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Why are we failing to implement effective therapies in cardiovascular disease?

Robby Nieuwlaat, Jon-David Schwalm, Rasha Khatib, Salim Yusuf
DOI: http://dx.doi.org/10.1093/eurheartj/ehs481 1262-1269 First published online: 1 February 2013

Abstract

Worldwide, there are ∼18 million deaths each year from cardiovascular disease and at least 2–3 times as many experience non-fatal cardiovascular events. Numerous evidence-based prevention and management guideline recommendations for cardiovascular disease are available. However, significant gaps between the evidence and its implementation persist (‘evidence–practice gap’). There exist ‘under-use’ gaps with lack of implementation of proven effective strategies and ‘over-use’ gaps with inappropriate use of strategies with strong evidence against, or insufficient evidence for their effectiveness and safety. To better tackle the global burden of cardiovascular disease (CVD), more effective strategies are needed. We discuss three selected areas where advances in implementation research for CVD could provide improvements. First, a better assessment and understanding of the most important modifiable context-specific barriers to evidence-based care will allow optimal tailoring of interventions to overcome them. Second, novel community intervention strategies from outside current CVD research should be considered, especially for CVD areas where major barriers exist and little progress has been made. Examples of such interventions include cell phone text messaging, non-physician health workers for the delivery community CVD care in areas of need, and low-cost single-pill combination CVD therapy. Third, increasing our understanding of successful implementation and sustainability of improvements is essential for CVD as a widespread chronic disease. Learning how to better implement effective therapies for CVD will have a larger effect on patient outcomes than most single new drugs and is a priority for tackling the global burden of CVD.

  • Cardiovascular disease
  • Management
  • Prevention
  • Guidelines
  • Adherence
  • Knowledge translation
  • Implementation

The problem

Worldwide, there are ∼18 million deaths each year from cardiovascular disease (CVD) and at least 2–3 times as many experience non-fatal CV events.1 Cardiovascular professional organizations and health authorities around the world endorse numerous evidence-based recommendations for the screening, prevention, and management of CVD. Partial adoption of these recommendations into clinical practice in the past decades has contributed to decreased CVD mortality in high-income countries (HIC).2,3 However, significant ‘evidence–practice gaps’ (EPGs) persist between the evidence-based recommendations and their implementation, and these are even more substantial in middle- and low-income countries (MIC and LIC), where 80% of the CVD burden occurs.4 Although the magnitude and causes of the EPGs and potential solutions may differ among LIC, MIC, and HIC, the EPGs described here are primarily global problems that affect rich and poor countries. Two different types of EPGs can be identified: (i) lack of implementation of proven effective strategies (‘under-use’) and (ii) inappropriate use of strategies with strong evidence against, or insufficient evidence for their effectiveness and safety (‘over-use’). ‘Under-use’ gaps lead to much smaller benefits than could be expected compared with what might be potentially achieved if an intervention was optimally deployed. ‘Over-use’ gaps waste resources and can put patients at unnecessary risks. Taken together, we are harvesting only a fraction of the potential health gains from the appropriate use of current evidence. Reducing these EPGs will likely lead to greater population benefits than the potential benefits of most novel treatments.5 In order to design more effective implementation strategies, we will have to better understand: (i) the types of gaps; (ii) where and why such gaps occur; (iii) why current efforts to overcome gaps are insufficient; and (iv) how we can narrow these gaps.

The evidence–practice gaps for cardiovascular disease

What types of EPGs exist for CVD and where do they occur? Over the past several decades, quality assessment projects, administrative databases, registries, and surveys have shown several important improvements in the implementation of established CVD evidence, especially in HIC. For example, patients with acute myocardial infarction encounter shorter in-hospital delays in initiating life-saving therapies.6 Patients more often undergo revascularization, and the majority leave the hospital with recommended prevention medications.610 In addition, smoking rates have declined in HIC11 and persons with hypertension,12,13 hyperlipidaemia,14 and diabetes15 are increasingly diagnosed and treated to recommended targets. However, these relative improvements remain suboptimal in HIC, and are low in MIC and LIC. Further, the use of secondary prevention strategies declines over time so that the EPGs widen after discharge from hospital. Several examples of EPGs in the screening, diagnosis, prevention, and management of common cardiovascular conditions will be reviewed (Table 1), which need to be addressed to improve population outcomes.

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Table 1

Examples of under-use and over-use gaps per step in the cardiovascular disease care process

Under-useOver-use
ScreeningSimple global CVD risk scoring16Exercise stress testing in low-risk patients17
DiagnosisPre-hospital ECG in emergency transport for patients with ST-elevation acute myocardial infarction18Left ventriculography despite availability of a non-invasive assessment of left ventricular function19
Primary preventionOral anticoagulation for stroke prevention in high-risk AF patients20Hormone replacement therapy in healthy post-menopausal women for CVD prevention21
Secondary preventionLow sustained use of aspirin, beta-blockers, ACE inhibitors/AT2 receptor blockers and statins following a myocardial infarction22Percutaneous coronary intervention for stable/non-acute coronary artery disease23
  • ECG, electrocardiogram; AF, atrial fibrillation; ACE, angiotensin-converting enzyme.

‘Under-use’ of proven therapies

The main challenge regarding implementation of best practice is to increase the application of proven therapies in appropriate patients. Over three-quarters of all CV deaths occur in individuals without vascular disease,24 and yet, combinations of risk factors which put individuals at substantial risk are highly prevalent in these asymptomatic persons.25 Comprehensive risk assessment in adults without known CVD using simple risk scoring tools can aid with identifying persons at high CVD risk (e.g. ≥20% in 10 years) and enables early preventive interventions.2628 However, only a minority of physicians use them, leading to a mismatch between evidence-based risk scores and physician risk assessment.16 What further complicates adequate CVD risk assessment is the patient's lack of awareness of easily diagnosable and treatable conditions: 20–50% of patients in HIC and 60–70% in MIC and LIC are not aware that they have hypertension (Chow et al., in preparation).12,13

Once a high-risk individual is detected, the provision of recommended care and achievement of treatment targets is frequently suboptimal. In primary CVD prevention, measures to aid patients with lifestyle changes usually cease at general advice and do not include more specific supportive measures, such as referral to a dietitian.19 When a CV event occurs, inadequate use of secondary prevention measures leave patients at risk for recurrent events. Although medication prescription rates at hospital discharge from an acute coronary event are impressive in HIC, and even in some LIC,29 persistence with evidence-based therapies decreases by 30 days and falls to as low as 50% by 6 months after discharge.3033 In addition, persistence is even worse for lifestyle recommendations such as quitting smoking, following a healthy diet, and exercising.34 Even in HIC, less than half of CVD patients are enrolled into cardiac rehabilitation programmes that facilitate short-term recovery and promote long-term adherence to lifestyle changes and medications.3538 Finally, reaching risk factor control targets is important for both primary and secondary prevention, but only about 40% of patients achieve recommended blood pressure and cholesterol targets, and about one-third achieve  glycosylated haemoglobin targets.35,36 These are clinic-based studies with selected patients accordingly, but community-based studies show larger EPG in HIC, MIC, and LIC. In the community, half of patients stop taking antihypertensive medications,39 more than half stop statins,40 and three-quarters stop aspirin within 1 year of receiving their index prescription,41 with even substantially lower proportions taking these medications at 5 years.42 The Population Urban Rural Epidemiology (PURE) study showed that in HIC only half of patients with known coronary artery disease and a third of patients with a previous stroke were using three or more recommended therapies at 5 years after the index event,22 and 50–75% of patients with known CVD in MIC and LIC were not using even one recommended medication. Add to these gaps the fact that half of those who remain on medication are not adherent,39 and the aggregate effect means that few persons at high risk in the community receive the full benefits of simple, inexpensive, proven, and safe therapies for CVD prevention (Figure 1).12,43

Figure 1

The cumulative effect of gaps for cardiovascular disease risk detection, treatment, and control in the National Health and Nutrition Examination Survey (USA).12,43

‘Over-use’ of ineffective or harmful therapies

Besides the problem of narrowing gaps for the ‘under-use’ of proven effective therapies, we also have to face the challenge of reducing the use of therapies that are proven ineffective or even harmful, or may be of value in one condition but is widely used for other conditions. About 20% of patients with a chronic condition and 30% of patients with an acute condition received ‘contraindicated’ care.44 For example, exercise stress testing with non-invasive imaging is a useful diagnostic tool when used in specific populations/situations, but it is often over-used in low-risk individuals with slight diagnostic benefit.17 While these non-invasive tests carry little upfront risk aside from radiation exposure, a ‘false-positive’ result leads to subsequent invasive tests, such as coronary angiography that involve increased risks. Also, while PCI is almost always appropriately used in patients with acute coronary syndromes, over-use of this invasive and costly procedure is common in patients with mild or stable symptoms of coronary artery disease.23 Not only are health-care providers exposing their patients to potentially harmful or ineffective strategies, but the use of such therapies may divert attention and resources from strategies that may be less ‘attractive’ but are equally or even more effective.17

Knowledge translation—a strategy to reduce evidence–practice gaps

Recognition of these EPGs has led to the emergence of the field of knowledge translation (KT) research, also known under many other names including, but not limited to, implementation science, dissemination research, and health services research.45,46 Knowledge translation describes processes that facilitate the transfer of high-quality evidence from research into effective changes in health policy and clinical practice, to ultimately improve patient outcomes.47 Knowledge translation research studies the determinants and effective methods to promote the uptake of evidence-based practice. To illustrate, several large-scale programmes such as the Get With The Guidelines initiative in the USA and the Canadian Hypertension Education Program have been associated with improved quality of CVD care and patient outcomes.13,48 Knowledge translation researchers aim to discern which potential obstacles have to be overcome to make such programmes a success, which interventions are most effective at achieving this (ideally evaluated in ‘pragmatic real-world’ randomized controlled trials), and how proven effective strategies can be integrated into different health systems.45

Evidence for current knowledge translation interventions

We have reasonable evidence for some KT interventions, which may be directed at the patient, health-care provider, or health system. Table 2 provides specific examples of their impact, which is largely based on the Cochrane Collaboration's database of the Effective Practice and Organization of Care (EPOC) review group.49

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Table 2

Examples of knowledge translation interventions at the patient, provider, and system level

Example of interventionDescriptionEffect
Patient-level interventions
 Patient decision aidsTools that help people become involved in decision-making by providing information about the options and outcomes of a treatment, and clarifying personal values60% increase in accuracy of patient's risk perception; 30% reduction in post-menopausal hormone use; 20% reduction in discretionary surgery50
 Self-managementPatients monitoring themselves, and making medication dosing decisions, with health-care provider back-upSelf-management of vitamin K antagonist: 49% reduction in thrombotic events51

Self-management of heart failure: 56% reduction in heart failure hospitalizations52
Provider-level interventions
 Continuing education meetingsConferences, lectures, workshops, seminars, symposia, and courses for health professionals6–10% increase in uptake of recommended care53
 Audit and feedbackAny summary of clinical performance over a specified period of time, given in a written, electronic or verbal format5–16% increase in the uptake of recommended diagnostic and therapeutic strategies54
 Educational outreach visitsVisits by a trained person to health professionals. ‘Face-to-face’ visits, also referred to as academic detailing5.6–21% increase in uptake of recommended care, depending on the clinical context
 Local opinion leadersHealth-care professionals considered by colleagues as ‘educationally influential’12% increase in uptake of recommended care55
 Computer-assisted clinical decision supportAutomated clinical decision advice, based on individual patient dataModest effects on process of care for a range of management issues5661
Organizational/system-level interventions
 Clinical pathwaysStructured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problemReduction of in-hospital complications for patients undergoing an intervention, primarily surgery (OR = 0.58 [0.36–0.94]), and improvement of documentation in medical records (OR = 11.95 [4.72–30.30])62
 Financial incentivesFinancial reward for professionals for affecting behaviour, including for a specified time period of work; for each service, episode or visit; for a patient or specific population; for providing a pre-specified level or providing a change in activity or quality of carePotential improvement in practice, but effects on patient outcomes are unknown63
 Legislation-based smoking bansLegislative smoking bans and restrictions affecting populationsAssociated with a substantial reduction in admissions for acute coronary syndromes, related to improvements in first-hand and second-hand smoking exposure64,65
  • OR, odds ratio.

Patient decision aids are an effective means to involve patients in the decision-making process and have been demonstrated to improve the quality of decision-making by significantly improving knowledge of the patient's health-care options, improving the patient's accurate risk perception, and improving value congruence with the chosen health-care option.50 At the provider level, audit and feedback is a common intervention used to highlight discrepancies in evidence-based care, which is potentially most effective when coupled with strategies to reduce the EPG.66 Finally, changes to legislation, government policy, and organization of care are aimed at improving the EPG at the health system level, but their impact is harder to discern, unless they are evaluated prospectively in studies with an appropriate design.64,65 Bearing these limitations in mind, it has to be noted that smoking bans are associated with improvements in smoking exposure and population cardiovascular outcomes (Table 2).

The need for more effective knowledge translation strategies

Despite the existing efforts of KT research, why are we continuing to fail at implementing what we know works in CVD care? Unfortunately, there are no ‘magic bullets’, and despite extensive evidence supporting several KT interventions, the impact on the uptake of evidence-based practice has been modest at best and effects on patient outcomes are often not evident.67,68 Therefore, we describe three potential areas of research to improve KT for CVD (Figure 2).69 Involving important stakeholders including patients, physicians, and governmental and regulatory bodies at each of these steps is essential to fully understand barriers to optimal CVD care, as well as designing, implementing, and sustaining effective strategies.

Figure 2

Three steps in the knowledge-to-action cycle that are the focus of this review (encircled).69 Copyright © 2006. The Alliance for Continuing Education in the Health Professions, The Society for Academic Continuing Medical Education, and The Association for Hospital Medical Education.

Identifying barriers to evidence–practice gaps

The first potential explanation for the limited success of KT interventions to date is inadequate knowledge about context-specific barriers (at the patient, provider, or systems levels) to the uptake of evidence-based CVD care. Following the identification of an EPG, the next step is determining which provider or patient behaviours should be changed to achieve implementation or de-implementation of a practice. Thereafter, understanding the factors that can impair appropriate change is an important step in the knowledge-to-action framework to select, tailor, and implement interventions (Figure 2).69 Database analyses and population studies can reveal disparities and identify population subgroups that require extra attention, for example based on age, sex, geographic location, or socioeconomic status.70 However, these indirect assessments usually cannot expose the actual reasons for the observed gaps.71,72 Evidence–practice gaps represent discordance between recommended behaviour and observed behaviour of health-care providers and patients. This behaviour is influenced by providers' knowledge of and attitudes towards the application of best practice, patients' knowledge of and attitudes towards adherence to recommendations, as well as external factors related to the health system (Figure 3).7376 These factors should be explored as barriers to evidence-based care.

Figure 3

Framework to go from gap identification, via barriers assessment to knowledge translation intervention design, using hypertension control as an example.

Barriers to evidence-based cardiovascular disease care

Potentially, multiple barriers can limit effective CVD care, and their importance depends on the specific context in which EPGs are revealed. For example, the availability and cost of care can be relatively more significant barriers in MIC and LIC compared with HIC. Figure 3 illustrates how some examples of barriers can explain the hypertension control EPG. At the patient level, barriers relate to reluctance to take medications that do not offer symptomatic improvement, and high costs of medications, among many others.77,78 At the physician level, example barriers that contribute to EPGs include limitations in practice infrastructure and time, and disagreement with guidelines.16,79 At the health systems level, barriers include lack of policy support for chronic care and prevention, and limited access to health-care resources.80

Barriers to the de-implementation or restriction of over-used/unproven CVD therapies have not been well described in the literature, but these need to be identified as well. Such barriers may include physician and patient attitudes or expectations, provider dependence on the revenues from such unproven but lucrative procedures/tests/practices, or simply a mistaken belief in the value of the above.

How to assess barriers to care

Physicians and decision-makers who have identified an EPG in their local context can use several methods to identify the main modifiable barriers, to inform the design of effective strategies to overcome the gap. Direct information from patients, health-care providers, policy-makers, and content experts can be obtained through methods such as in-depth interviews, focus groups, questionnaire surveys, and meetings or workshops.81 Sampling from specific settings or subgroups that are performing well vs. inadequately will allow identifying the reasons for any observed variations in practice. Using a theoretical framework to organize barriers can aid with identifying specific intervention targets, which we will illustrate using hypertension as an example at the patient, provider, and health system level.

At the patient level, Turner et al.82 designed a questionnaire to assess patient-reported barriers to antihypertensive medication adherence based on the theory of planned behaviour. They identified problems with medication filling/use (perceived behavioural control), patient–provider interaction (subjective norms) and poor hypertension knowledge as the most significant barriers. At the provider level, Roumie et al. qualitatively assessed reported reasons for (in)action for prescribing antihypertensive medications among primary care physicians following reminder alerts.74 Results were sorted into the framework by Cabana et al. to explain the variations in guideline adherence, whereby clinical inertia (health-care providers choosing to postpone therapy initiation or intensification when this was recommended) was identified as the primary reason for failing to apply recommended hypertension care.83 Finally, at the health system level, barriers regarding resources and delivery of care can be obtained through interview of policy makers, providers, and patients, as well as observation of local resources. Balabanova et al.84 used such an approach (‘rapid appraisal’) to map regional diabetes care in Georgia, using a framework to describe the availability of resources and the processes to utilize resources. They identified that appropriate resources were available, but that constraints within the system, including troublesome access to medications and poor linkage between primary and secondary care, prohibited the delivery of accessible and affordable care. A similar approach could be used to describe barriers to the effective management of hypertension in a range of settings and for other chronic conditions.

Despite the examples above, the assessment of barriers is a nascent, evolving area and requires much work. Currently known barriers to best practice have been primarily studied in HIC. Their relative importance is context-specific and so similar studies need to be carried out in a range of settings, including affluent and deprived communities, in LIC, MIC, and HIC, and in urban and rural communities as some examples. In addition, tools to assess barriers should ideally be validated and provide reliable results in varying settings. Efforts to improve the overall quality of such studies will allow better comparison of barriers among different contexts and facilitate linking effective intervention strategies to specific barriers.

Selection of knowledge translation interventions

A second explanation for the limited success of KT interventions to date could be the lack of tailoring KT interventions to the most important modifiable barriers, or simply using ineffective intervention strategies.

Tailoring interventions to modifiable barriers

It has been demonstrated that interventions tailored to identified barriers have a greater impact compared with non-tailored interventions.81 Examples of tailored interventions include (i) point-of-care reminders, if physicians' forgetfulness is the main barrier to guideline adherence and (ii) continuing medical educational sessions if physicians' lack of knowledge regarding established guidelines is the primary problem. The methods by which interventions are tailored to barriers often remains unclear, especially when multiple barriers exist, which is usually the case.81,85 Considering that the ultimate goal is to change the behaviours of providers and/or patients, behavioural theory can be used to link interventions to identified barriers. French et al.86 used the Theoretical Domain framework to label provider-reported barriers for applying recommended acute low back pain management in primary practice to theoretical domains for behavioural change. Thereafter, a panel of content experts selected interventions that are known or likely to affect the identified domains. For example, physicians' beliefs about the risks and benefits of following the guidelines limited the application of recommended care (‘beliefs about consequences’), which could be targeted with monitoring the quality and consequences of practice for feedback to providers, as well as having a local opinion leader reinforcing the guidelines.

The importance of a barrier assessment to tailor interventions was illustrated in a recently published large-scale, cluster randomized controlled trial evaluating the use of non-physician health-care workers (NPHW) to improve the screening and uptake of guideline-recommended CVD therapies.87 The NPHWs were significantly better than usual care at identifying high-risk individuals and provided a management strategy that was similar to that of physicians. However, the intervention involving NPHWs did not translate into an increased uptake of proven therapies, which was due to two health systems-related barriers. First, NPHWs were not authorized to prescribe medications. Second, the costs of these proven therapies and the required visits to physicians were often prohibitive. Knowledge of these barriers in advance may have helped to tailor the intervention (e.g. by getting special permission for trained NPHW to prescribe a limited range of inexpensive and safe drugs), and in turn positively impact on clinical care.

Identifying promising components for knowledge translation interventions

Even if KT interventions target the most prominent modifiable barriers, the intervention's impact may still be limited as the selected intervention components are simply not effective enough to overcome such barriers. To optimize the use of effective intervention components, adequate evaluation of complex CVD interventions must be undertaken and novel approaches from KT research in other fields need to be considered.

Multi-faceted interventions

Usually complex (multi-faceted) interventions are used in KT research. The BRIDGE-ACS trial in Brazil randomized 36 public hospitals—enrolling 1150 patients with an acute coronary syndrome—to either a multi-faceted intervention (including educational resources, reminders, and the use of a case manager), or to ‘routine care’. The intervention improved the acute application of the full package of secondary prevention medications from 50% (routine care) to 68%, which persisted at discharge (32 vs. 51%).88 However, even when such a cluster of interventions was effective it was not known which specific components primarily contributed to the benefit and what the causal mechanisms were. In contrast, when a complex intervention was not effective, one or more effective components could have been obscured by other ineffective or harmful components. To better understand why complex interventions are effective or not, and to single out promising components, formal process evaluation of interventions is needed.89 Studies often lack sufficient details to identify effective components, thereby limiting the intervention's generalizability and limiting systematic reviews.90 Therefore, it is important to report intervention details, explain the presumed change process and intervention design, provide access to protocols and describe active control strategies in sufficient detail.91 Furthermore, qualitative process evaluations that are conducted in parallel with trials, rather than post hoc analysis, can help to explore intervention uptake, and causal mechanisms for achieving behavioural change, thus optimizing the interpretation of individual trial results.89,92

Adopting proven interventions established outside of cardiovascular disease research

Knowledge translation research for CVD needs to learn from promising interventions and strategies from other specialties of medicine that have not yet been extensively tested for CVD. Optimizing the use of information communication technology, restructuring of the frontline health-care workforce, and innovative pharmaceutical delivery are examples of novel strategies that could aid with improving delivery and uptake of evidence-based CVD care.

Using available information communication technology for knowledge translation

Poor long-term medication persistence and adherence of patients is a complex issue resulting in increased mortality,93 and shares many parallels with other chronic medical conditions, including HIV. Both involve a long-term commitment to medication that may not have noticeable symptom benefits for the patient and improve day-to-day quality of life. Novel interventions that optimize current technology should be further explored. Cell phone text messaging has been shown to improve adherence to antiretroviral therapy in two randomized controlled trials in Kenya,94 improved healthy behaviour and diabetes control,95,96 reduced non-attendance to outpatient clinics, which is a known surrogate for medication non-adherence,97 and increased smoking cessation rates.98 Adopting this strategy to target long-term medication adherence and lifestyle modifications in CVD care could have a great impact considering the high rates of cell phone subscriptions in most countries.99 Overcoming potential issues related to language, timing of messages, mobile network fluctuations, lack of financial incentives, data privacy, and mobile phone turnover should optimize its widespread use.100

Task shifting: transferring clinical tasks from physicians to trained non-physician health workers

A second example of a potential novel strategy to improve the uptake and delivery of CVD care involves task shifting from high-cost health workers (e.g. physicians) to lower-cost-trained personnel (e.g. NPHWs) to deliver a sustainable model for chronic CVD care in areas of need. As illustrated by the example study before,87 their effectiveness depends on support by the health-care system. Non-physician health workers have been successfully used in LIC and MIC, and in areas of low socio-economic status in HIC, to deliver maternal and child health care as well as to improve the quality and coverage of HIV management.101 Furthermore, NPHWs including nurses, pharmacists, and community health workers have occasionally been successfully used in HIC for the management of patients with hypertension and CVD, and are more effective than physicians in improving adherence to chronic medications or healthy lifestyles.102105 Given the success in several observational studies for HIV management in sub-Saharan Africa, the World Health Organization proposed Global recommendations and Guidelines for task shifting in other chronic diseases including CVD in 2008.106 Recent randomized controlled trials indicated that NPHWs can provide comparable HIV care as physicians, and can improve comprehensive care and wellbeing for HIV patients.107,108

Low-cost fixed-dose combination pills for cardiovascular disease prevention

Finally, the use of easy-to-dose and administer, low-cost CVD combination therapy has great potential for the population-wide uptake of evidence-based care. As outlined above, extensive EPGs exist with respect to the use of CVD therapies for both primary and secondary prevention. Furthermore, some of the barriers include the need for repeated monitoring and dose titrating accordingly, polypharmacy, prohibitive costs, and difficulties with long-term adherence. A fixed-dose, single pill combining key evidence-based primary or secondary preventative medications is a KT intervention in itself that targets and potentially overcomes such barriers by increasing efficiency of the health-care provider, improving affordability because of lower medication costs and fewer doctor visits, and enhancing long-term adherence.109 Several studies have demonstrated the feasibility, efficacy, and safety of a CVD fixed-dose, combination pill, and studies evaluating its effect on patient outcomes are underway.109

Implementation and long-term sustainment of knowledge translation interventions

If we target the relevant barriers with a proven effective KT strategy, we still might not show an improved use of evidence-based care and patient outcomes in the population due to problems that arise in scaling up a strategy for widespread or long-term use.

Knowledge translation interventions, which appear to be effective in research studies, may not be effective in practice due to lack of generalizability.109,110 An intervention which can be specifically tailored to the research setting, or is delivered with dedicated personnel who are hired for the study, makes it less likely that the intervention is generalizable to other settings. An example of successful adaptation is the Diabetes Prevention Program (DPP),111 which was effective in a multi-site research study and was consequently adapted in community lifestyle intervention programmes that replicated benefits for glucose lowering and weight loss.112114 When deciding on the choice for an implementation strategy in general, a programme as the DPP should be considered more likely to be successful than interventions from single-centre studies that have not been replicated. Further, successful implementation in health-care organizations depends on whether the intended change is in line with local policy, does not interfere with other processes that are effective, has the support from those persons who will need to change, and whether actual change can be monitored for feedback.115 The Cardiovascular Health Awareness Program (CHAP) study used the involvement of lead organizations with a strong interest in health promotion, an implementation guide with specific implementation steps, and monitoring of progress to deliver volunteer-led pharmacy-based CVD risk assessment sessions.116 This study succeeded in balancing standardization of the intervention with flexibility to adapt, which is important to maintain delivery of the intervention as proven effective, while still being able to tailor to the local context. Once a strategy is successfully implemented, its use should be sustained over the long term. This is challenging in the hospital setting, but even more difficult to achieve in the community given greater variability and relatively less availability of health care and monitoring resources in the community.

Future directions

There is a critical need and a major opportunity to improve population outcomes by means of better implementation of proven strategies for CVD. However, our current limited understanding of effective KT is preventing substantial advances. We have proposed specific approaches in three areas to narrow EPGs more effectively (Table 3): (i) better assessment and understanding of the observed gaps by means of barrier assessments; (ii) considering innovative intervention strategies from outside current CVD research, especially in areas where major barriers exist and little progress has been made; and (iii) Increasing our understanding of successful implementation and sustainability of improvement. Advances in fundamental research to develop effective KT techniques, and in applied research to successfully deliver those techniques in a range of contexts, are both needed to tackle the burden of CVD.

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Table 3

Summary of recommendations for advancing cardiovascular knowledge translation research

ApproachAnticipated improvementExamples
Validated and reproducible assessments of barriers to recommended careMore reliable barrier assessments that will facilitate comparison of barriers across settings and design of tailored interventions, increasing the likelihood for successful KT
  • Use a theoretical framework

  • Standardized patient and provider questionnaires, per health issue

  • ‘Rapid appraisal’ of local process of care

Consider innovative interventions, also from other disease areasPotential for larger effect than with current efforts in CVD
  • Dissect complex interventions

  • Combination therapy

  • ‘Task shifting’

  • Cell phone communication

Design flexible and generalizable interventionsPromote long-term widespread uptake of successful interventions beyond the study setting
  • Assess the needs of, or involve, all stakeholders in study design

  • Develop an implementation guide

  • Evaluate successful programmes

Acknowledgements

We thank R Brian Haynes for his valuable feedback for this manuscript.

Conflict of interest: none declared.

References

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