Translational Health Research

Professor Warren PaynePro Vice-Chancellor (Research & Research Training)Victoria University

Overview

• The need for Translational Research, • Approaches to Translational Research, • The role of non-commercial translational research in combating

chronic disease, • A potential implementation model.

The need for translational research

• “In Australia, the debate has relied too much on arguments about increasing resources, and not enough on improving productivity and effectiveness through micro-economic reform and translation of innovations from research”

• “…. disconnect between those areas which predominantly carry out the research, those areas where the services are delivered, and the sources of investment and consumption.”

• “This disconnect has impeded the translation of research findings into better healthcare practice and products”

(Strategic Review of Health and Medical Research, 2013)

Health outcomes and cost- effectiveness

Linking translation and health outcomes

Approaches to translational research

• What is translational research?• T1 and T2 (Woolf, 2008)

1. Bench-to-bedside• Harnessing knowledge from basic sciences to produce new drugs, devices and

treatment options• Interface between basic science and clinical science• End point is clinical use or commercialisation• “effective translation of the new knowledge, mechanisms, and techniques

generated by advances in basic science research into new approaches for prevention, diagnosis, and treatment of disease is essential for improving health” (Fontanarosa and DeAngelis, 2002).

Approaches to translational research

• T1 and T2 (Woolf, 2008)2. Health services and public health

• Translational research is the translation of research into practice• Making sure new research knowledge and practices actually reach the intended

populations and are implemented correctly• Bench-to-bedside is the start of the process• Close the gap and improve quality by:

– Improving access,– Reorganising and coordinating systems of care– Helping clinicians and patients to change behaviours and make more informed choices,

providing reminders and point of care decision support tools,– Strengthen the patient, clinician relationship

• Note: Limited view of public health focused on patient/clinician relationship

Approaches to translational research

• A more recent development (Khoury et al., 2010)• US NIH T1 – T4 Translation Framework

• T1 - Discovery research to health applications (test, interventions)

• T2 – From health application to evidence guidelines

• T3 - From guidelines to health practice

• T4 – From health practice to population health outcomes

• (Note: Change in language: Public Health to Population Health)

Approaches to translational research

Approaches to translational research

• Current focus is on bench and bench-to-bedside with less emphasis on health services and public (population) health research and public health outcomes (population) (Woolf = T2)• <15% of total NHMRC expenditure on population health research• 5% of total NHMRC expenditure on health services research

• Yet these are two of the areas with the potential for the greatest gain in health outcomes (QALs).

• Why is there less engagement in thinking about population health and health services research?:• Few if any commercial drivers (overt)• Impact of interest groups• Capacity constraints• Need to work outside of the medical model: mixed approach• Difficulty in demonstrating impact or change in health outcomes

• “Just show me something that works!”

Translation needs to be iterative (Ogilvie et al., 2009)

The importance of context and replication in translational research

• Evidence-based practice relies on the potential to transfer evidence between contexts (Rychetnik et al., 2012)

Characteristics of the translational framework for population health benefit

• Redefines the endpoint from that of institutionalising effective interventions to that of improving population health

• Incorporates the epidemiological traditions of population health surveillance and the identification of modifiable risk factors

• Reflects a spectrum of determinants of health from the individual to the collective level and a corresponding spectrum of level of intervention

• Embraces a wide range of biomedical, social and environmental ‘basic sciences’ that have roles throughout the framework, not merely in supplying knowledge to be implemented

• Identifies a pivotal role for thoughtful and inclusive evidence synthesis• Describes the iterative and bi-directional processes by which population health

research and population health action may influence each other• Recognises the non-linear and inter-sectoral interfaces with the public realm

where decisions that influence population health are made(Ogilvie et al., 2009)

The potential for translational research to address a major health dilemma: Rising chronic disease• Characteristics of chronic disease(s) in Australia:

• Most deaths due to chronic disease• Australians are dying from multiple chronic diseases (70,000 deaths pa are

preventable)• Australians are living with multiple chronic diseases• Many chronic diseases do not result in premature deaths but reduce quality of

life• The burden of chronic disease is unevenly distributed.• Is an important driver of health system utilization and costs

• Cardiovascular disease• Cancer• Kidney disease

• Causes significant productivity losses due to reduced workforce participation• Are caused by many factors, not just health/lifestyle behaviours(AIHW, Australia’s Health 2014)

Health status (including chronic disease) is determined by many factors

AIHW Australia’s health 2014

We know chronic disease can be prevented through cost-effective population health approaches• Prevention at a number of levels

• Primordial prevention• Preventing the emergence of predisposing social and environmental conditions that

can lead to causation of disease• Primary Prevention

• Limit the incidence of chronic disease through eliminating or reducing specific risk factors and other determinants, while promoting factors that are protective factors

• Secondary Prevention• Reducing the progression of chronic disease through early detection and early

intervention.• Tertiary Prevention

• Improving function and minimising the impact of established disease

We know there are many opportunities to prevent chronic disease before its onset

We know population-based prevention strategies have advantages compared with targeting individuals

Ways to assess cost-effectiveness of translational strategies have been developed

Examples of known evidence-based translational strategies and policies

Integrated implementation pathways are most effective

Actions to prevent chronic diseases: what we have and have not done

• Australia has signed up to the WHO Global Action Plan for chronic disease

• Have not established an integrated, public performance reporting on Australia’s progress in preventing chronic diseases

An approach for the future

• Mitchell Institute for Health and Education Policy at Victoria University• Recognised the limited focus on preventive health targets and accountability to

prevent chronic disease (in contrast to public hospital performance)• Has mapped the targets stated in the now terminated National Partnership

Agreement (NPA) on Preventive Health and the Performance and Accountability Framework (PAF) against the WHO Global Action Plan to summarise Australia’s position as follows:

• Australia is focused on a narrow suite of indicators to measure the prevention of chronic disease

• While the Australian targets are narrow in scope, they are challenging relative to the WHO targets and their achievement would represent considerable progress in preventing chronic diseases

• The NPA includes measurable targets but the PAF does not appear to set targets to prevent chronic disease

• There is no regular reporting against chronic disease prevention targets• There is no ongoing commitment to measure progress on preventing chronic

diseases with the cessation of the NPA and the COAG Reform Council

An approach for the future

• The Mitchell Institute has emphasised four domains against which the prevention of chronic disease can be evaluated:1. A national commitment to preventing chronic diseases (through national

strategy and action plan with agreed responsibilities and public accountability)

2. Backed up by dedicated funding to allow investment in evidence-based primary prevention chronic disease interventions

3. Given effect by a well-stocked ‘intervention toolbox’ that includes an array of approaches for use in a range of settings and population groups

4. Underpinned by national intelligence and evaluation capabilities.

An approach for the future

• Using the Mitchell Institute Framework what are the recent successes and gaps?• There is a preventive health strategy, but there is no clear pathway for ongoing

action• The is no longer identified funding for the prevention of chronic diseases nor

ongoing reporting on expenditure on public health and prevention• Some valuable interventions have been introduced to prevent chronic

diseases, with prevention programs also implemented in a wide range of settings

• There has been some investment in new research and expanded datasets, but research and evaluation of policies and programs to prevent chronic disease are still underdeveloped.

An approach for the future

• The Mitchell Institute recommends a national action plan for chronic disease prevention could be guided by four key directions.

• PURPOSEFUL TRANSLATIONAL RESEARCH IS NEEDED THAT FOCUSES ON 1. Promoting and implementing interventions that impact early in life, as well as

targeting high risk populations2. Investing in cost-effect prevention, while innovating and building the evidence

base on what works to reduce chronic disease3. Measuring progress on reducing chronic disease and engendering

accountability for actions4. Recognising that many of the levers to prevent chronic disease involve

changes outside of the health system that create healthier environments at a whole-of-population level.

CHALLENGE TO ALL

• FOCUS ON REALISING POPULATION-BASED BENEFITS