Abstract
Amidst the relentless pace of modern personal and professional life, maintaining excellence in spine care is not just a choice but a necessity for clinicians committed to delivering the highest standard of care. For the busy clinician operationalizing and maintaining this commitment to excellence is difficult at best and represents the essence of the challenges and complexities around Knowledge Translation. Knowledge Translation (KT) is difficult to succinctly define as it has evolved into a broadening philosophy, but simplistically described KT is the moving of research findings into clinical practice. An intuitive, seemingly straight forward process, but a process that clinical and health services research reports consistently fail; 1 tragically as a result, patients fail to benefit and health care systems are exposed to unnecessary expenditure. Inexplicably researchers have found that, on average, it takes 17 years for scientific evidence to be adopted at a clinical level. 2 Analyzing and pursuing solutions to the overcome these roadblocks to KT is well beyond the confines of this article, but we are hopeful this new offering from the GSJ can make an impact on the KT process for spine care providers. Please join us in this small transformative journey of getting cutting edge research into your practice quickly and more efficiently.
The first quarter of this century has seen current spinal surgical practice progress and evidence-based medicine progress at an exceptional pace. Research and technology-driven breakthroughs have dramatically changed the way spine patients are managed. This is not unique to one domain, but is ubiquitous across all pathologies including deformity, degenerative, trauma, oncology, and spinal cord injury. Improved diagnostics, minimally invasive techniques, better implants, biologics, navigation, robotics, and emerging artificial intelligence are leading to better outcomes and safer patient care. Couple this enduring technical progress with exponential growth in clinical and basic science research and KT becomes an even more daunting undertaking. To reign in and govern this unprecedented growth, evidence-based medicine (EBM) evolved to become the gatekeeper of clinical research moving into clinical practice, but did this make the KT process easier?
The techniques for critically weighing the medical evidence have been honed and provide a solid framework for evaluating the literature; however, are these EBM principles an integral part of sound medical and surgical practice? Are clinicians expected to obtain the knowledge and apply it to the critical appraisal of the literature? Not-to-mention the next step of incorporating the findings into clinical practice? In an ideal world the answer to these questions would be yes, but in the real world the answer is no. Clinicians do not have the time, drive or fortified training to perform this process. Generically EBM has taught clinicians the validity around patient-reported outcomes and the hierarchy of study design and its implications, but beyond these principles little more can be expected from the busy clinician.
EBM involves the measured integration of clinical research into therapeutic decision-making. 3 Building on the methodology-based foundation laid out by Cochrane in 1972, 4 the hierarchy of “best evidence” was initially published in the nineties, providing for the first time a powerful tool for critically appraising the evidence for quality and applicability to patient care.5,6 These strict principles became the cornerstone of EBM; however, pragmatism slowly overcame academic idealism and the previously rejected components of medical decision-making, namely clinical expertise and patient preference returned to the evaluative process. Now EBM can be defined as an approach to health care that promotes the gathering, interpretation, and assimilation of valid, relevant, and applicable patient-reported, clinician-observed, and research-derived evidence with patient conditions and preferences, all applied in the context of clinical experience and expertise. 1 Hence, evidence-based practice is a combination of a critical evaluation of the scientific literature with clinical expertise, while preserving a strong obligation to patient-centeredness and humanistic values. 7
This resurgence of clinical expertise and patient values linked to methodology lead to the development of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. 8 This provided a framework on which clinical recommendations could be based. Anchored by the quality of the scientific evidence, but modified by patient preferences and values, risk/benefit, feasibility, and resource implications, a strong or weak (now termed conditional) recommendation could be made as to the integration of an intervention into practice. Various professional societies have adopted these guidelines, some with slight modifications.9–11 These societies provide organizational EBM as opposed to individual clinicians using the GRADE system. Obviously, the former is more thorough and comprehensive, but organizational EBM often lacks clear direction despite reviewing common clinical pathologies; a common statement being “more research is needed”. Does that help the busy clinician making patient care decisions?
In the GSJ “Streamlining the journey of research into clinical practice” articles we will use the current GRADE system as a framework to provide clinicians with recommendations. They will either be strong or conditional recommendations to incorporate a particular finding into your clinical practice. 12 A strong recommendation means the desirable effects of the intervention outweigh the undesirable effects. A conditional recommendation means the desirable effects probably outweigh the undesirable effects. 12 The recommendations will be generated by the AO Spine Knowledge Forums (KF) in their area of subspecialty, i.e., Spine Trauma. A KF panel will compose of key opinion leaders with content expertise and methodologists so the GRADE approach can be properly applied. Only studies felt worthy of consideration to be incorporated into clinical practice will be reviewed – this will not be a journal club but serve as a KT tool to help clinicians make their practice and patients better.
Spine surgery is a challenging specialty, not only with technical demands, but in decision making and surgical risk profile. A surgeon’s training, technical skill, tacit knowledge, and experience play a big role in guiding their practice and likely make introducing change more demanding than in a medical or straightforward surgical practice. Thus, KT to a surgeon is different than a physician, is different for a community surgeon vs an academic surgeon and is different in early vs mid-career. As mentioned previously we cannot solve the complexities and impediments to KT in one go, but hopefully the “Streamlining the journey of research into clinical practice” articles will make your patients and practice flourish.
