Annual Report 2009-2010

Knowledge to Action: CIHR-Supported Health Research at Work for Canada and Canadians

[ Table of Contents ]

Putting Knowledge into Action

When CIHR was established, the CIHR Act included explicit reference to knowledge translation (KT), a concept and practice particularly pertinent to the research environment.

KT is integral to the research process and an important aspect of CIHR's work. In the new five-year Strategic Plan, we have reinforced our commitment to KT to ensure that Canadians achieve the full value of investments in health research made on their behalf.

KT is about making users aware of new knowledge and helping them use it to improve the health of Canadians and the health-care system.

For example, research teams have been synthesizing recent health research information to pinpoint the findings that, when put into practice, are likely to have an impact on improving the health of Canadians. Similarly, other teams are already at work with decision and policy makers in taking high-impact research evidence and using it to change health-care practices. Other activities have focused on partnership building, engaging the public and helping researchers commercialize the results of their work.

KT is all about turning research into action. It's about closing the gap between knowing and doing. It's about accelerating the capture and practical application of the knowledge uncovered by research.

When knowledge is turned into action, it can have a number of powerful impacts such as:

In the following section, we have provided detailed accounts of four projects that reflect these types of impacts and demonstrate the transition from knowledge to action.

Beyond Damage Control: Making a (Bio)mark on Arthritis

What if you had a painful disease that doctors told you couldn't be treated? Or, what if you were given a drug with no assurances that it would actually work on your condition?

Welcome to life with arthritis.

There are currently no therapies that can stop the progress of osteoarthritis – the most common form of arthritis – in which cartilage lining the joints deteriorates and the bones chafe against each other. Its onset is often painless and difficult to detect before much damage has been done. While there are drugs for rheumatoid arthritis – in which the body's immune system attacks healthy tissue, damaging joints, inflaming cartilage and causing pain and swelling – it can take a year to tell whether a therapy is preventing joint destruction. It's a problem for patients, doctors and the companies trying to develop treatments.

The challenge
Efforts to find treatments have been hampered by the often slow or unpredictable way arthritis takes hold and develops, especially in the case of osteoarthritis.

The response
McGill’s Dr. Robin Poole has found biomarkers that can detect the presence of osteoarthritis before the damage is done and identify which patients will likely show a quicker progression of the disease for inclusion in clinical trials of new therapies.

The numbers
According to the Canadian Arthritis Network, more than 4 million Canadians aged 15 years and over have some form of arthritis and 100,000 cases are diagnosed each year. The economic burden of arthritis in Canada is estimated at $4.4 billion annually, with long-term disability and lost productivity accounting for almost 80% of the costs.

CIHR role
Support for research carried out by Dr. Poole and investment in the Canadian Arthritis Network.

CIHR-funded researcher Dr. Robin Poole, Emeritus Professor at McGill University, has dedicated four decades of his life to the battle against arthritis, directing the Joint Diseases Laboratory at Montreal's Shriners Hospital for Children from the lab's inception in 1977 until he retired in 2005.

Dr. Poole's work, with colleagues in the Canadian Arthritis Network, funded by CIHR through the NCE program, and as part of international collaborations, has led to new ways to detect the presence of osteoarthritis before it does any damage and see, after only a few weeks, whether drugs for rheumatoid arthritis are offering protection against joint destruction. Further, he has helped a Canadian company become a leading international producer of the toolkits used for early detection of osteoarthritis and monitoring disease activity in all patients with arthritis.

This work is now proving instrumental in helping the recruitment of osteoarthritic patients for clinical trials for new arthritis treatments and is benefiting researchers and pharmaceutical firms alike.

Research Response
In health research, biomarkers are specific biochemicals with unique molecular qualities that can be used to measure the presence or progress of a disease. Dr. Poole's approach has been to identify signs of joint tissue breakdown and synthetic products found in blood and urine that indicate the impact of arthritis and assess the short-term effects of treatments.

What is a biomarker?
A biomarker is any physical trait that can point to the presence or progress of a disease or condition – the way a raised temperature signals a child's fever.

Dr. Poole identified a single serum and urine biomarker called C2C that can measure collagen deterioration in cartilage in osteoarthritis and rheumatoid arthritis. Working with Drs. Jolanda Cibere and John Esdaile of the University of British Columbia, he found that C2C and other biomarkers he has developed can be used singly and in combination to help detect the early onset of osteoarthritis when there are no apparent symptoms.

With Dr. Leena Sharma of Northwestern University in Chicago, Dr. Poole developed a blood test to identify the progression of osteoarthritis. The blood test can identify those patients who are more likely to show progression of osteoarthritis, which is critical information for selecting the right persons to include in clinical trials.

"One of the problems in conducting clinical trials with arthritis is that often only
15–25% of the patients actually show the progression of joint destruction over a one- to two-year period," says Dr. Poole. "Using biomarkers to identify those patients who likely will show progressions – as opposed to recruiting a random population – is really quite exciting."

Dr. Poole's biomarker discoveries were patented, and a Montreal-based biotech company has licensed the technology. "Dr. Poole's contribution has helped us considerably," says Mr. Paul Baehr, President and CEO of IBEX Technologies.

IBEX has developed a product line of arthritis assays (kits to determine the presence and amount of different substances in blood and urine that indicate joint disease activity) based on Dr. Poole's research. Mr. Baehr estimates the assays make up a quarter of company revenues and help keep it profitable – no mean feat in a biotech industry in which new technologies take time to become established.

The assays are used by academic researchers who are looking into disease mechanisms and by industrial clients doing early stage drug development as well as preclinical and clinical trials for rheumatoid arthritis and osteoarthritis therapies. "The biggest volume of our assay sales comes from industry clients – the pharmaceutical companies," says Mr. Baehr.

For Dr. Poole, a co-founder of the Canadian Arthritis Network, its former Scientific Director and a recipient of a Lifetime Achievement Award from the Osteoarthritis Research Society International, the work carries on.

"The last couple of years, I've been involved in helping prepare a document for the US Food and Drug Agency to help guide development of new drugs in the treatment of osteoarthritis," he says. "It includes a white paper on the use and application of biomarkers. This is the first guidance document impacting clinical trials for osteoarthritis in many years."

In essence, his work has set the stage for the next generation of researchers to find treatments for osteoarthritis, a debilitating disease that has so far frustrated the best efforts to unlock its secrets.

That it has taken decades for his discoveries to be transformed into products and procedures doesn't surprise him. "Research is very much like fine art. It sometimes takes people a while to catch on to the new opportunities," says Dr. Poole. "All of these activities are now translating what we have discovered into practical applications."

"With a small company, any additions to the product line and revenues are very meaningful. In addition to the assays we currently market, there are new assays that will flow from patents that are in the process of being filed on work initiated by Dr. Poole."
Mr. Paul Baehr, President and CEO of IBEX Technologies

Acting on the Need to Know: Using Research to Change Health Policy

There are few things as wasteful as an unread research report. The time, talent and money invested in it are for naught if the information produced isn't put to good use.

In health services – where the demands are unlimited but the budgets are fixed – producing reports that collect dust is something no one can afford.

The challenge
Because communication between researchers at the Manitoba Centre for Health Policy and the Regional Health Authorities was limited, research was not being put to use.

The response
Dr. Patricia Martens created The Need to Know Team, which brings researchers and Regional Health Authorities together to decide on and execute research projects.

CIHR role
Provided a five-year team grant to support the creation of The Need to Know Team.

Dr. Patricia Martens, Director of the Manitoba Centre for Health Policy, understands this better than most. Her Centre, part of the University of Manitoba's Faculty of Medicine, produces several research reports each year examining health services and population health. But until the Centre changed its approach and began doing a better job of reaching out to the people who can put information to work, those reports often were left to sit on shelves.

Until the late 1990s, this was the situation facing the Centre's researchers and the decision makers who manage health care at Manitoba's Regional Health Authorities. Managers often felt what they were learning from the reports wasn't applicable to their needs. So, when it came time to make plans, they often based decisions on previous practices and anecdotal evidence.

Things are different now. "On every research project, we try to incorporate the decision makers in a working group scenario all along the way to make sure we're getting it right," says Dr. Martens. "Then we don't really have to push it (the research) out the door. It automatically gets used because of the process."

Research Response
Recognizing the need to involve the Regional Health Authorities in the research process from conception to completion, Dr. Martens, successfully secured CIHR funding in 2001 to create The Need to Know Team.

Who needs to know?
In a unique collaboration between the research generators and end-users, The Need to Know Team is made up of researchers and graduate students from the Manitoba Centre for Health Policy, representatives of the Regional Health Authorities and planners from Manitoba Health.

The Team, with two decision makers from each of the 11 Regional Health Authorities and planners from Manitoba Health, works alongside researchers to choose and conduct the Centre's research projects. The projects focus on strengthening health services and improving population health by analyzing data available through anonymized administrative records.

In what has become a truly collaborative approach, the Team's Regional Health Authority members have gained new understanding of just how research is done while the researchers have learned about the hard realities of day-to-day decision making in the regions.

Working with the Centre's researchers, The Need to Know Team, now co-directed by Dr. Martens and Dr. Randy Fransoo, has co-authored two iterations of The Manitoba Regional Health Authority Indicators Atlas (2003, 2009), a comprehensive examination of health status, health-care use and quality of care for Manitobans.

Realizing that the Regional Health Authorities needed more information on the extent of mental illness and its impact on health care, The Need to Know Team co-authored Patterns of Regional Mental Illness Disorder Diagnoses and Service Use in 2004. They also helped produce What Works? A First Look at Evaluating Manitoba's Regional Health Programs and Policies at the Population Level in 2008.

The Regional Health Authorities use the Atlas to examine how their programs are performing.

"As an example, from data on diabetes and chronic diseases in the Atlas we could tell which of our districts had poorer outcomes," says Ms. Kathy McPhail, CEO of the Central Manitoba Regional Health Authority. "We looked at our program and placed more resources in the districts with the poorest indicators. We just finished doing that about six months ago, but I expect we will have significant outcome improvements."

Ms. McPhail says her board is in the process of drawing up its next five-year strategic plan, and the Centre's research will colour both the broad strokes and fine details. "Our board, and I'm sure other boards, really utilize those statistics," says Ms. McPhail.

The Team is also having an impact on how Manitoba manages health care, says Ms. Arlene Wilgosh, former Manitoba Deputy Minister of Health.

"Our whole philosophy is health planning based on evidence, so you need that data, you need the information," says Ms. Wilgosh, who recently became CEO of the Winnipeg Regional Health Authority. "It helps, if it's all based on information, when we're arguing to give health more money."

Ms. Wilgosh says that over the years, the research reports have "influenced our decisions around resources." She cites 2004's mental health report and 2008's What Works? evaluation of programs and policies as particularly helpful. "They showed what the evidence is and how you can apply it," she says.

Says Dr. Martens: "We have a really great team approach in Manitoba with the researchers, the regional decision makers and the provincial government all working together to get things working better. We give the impetus for people to figure out what needs to be changed. The bottom line is we want evidence-informed decision making."

"Having people on the ground who are involved in system care and management be involved in doing research is great because it instills in our providers a natural curiosity. So, they're asking questions about how they're doing the work and if there is a better way to do the work."
Ms. Arlene Wilgosh, former Manitoba Deputy Minister of Health

One Every Ten Minutes: A Research-led Revolution Is Improving Stroke Care Across Canada

Ten years ago, if you had a stroke in Canada, your chances of surviving and making a complete recovery depended largely on luck.

You were lucky if the emergency room doctors were up to date on using clot-busting drugs. Such drugs can reopen blocked blood vessels and reduce brain damage if given within hours of the most common form of stroke.

What is a stroke?
Often called a "brain attack," an ischemic stroke disrupts the normal flow of blood and oxygen to the brain. The result: oxygen-deprived cells die.

You were very lucky if your hospital had a designated stroke unit with an expert team of doctors and nurses ready to provide specialized care. And if you had a transient ischemic attack – often called a mini stroke – you were lucky to get coordinated follow-up care. Mini strokes often predict major strokes.

Over the past decade, however, stroke treatment in Canada has been undergoing a revolution, providing proof of how evidence-based research, when effectively integrated into clinical practice, saves lives, reduces disabilities and eases the economic burden on the health-care system.

The challenge
Across Canada, there has been a lack of standardization of stroke care, limited use of a new drug treatment and little follow-up care for people at risk of major strokes. Until recently, few cities had hospitals with designated stroke units.

The response
Calgary's Dr. Michael Hill is part of a revolution in stroke care in which evidence-based research is driving changes in clinical practice to save more lives, reduce disabilities and provide more efficient treatment.

The numbers
About 50,000 Canadians have a stroke each year – one every 10 minutes.

CIHR role
Support for several key clinical trials involving stroke treatment protocols and investment in the Canadian Stroke Network, which has helped revolutionize stroke treatment in Canada.

Dr. Michael Hill, an Associate Professor at the University of Calgary, has been a leader in that revolution. A practising neurologist at Calgary's Foothills Medical Centre, he has been a leading advocate of applying evidence-based clinical research for standardized stroke care.

Research Response
Funded by CIHR since 2001, Dr. Hill has led some of Canada's most important research projects in stroke and is a lead author of national guidelines on its treatment. In 2005, he led a major study that tracked more than 1,100 patients and showed that a clot-busting drug known as tissue plasminogen activator, approved by Health Canada in 1999, is a safe, effective therapy for ischemic stroke (the most common form of stroke, in which blood flow to the brain is interrupted). Dr. Hill co-authored a 2008 study warning that people with mini strokes are at risk for major ones and should receive blood-thinning therapy and follow-up preventive care.

Stressing that "knowledge translation is never the result of one person," Dr. Hill is keen to point out that he is just one person in "a community of people across Canada" trying to improve stroke care. A key piece in this community is the Canadian Stroke Network, funded by CIHR through the Networks of Centres of Excellence program.

"In terms of the big picture, Dr. Antoine Hakim, CEO of the Canadian Stroke Network, is the leader. In Ontario, which was really the vanguard province in this, it was Dr. Frank Silver at the University of Toronto who, along with the Heart and Stroke Foundation of Ontario, made the case to the Government of Ontario to get organized. And Dr. Ashfaq Shuaib of the University of Alberta has been key: as Chair of the Education Committee of the Canadian Stroke Consortium (a national network of neurologists), he has played a big role."

Dr. Hill is also a major contributor to the Canadian Stroke Strategy, a joint initiative of the Heart and Stroke Foundation and the Canadian Stroke Network to encourage an integrated approach to stroke prevention, treatment and rehabilitation across the country. He is a lead author of the Canadian Best Practice Recommendations for Stroke Care. Revised every two years, the guidelines are published in the Canadian Medical Association Journal and disseminated to physicians and other health-care professionals across the country.

On his home turf, Dr. Hill helped create the Calgary Stroke Program and advocated for the Alberta Provincial Stroke Strategy, a province-wide system of stroke care.

"Stroke-related neurological disability is so expensive to care for after the fact," he says. "If you can deal with it at the front end – make patients better through better acute care or by preventing the stroke in the first place – then you can also save a lot of money."

Ms. Joan Berezanski, an Executive Director with Alberta Health and Wellness, says Dr. Hill has made an important contribution. "He did very key work that fit into the provincial strategy. We needed this research."

While there are no national statistics for tissue plasminogen activator use in stroke, Ontario regional stroke centres report a jump in its application. Alberta also has seen a significant increase in the use of this drug. The key recommendations for follow-up treatment of transient ischemic attacks have been incorporated into the Canadian Best Practice Recommendations.

As for proving the effectiveness of designated stroke units, Dr. Hill and his colleagues at Foothills compared data for stroke patients on general neurology/medical wards to those on a stroke ward and found the designated units cut the average length of stay to 15 days from 19 days. Given that the average acute care costs are about $27,500 per stroke, this represents noticeable savings. And the stroke unit care is better: fatalities were reduced by 4.5%.

As part of his knowledge translation efforts, Dr. Hill has been a frequent guest speaker on acute stroke care, including appearances at annual conferences of the Canadian Stroke Consortium where neurologists, internists and emergency room physicians discuss the latest research developments.

"A really important concept that many people don't get is the integration of research and clinical care," says Dr. Hill. "They are just so inextricably linked."

"Dr. Hill is a leader clinically and he has a fabulous willingness to contribute to and promote knowledge translation."
Ms. Elizabeth Woodbury, Executive Director of the Canadian Stroke Strategy

Solving Malnutrition a Single Serving at a Time: Knowledge Translation That Helps Children Thrive

Dr. Stanley Zlotkin's concern for kids in the developing world goes back to his medical school days.

"In my final year, I did a three-month elective in Nigeria where I got a glimpse of the big picture of health issues," says the now 62-year-old Dr. Zlotkin, a Senior Scientist at Toronto's SickKids Hospital Research Institute. "After that, I looked for opportunities."

His big opportunity came in 1996 when UNICEF challenged the pediatric nutrition community to come up with a solution to the global dilemma of childhood anemia and vitamin deficiencies.

The challenge
Children in many developing countries don't get the nutrients they need to develop to their full potential. Micronutrient malnutrition is blamed for about half of childhood deaths in the developing world and leads to anemia and pediatric cognitive and physical disabilities.

The response
Dr. Stanley Zlotkin of SickKids Hospital in Toronto created and developed Sprinkles to prevent and treat micronutrient deficiencies among young children and other groups at risk.

The numbers
Per sachet cost of Sprinkles: about 2 cents. UNICEF is currently working with approximately 30 countries to initiate or scale up the use of Sprinkles.

CIHR role
Support for research testing effectiveness of Sprinkles and major award for Dr. Zlotkin recognizing accomplishments in knowledge translation.

Children in many developing countries around the world may not be starving, but they aren't getting the nutrients they need to thrive. The World Health Assembly ranks the control of vitamin and mineral deficiencies as the number two global health priority, second only to HIV/AIDS. Efforts to combat childhood micronutrient malnutrition, however, have had very limited success. Supplements in syrups and drops are unpopular because they are difficult to measure, have a metallic taste and stain teeth and clothes.

"It's a huge problem," says Dr. Zlotkin. "But I love the idea of problem solving and I love to be able to see the research that I take on have a very practical application."

Research Response
Sitting in his SickKids office, Dr. Zlotkin came up with "a one-page concept" for a tasteless and odourless micronutrient powder called Sprinkles that could be packaged in single-serving sachets like sugar packets and added to almost any food.

The idea intrigued him and he was prepared to roll up his sleeves, both literally and figuratively, to make it work. He test-produced the powdered mixture at night in the SickKids kitchen, after the cook and his crew had gone home. "In order to do research, I had to have the product. So, I had to make the product – this mixed concoction of vitamins and minerals – in the hospital kitchen at night."

What are Sprinkles?
Sprinkles are sachets that contain a blend of powdered micronutrients. Adding Sprinkles to almost any food will fortify it without altering its taste.

Getting the H.J. Heinz Company on board as a research funder and partner for the production of sachets was, he says, pure serendipity.

"They were looking for a project to support. This fit their needs well and it fit my needs because Heinz makes things – like ketchup and vinegar – and puts them in sachets. They were willing to help with the technical component and their foundation was willing to support the research."

With a private-sector partner in place and a product in hand, Dr. Zlotkin still had to sell UNICEF and other global aid agencies on Sprinkles. "I made it my business to go to New York twice a year to visit UNICEF to give them updates on the research and to remind them that when we reached a certain stage it was going to be their responsibility to take this on."

He also had to show the developing countries that Sprinkles was a good thing. He began the first research study to prove Sprinkles' efficacy in Ghana in 1999, a project supported by CIHR. Similar research projects have been organized in more than a dozen countries including Bangladesh, Benin, Bolivia, China, Guyana, Haiti, India, Indonesia, Kyrgyzstan, Mexico, Pakistan and Vietnam.

The Sprinkles program – which became the Sprinkles Global Health Initiative – was implemented on a large scale in 2001 in Mongolia, a country whose children had unacceptable rates of anemia and rickets (a condition stemming from vitamin D deficiency).

UNICEF is currently working with approximately two dozen countries – primarily in Asia and Latin America – to initiate or scale up the use of Sprinkles.

Today, hundreds of millions of Sprinkles single-serving sachets of micronutrients have been supplied to children around the world.

In Mongolia, large-scale use of Sprinkles resulted in significant reductions in anemia (38%) and vitamin D deficiency (28%) over four years.

Ms. Nita Dalmiya, a nutrition specialist with UNICEF, says Sprinkles is not only a low-cost way of addressing pediatric anemia, it also provides an entry point to talk to mothers about their children's nutrition.

"That has the potential to make a huge difference to malnutrition rates," says Ms. Dalmiya. "For us, Sprinkles, or multiple micronutrient powders as we refer to them generically, is a promising approach for us to address childhood nutrition problems in many countries."

The partnership with Heinz, meanwhile, remains strong.

"Importantly to Heinz, Dr. Zlotkin directed much of his research and routinely ventured into the field to learn first hand about the issues," says Mr. Jack Runkel, an H.J. Heinz Company Vice-President and Chairman of the H.J. Heinz Company Foundation. "In fact, we affectionately referred to him as a missionary for the cause."

To broaden Sprinkles' reach, Dr. Zlotkin and Heinz have put the technical specifications in the public domain outside of Canada and the United States so that manufacturers can produce it without paying royalties. About 15 million children received Sprinkles – or some form of the micronutrient powder – in 2009.

In recognition of these partnership building efforts and his tireless work to facilitate the use of Sprinkles, in 2006 Dr. Zlotkin was awarded a prestigious CIHR Health Research Award for Knowledge Translation.

Dr. Zlotkin admits he had "no idea of what was going to happen" when he took up the challenge 14 years ago.

"I remember, early on, drawing a map and thinking, 'OK, if I do this and this and this, what's going to happen over the next six or seven years? Well, if it all falls into place, then UNICEF will take it on and make it part of their programming so that we can reach millions of children. I did have that vision. It just took longer than I anticipated."

"The work that Dr. Zlotkin has published, and that of other collaborators in consultation with him, this is what informs most of the program's introduction and scale-up in many of these countries. We have taken that work, taken the best lessons from it and applied it."
Ms. Nita Dalmiya, UNICEF Nutrition Specialist

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