Many representations of the movement of healthcare knowledge through society exist, and multiple models for the
translation of evidence into policy and practice have been articulated. Most are linear or cyclical and very few come close
to reflecting the dense and intricate relationships, systems and politics of organizations and the processes required to
enact sustainable improvements. We illustrate how using complexity and network concepts can better inform knowledge
translation (KT) and argue that changing the way we think and talk about KT could enhance the creation and movement
of knowledge throughout those systems needing to develop and utilise it. From our theoretical refinement, we propose
that KT is a complex network composed of five interdependent sub-networks, or clusters, of key processes (problem
identification [PI], knowledge creation [KC], knowledge synthesis [KS], implementation [I], and evaluation [E]) that
interact dynamically in different ways at different times across one or more sectors (community; health; government;
education; research for example). We call this the KT Complexity Network, defined as a network that optimises the
effective, appropriate and timely creation and movement of knowledge to those who need it in order to improve what
they do. Activation within and throughout any one of these processes and systems depends upon the agents promoting
the change, successfully working across and between multiple systems and clusters. The case is presented for moving to
a way of thinking about KT using complexity and network concepts. This extends the thinking that is developing around
integrated KT approaches. There are a number of policy and practice implications that need to be considered in light of
this shift in thinking.
BackgroundIndigenous peoples in Australia, New Zealand and Canada carry a greater burden of chronic kidney disease (CKD) than the general populations in each country, and this burden is predicted to increase. Given the human and economic cost of dialysis, understanding how to better manage CKD at earlier stages of disease progression is an important priority for practitioners and policy-makers. A systematic review of mixed evidence was undertaken to examine the evidence relating to the effectivness, cost-effectiveness and acceptability of chronic kidney disease management programs designed for Indigenous people, as well as barriers and enablers of implementation of such programs.MethodsPublished and unpublished studies reporting quantitative and qualitative data on health sector-led management programs and models of care explicitly designed to manage, slow progression or otherwise improve the lives of Indigenous people with CKD published between 2000 and 2014 were considered for inclusion. Data on clinical effectiveness, ability to self-manage, quality of life, acceptability, cost and cost-benefit, barriers and enablers of implementation were of interest. Quantitative data was summarized in narrative and tabular form and qualitative data was synthesized using the Joanna Briggs Institute meta-aggregation approach.ResultsTen studies were included. Six studies provided evidence of clinical effectiveness of CKD programs designed for Indigenous people, two provided evidence of cost and cost-effectiveness of a CKD program, and two provided qualitative evidence of barriers and enablers of implementation of effective and/or acceptable CKD management programs. Common features of effective and acceptable programs were integration within existing services, nurse-led care, intensive follow-up, provision of culturally-appropriate education, governance structures supporting community ownership, robust clinical systems supporting communication and a central role for Indigenous Health Workers.ConclusionsGiven the human cost of dialysis and the growing population of people living with CKD, there is an urgent need to draw lessons from the available evidence from this and other sources, including studies in the broader population, to better serve this population with programs that address the barriers to receiving high-quality care and improve quality of life.
Hypercholesterolaemia is a highly prevalent condition that has major health and cost implications for society. Pharmacotherapy is an important and effective treatment modality for hypercholesterolaemia, with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors ('statins') the most commonly used class of drugs. Over the past decade, there has been intensive research to identify pharmacogenetic markers to guide treatment of hypercholesterolaemia. This study aimed to review the evidence of incremental cost, effect and cost effectiveness of pharmacogenetic-guided treatment of hypercholesterolaemia. Three cost-effectiveness analyses (CEAs) were identified that studied the value of screening for genotypes of angiotensin I converting enzyme (ACE), cholesteryl ester transfer protein (CETP), and kinesin family member 6 (KIF6) prior to initiating statin therapy. For all three CEAs, a major limitation identified was the reproducibility of the evidence supporting the clinical effect of screening for the pharmacogenetic marker. Associated issues included the uncertain value of pharmacogenetic markers over or in addition to existing approaches for monitoring lipid levels, and the lack of evidence to assess the effectiveness of alternative therapeutic options for individuals identified as poor responders to statin therapy. Finally, the economic context of the market for diagnostic tests (is it competitive or is there market power?) and the practicality of large-scale screening programmes to inform prescribing in a complex and varied market may limit the generalizability of the results of the specific CEAs to policy outcomes. The genotype of solute carrier organic anion transporter family member 1B1 (SLCO1B1) has recently been associated with increased risk of muscle toxicity with statin therapy and the review identified that exploration of cost effectiveness of this pharmacogenetic marker is likely warranted.
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