Science – Part 4: From medical research to clinical practice

In the fourth part of our blog series on science, we look at the implementation of research results in clinical practice: How does this process work – and why does it often take so long?

Science is increasingly present in our lives. We are confronted with the results of scientific studies in newspapers, on television and in the online media. The headlines are often striking, announcing breakthroughs such as:

• “New injection technique may boost spinal cord injury repair efforts”
• “'Cell pores' discovery gives hope to millions of brain and spinal cord injury patients”
• “Scientists regenerate neurons in mice with spinal cord injury and optic nerve damage”
• “Benefits of stem cells for treating spinal cord injuries assessed. A realistic hope for spinal cord injury patients”

Especially when we are suffering from a serious health condition, we hope that these findings will be translated quickly into clinical practice so that we can benefit from them as soon as possible.

However, many of these studies are still at an early stage. As mentioned in the first part of this blog series, even when research is promising, is still has a long way to go from experimental research on mice to human trials. And once a treatment has shown promising results in clinical trials, there is still a long way to go before it can be implemented into clinical practice.

However promising research results may be, it usually takes a long time before they are applied in clinical practice. (Source: Hillary Sanctuary / École polytechnique fédérale de Lausanne EPFL)

In this blog post, we explain the path from of scientific results into clinical practice. Being aware of the steps and hurdles can help us better understand the complexity of implementation. But it is also helpful in appreciating the work that clinicians do to ensure that we benefit from the best scientific evidence, while at the same time respecting our needs and preferences.

How research finds its way into clinical guidelines

Research findings often have a long way to go before they become part of clinical practice. It can take years. In fact, as mentioned in the second part of this series, it is rare for a single trial to be integrated into clinical practice. The results of one study must be replicated in other studies, and the results of all these studies must be aggregated, analyzed and synthesized before recommendations for the clinical practice can be developed.

These recommendations often take the form of clinical guidelines, which are documents that describe how to treat patients. They are based on the best available evidence and on systematic and transparent consensus processes, involving a wide range of experienced health professionals and researchers (see Council of Europe, 2002). These documents are often initiated by public or governmental institutions and produced by international scientific societies (e.g. International Spinal Cord Society) or national or local institutions (e.g. Swiss Paraplegic Centre).

Barriers to implementation of guidelines in clinical practice

The implementation of national and international guidelines in everyday clinical practice varies greatly from country to country. Several non-scientific factors influence their uptake, such as government policy, cost-effectiveness and health insurance reimbursement.

There are many barriers to the rapid trantslation of new guidelines into clinical treatment practice. The image shows a wheelchair user performing virtual walking at the Swiss Paraplegic Center.

But political and economic issues are not the only hurdles; training and time are other issues. Indeed, clinicians and practitioners need to be aware of the new guidelines and learn about the recommended treatments. In fact, despite the large number of studies produced on a daily base in hospital and primary care settings, patient care is not based solely on scientific evidence; instead, clinical experience and historical developments play an important role.

In addition, clinical practice guidelines from different countries sometimes provide conflicting recommendations. In such cases, clinicians need to be able to make informed decisions about which treatment is more appropriate (see Oxman et al, 2008).

Guidelines do not take into account the individual situation of the patient

Finally, guidelines are often very narrow in scope; to implement them, however, practitioners must also consider the specific situation of the patient. For example, there are several guidelines for the prevention of pressure injuries in spinal cord injury patients – but how can the recommended behaviors be integrated into the person's life, taking into account other health conditions and self-management requirements? One guideline might be to do regular push-ups in a wheelchair, but what if the person has shoulder pain? Or a guideline might prescribe a surgery followed by three months of inpatient rehabilitation, but what if the patient wants to avoid invasive procedures to preserve his or her family life?

As we can see, the translating research into clinical practice is not a linear process. Many factors play a role in deciding whether and how to use them for the benefit of patients. Each patient is unique: they may have similar clinical situations, but they often have different needs and preferences. Clinicians must take these into account when proposing a medical procedure; no “automated” process will be able to define what is best for every patient. For this reason, the interaction between clinicians and patients is central to any medical decision.

Communication between patients and health professionals and consideration of the patient's individual situation are crucial to any medical decision.

References:

• European Science Foundation (2011). Forward Look: Implementation of Medical Research in Clinical Practice. Link (pp. 30-31, “Major issues”)
• European Science Foundation (2012). Implementation of Medical Research in Clinical Practice. Science Policy Briefing No. 45. Link
• Council of Europe 2002. Developing a Methodology for Drawing up Guidelines on Best Medical Practices. Recommendation (2001)13 and explanatory memorandum. Link (German version)
• Oxman A et al. What should clinicians do when faced with conflicting recommendations? BMJ 2008;337:a2530. Link