OutBox

264 Years Is Too Long

By Maulik Joshi

We need to better educate and integrate research into practice

As we find better ways to deliver health care, a challenge arises: How do we “spread” or disseminate best practices and innovations from one area of the hospital system to another? Whether it is called knowledge transfer, translating research into practice, diffusion of innovations or disseminating best practices, taking something that works well from one part to the rest of the system is no easy task.

A classic example, noted by Donald Berwick, M.D., of the Institute for Healthcare Improvement, of the extensive time it takes to disseminate best practices dates back to the British Navy’s fight against scurvy, a disease caused by vitamin C deficiency. Death from scurvy is rare today, but the death toll was once significant.

In 1601 on a voyage from England to India, Capt. James Lancaster gave three teaspoons of lemon juice per person daily on one of his four ships. Halfway through the journey, 40 percent of the crew from the ships who did not get juice died of scurvy; no crew members died of scurvy on the ship that received juice.

Yet practice was not changed.

In 1753 James Lind, a ship’s surgeon, published A Treatise of the Scurvy, one of the earliest accounts of a prospective clinical trial, comparing six scurvy treatments.

But practice did not change.

Other rations of juices were tested and provided, but it was not until 1865 that the British Board of Trade mandated citrus fruit for all merchant marine vessels. Finally, practice was fully implemented. (Stephen Bown tells this story in Scurvy.)

Although a 264-year journey from initial discovery to full implementation may not be the norm, a slow rate of adopting innovation is common. In 2001, the Institute of Medicine estimated that it takes up to 17 years to integrate only 30 percent of clinical recommendations from medical research. Regardless of the specific number, the magnitude of the number is grave to health care leaders: Patients’ lives and health are at stake. The most compelling best practices or improvement results will not easily transfer to other areas unless a formal dissemination plan is designed and monitored to ensure success.

Everett Rogers has published seminal work on diffusing innovations. He describes innovators as the first to try change, followed by early adopters, early majority, late majority and then laggards. It is important to find innovators and early adopters to create change momentum for others to follow. Also, a person may be an innovator for trying a new clinical guideline but in the late majority for adopting a new physician referral form. We must find the innovators and early adopters for each innovation to reach the mass.

Research is essential to transforming the U.S. health care system. But 17 years to integrate research is too long when people’s lives are at stake. We need to better educate and better integrate research into practice. Whether using Rogers’ model or another, we need a dissemination plan targeted to our objective: raising awareness of best practice and getting people to use it.

Maulik Joshi, Dr.P.H., is president of the Health Research & Educational Trust (HRET) and senior vice president for research at the AHA.

You can contact our guest author at mjoshi@aha.org.

This article 1st appeared in the March 2009 issue of HHN Magazine.

To respond to this article, please click here.