assist clinicians in understanding how to implement the best treatment protocols. Sufficient details of the intervention, including the theoretical and empirical evidence of the mechanisms by which the intervention work, are missing from many efficacy studies to enable clinicians to consider the logistics of translation. Translation requires the transformation of one entity to another. This requires definition of the original entity alongside the context and culture of the translated version to determine what has shifted and whether any discrepancies exist that may influence/explain a particular individual’s response to that intervention. This may well be at the individual level (child outside inclusion criteria of the literature), environmental level (intervention did not conform to evidence, e.g. facility, expertise of staff) as well as at procedural levels (including timing, dosing, and duration of intervention). 3 In reality, few studies clearly define