Our 17-Year 'Knowledge Transfer' Gap Is a System Feature, Not a Bug

We have a gap in healthcare between research and practice, between knowing and doing. This “knowledge transfer” gap is actually a delay, averaging 17 years, in applying research evidence to clinical practice. This gap is one reason many experts have been arguing for decades that healthcare needs fundamental reform. Think of this transfer as a critical stage in what is called evidence-based practice.

Too many discussions of evidence-based practice seem to suggest our work is done. We have a nice selection of practices on the shelf. However, the knowledge transfer gap in healthcare is more complex than that, especially in our field. Pharmacology is relatively straightforward compared with the subjectivity of psychotherapy. Therapists have knowledge, but transferring it is a challenge.

Once we endorse basing real-world care on the uptake of research, what knowledge gets transferred? The reality is that research frequently generates conflicting findings with no final consensus. No ruling body or czar maintains an official register of findings and conclusions. Consider psychotherapy. What conclusions about it should inform a knowledge transfer process?

We have impartial lists of evidence-based therapy practices (e.g., by APA), but many researchers prefer the more comprehensive analysis gained by using meta-analysis. While not without problems, this statistical approach aggregates multiple studies and objectively synthesizes outcomes. Meta-analytic conclusions can differ from single studies, and this is evident in the literature on therapy outcomes.

Wampold’s landmark meta-analytic studies found established therapies, from psychodynamic to CBT, to be highly efficacious. Yet there are no “winners” since these therapies are quite comparable in results. Surprisingly, the therapist accounts for more variability in the results (“therapist effects”) than therapeutic techniques. How do we transfer these findings to practice? Based on what authority?

Meta-analytic work is valued, but studies in conflict with that work still get major funding and respect.  Aggregated research may suggest focusing on therapists and their variability in outcomes. However, our healthcare system thrives on discrete studies, not on meta-analytic or comparative research studies. Why? In part, this is because the FDA’s drug approval process sets the model everyone follows.

This means all validated treatments, including non-pharmaceutical ones, have equal status once approved. Any further comparison or meta-analysis is not required.  Concerns about therapist effects or variability among therapists are interesting, but can be ignored by payers. Two randomized controlled trials (RCTs) are needed for FDA approval. There is no required next step beyond that.

It might be argued that FDA approval signifies meeting a minimum standard, after which additional studies are conducted by a wide range of researchers. However, additional research has no regulatory impact and uncertain business influence. The same is true of research validating psychotherapy. Basic validation is sufficient to launch general use. Business growth may be independent of any further study.

Knowledge transfer may be essential, but we have no structure or authority for tying transfer to evidence of superior outcomes. As drug companies have long worried, any search for superiority risks demonstrating the inferiority of your product. Funding for such probing is limited. We end up with many validated treatments, not knowing if one is superior to the next.

This is not a criticism of public funding. Our government funds everything from the early research generating new medications to a multitude of clinical effectiveness studies. Our focus for change needs to be total spending, knowing full well that our healthcare system lacks a central planning function. We spend nearly $4 trillion annually. We should improve knowledge transfer by re-examining priorities.

Let us remember the reason empirically supported treatments are such a big advance. We know that all of healthcare, not just care provided within our field, is riddled with treatments lacking in any validation. It is a step forward when healthcare systems are encouraged to abandon remedies favored by tradition or personal preference in exchange for validated approaches. This is certainly scientific progress.

The problem is that this progress runs out of funding and focus. The economics are chaotic after the point of validating a treatment. For example, decades after Wampold showed technique to be a minor factor in outcomes, we still champion therapy techniques. CBT exemplifies this as it thrives as a “digital therapeutic.” Would it not be better to validate therapists empirically and prove their effectiveness?

The FDA controls entry into the marketplace for new drugs. Competition then shifts from clinical to financial outcomes. No governmental entity thwarts that process. Once private control and funding takes over, every aspect of knowledge transfer competes for dollars with everything else.

Our healthcare system has no knowledge transfer process built into it. We neither incentivize nor fund it sufficiently. The chasm between research and practice should be no surprise. It is a feature, not a bug.

Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as President at ValueOptions and Chief Clinical Officer at PacifiCare Behavioral Health.