From evidence to influence: dissemination and implementation of scientific knowledge for improved pain research and management

Scientific research in painwill only help patients if it can be effectively disseminated and implemented. Much attention has been devoted in recent years to the insufficient progress made in translating laboratory research in pain into clinical practice. This discussion, however, is typically focused on the challenge of moving findings from basic science studies to human clinical research studies. There is a second, equally important, and challenging translational step in the research continuumthat is often overlooked: theprocess whereby evidence from clinical research is moved into clinical practice. As noted in Figure 1, there are 2 gaps along the translational continuum, referred to as the “Valleys of Death,” with valley 1 representing the first gap (ie, the gap between basic science and clinical science) and valley 2 representing the second gap (ie, the gap between clinical science and clinical practice). With an estimated 2.5million scientific articles published each year, and global scientific output doubling every 9 years, it cannot be assumed that this vast research knowledgewill automatically result in improvements in clinical practice that will benefit patients. Various estimates show that it can take 17 years on average for research findings to be adopted into practice. Moreover, as shown in Figure 2, it is a leaky pipeline; only 14% of clinical research ever finds its way to practice. Across health settings, it is estimated that one-third of patients do not benefit from evidence-based treatments; one-quarter of patients receive care that is not needed or is potentially harmful; up to three-quarters of patients, and over half of physicians, report not having the information they need for decision making. Gaps between evidence and practice are also evident in pain research and management. In the area of pediatric pain, a recent review of the scientific literature published from 1975 to 2010 demonstrated exponential growth in the field. Yet, despite the availability of high-quality evidence and clinical practice guidelines for effective management, best available evidence is rarely used in practice for managing children’s pain. Stevens et al. collected data on procedural pain assessment and management practices at 8 Canadian children’s hospitals and showed that approximately 80% of the hospitalized children whose medical records were reviewed experienced at least 1 painful procedure over 24 hours (the average was 6 procedures per child). More than two-thirds of these children had no documented pain management intervention for their procedures. This result is concerning, given significant research evidence in support of a variety of effective procedure pain management strategies that have been reported in randomized clinical trials (eg, breastfeeding and sucrose for infants, positioning, topical anesthetic creams, and distraction), summarized in systematic reviews and clinical practice guidelines, and recommended for global health implementation. Similar knowledge to action gaps have been reported for children’s pain in the emergency department (with most procedures being performed without any analgesia), after surgery (with many children having proper postoperative pain management withheld or diminished because of concerns about addiction), in the Neonatal Intensive Care Unit (NICU; with many babies not receiving pain management for procedures) and in the management of children experiencing chronic pain (with limited accessibility to multidisciplinary pain clinics and long waiting times). These gaps are alarming because poorly managed pain in children is associated with a range of negative shortand long-term effects, including delayed healing, altered brain development, pain sensitization, and health care avoidance. The reason for these knowledge to action gaps is underpinned by the typical approach to moving scientific discoveries into practice that has largely been haphazard, driven primarily by initiatives such as continuing medical education and clinical practice guideline development. These efforts, while important, have been insufficient on their own to ensure improvements in clinical practice and health outcomes. Most clinical practice guidelines are never used in practice, and the amount and frequency of continuing medical education activities have been found to be unrelated to improvements in health professional practice change. A broader approach is urgently needed to ensure that scientific research in pain is effectively disseminated and implemented to help patients with pain. The objective of this article is to inform pain researchers and clinicians regarding the rapidly developing field of dissemination and implementation research and its potential to be applied to pain. The article provides an overview of the science and practice of dissemination and implementation including key terms, theoretical frameworks, research designs, and outcomes used in implementation and dissemination research. Different strategies for dissemination and implementation are presented, including examples from the area of pediatric pain. Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Departments of a Pediatrics and, b Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada, c Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada