The gap as two problems 68

The gap is described as made up of two types of problems in the discourse. One is expressed as a problem of timing, that is, as a form of delay or unevenness to get research results into the expected action. Strong language is used to describe this problem, such as “haphazard” and “unacceptably long”, emphasizing the seriousness of this problematization. These adjectives also describe the second gap-related problem: the negative consequences of research results not being incorporated into practice in a timely manner. Dire consequences are predicted such as patients being denied necessary treatment. The linking of a time or uneven delay between the incorporation of health research into practice and serious consequences suggests a subtle cause

and effect relationship between health research and expected outcomes. These problems are evident in the following quote that demonstrates a discursive linking of both gap problems with an aspect of the second rationality, financial accountabilities (Section 5.2.2). Connecting the gap with financial accountabilities suggests a relationship between investment in health research and the problem of the transfer of research results into practice. The gap as a problem occurs despite “considerable resources” that are available for health research:

Despite the considerable resources devoted to health sciences research, a consistent finding from the literature is that the transfer of research findings into practice is often a slow and haphazard process. This means that patients are denied treatment of proven benefit because the time it takes for research to become incorporated into practice is unacceptably long. (Graham, Logan, Harrison et al., 2006, p. 13)

The gap is constructed as a “consistent” problem, particularly given a time delay that is considered “unacceptable”. The next quote frames the gap within the language of health (i.e., “realization of health”) and economic accountabilities. The linking of these themes is common in many of the texts. The gap also becomes identified as a “common” international problem that is not just confined to Canada. This language suggests that the gap as a problem is widespread, experienced by other countries, adding a quality of shared responsibility to potential solutions for bridging the gap:

While health research has made revolutionary strides over the last 50 years, there remains an unacceptable lag time between discovery and the realization of health and economic benefits from applying the knowledge generated through research. Thus, countries and societies face the common challenge of how best to mobilize research to bridge the gap between what we know and what we do. (CIHR, 2004b, p. 6)

Further, the gap is presented as having been a problem almost as long as the successful outcomes of health research have existed, with a history of at least 45 years, previously in the realm of quality assurance work. The explicit linking of the gap with health and economic accountabilities, together with the mobilization of an evidence based medicine discourse brings the gap forward from quality assurance to a more “current”time frame:

Although it has been ongoing since the early quality assurance of Donabedian in the 1960’s, the growing awareness that research findings are not making their way into practice in a timely fashion, coupled with the current emphasis on evidence-based, cost- effective, and accountable health care, has stimulated increased interest in finding ways

to minimize what might be described as the knowledge-to-action (KTA) gap. (Graham, Logan, Harrison et al., 2006, p.14)

The gap is frequently mentioned in the documents I analyzed, and is constructed in the KT discourse as having attained the status of being self-evident. The Graham et al., (2006) document is the only one of the thirteen documents of my sample that reviews any specific evidence for the gap, and is the only document cited as providing this evidence. The literature cited by Graham et al., covering the time period from 1990 to 2005, draws on the language of the well-established discourse of evidence-based medicine. This focuses attention on results of randomized controlled trials, practice audits, and patients not receiving care based on the best evidence. Specific problems cited in the Graham et al. document include patients not receiving scientifically proven care, care that is not needed, outdated, not consistently applied, or harmful:

Also, practice audits performed in a variety of settings have revealed that high-quality evidence is not consistently applied in practice. For example, although several randomized trials have shown that statins can decrease the risk of mortality and morbidity in poststroke patients, statins are considerably underprescribed. In contrast, several studies have shown that antibiotics are overprescribed in children with upper respiratory tract symptoms. At the same time, there are problems with premature adoption of some treatments before they have been shown to be beneficial. When this occurs, patients are exposed to potentially ineffective and even harmful treatments. (Graham et al., 2006, p. 13)

There are also estimates of reduced mortality from cancer with optimum application of knowledge (as of 2006), and problems with the volume of research literature that make it difficult for practitioners to keep current. Citing this particular literature supports the construction of the “knowledge-to-action gap” as a problem that requires a solution:

There is also the issue of the growing accumulation of evidence and practitioners’ ability to keep up to date. Focusing on studies of cirrhosis and hepatitis in adults published between 1945 and 1999, by 2000, only 60% of the conclusions were still valid, 19% were considered obsolete, and 21% were considered false. For many reasons, research findings are not being taken up in practice settings, and many patients are not receiving the best possible care. This situation results in inefficient use of limited health care resources. (Graham et al., 2006, pp. 13-14)

From a governmentality perspective, the finding that only one of the thirteen documents analyzed for the present study provides evidence for construction of the gap and is cited for that

evidence, suggests that the existence of the gap within the discourse of KT at CIHR has become a truth that is generally uncontested. That is, the acceptance of the gap as self-evident is so prevalent within the discourse that in explanations of why knowledge translation is important to CIHR, it is presented as requiring no explanation and thus as offering few opportunities for questioning. This is demonstrated in three quotes below, each of which refers to the same text that is widely repeated in my sample of CIHR documents. The similarity of the language describing the need to close the gap and the expectations of particular beneficial outcomes evident in these quotes from multiple documents is another indication of the gap as self-evident:

KT is important to CIHR because:

The creation of new knowledge often does not on its own lead to widespread implementation or impacts on health. (CIHR, 2010a, p. 1; Tetroe, 2007, p. 2) CIHR wants to close the gap between the knowledge that the research community generates and what is done with that knowledge. (CIHR, 2010b, p. 1)

Knowledge translation (KT) is about:

- Making users aware of knowledge and facilitating their use of it to improve health and health care systems

- Closing the gap between what we know and what we do (the know-do-gap) - Moving knowledge into action (CIHR 2009b, p. 6)

5.2.2 Accountabilities: improving health and the health care system while demonstrating