Dissemination and Implementation

Ellen Goldstein, MAKevin Grumbach, MD

Translating Practice into Evidence: Community Engaged Research

Institute of MedicineDefinition of “T2” Translational Research

• “the translation of results from clinical studies into everyday clinical practice and health decision making”

• “from bedside to community”

• Westfall et al further distinction:– “T2” as translation to patients– “T3” as translation to practices

Dissemination and Implementation are Key Aspects of T2 and T3

Translation

Definitions

• Dissemination is the targeted distribution of information and intervention materials to a specific public health or clinical practice audience

• Implementation is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings– “Scaling up” of interventions

Source: Schillinger et al, CTSI CEP An Introduction to Effectiveness, Dissemination and Implementation Research http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf

The Process of Dissemination and Implementation is Itself Researchable

• Dissemination research is the systematic study of how the targeted distribution of information and intervention materials to a specific public health audience can be successfully executed so that increased spread of knowledge about the evidence-based public health interventions achieves greater use and impact of the intervention

The Process of Dissemination and Implementation is Itself Researchable

• Implementation research is the systematic study of how a specific set of activities and designed strategies are used to successfully integrate an evidence-based public health intervention within specific settings (e.g., primary care clinic, community center, school)

And 1 More Concept

• Diffusion research is the systematic study of the factors necessary for successful adoption by stakeholders and the targeted population of an evidence-based intervention which results in widespread use (e.g., state or national level) and specifically includes the uptake of new practices or the penetration of broad scale recommendations through dissemination and implementation efforts, marketing, laws and regulations, systems-research and policies.

What is Fundamentally at Issue

• Does the world change because a study demonstrating the efficacy of an intervention is published in a peer-reviewed journal?

Why focus on Dissemination?

• This is how science makes a difference in people’s health.

• Your results shouldn’t be hard to find or top secret

Traditional academic culture

• While there are clear guidelines for grant submission, human subject protections, research methods…

• There’s no standard expectation or training on dissemination outside academic circles

Value of Good Dissemination

• Impact on public and individual health

• Develop new partners

• Generate new ideas

Risks of Poor Dissemination

• Outraged Public

• Outraged Partners

• Outraged Participants

• No impact on health

Ethical issues

• Public dollars

• Citizen participants

• Health disparities

Dissemination Planning

•

Audiences

• Study Participants

• General Public

• Clinicians

• Community agencies

• Policymakers

Purpose

• Why are you sharing this information at this time and with this audience?

– Tailor this field for each audience– Is this the right time to disseminate?– Assess the cost/ benefit of publicity

Content

• What you learned – process data– Recruitment– Baseline data

• What you learned – outcome data– Positive and negative results

• So what?– Implications for health, clinical care,

programs, policy– Recommendations

Messagingcrafting take-home messages/ sound bites

• Redefine “media moment”

• Context of data within body of research

• Working with community to refine message

• Right findings to the right audience

• Statistics and stories, depending on audience

Channels - venues

• Media

• Presentations – Conferences– inservices, grand rounds– community meetings

• Websites/ blogs/ Facebook/ webinars

• Written reports for lay audiences

• Policy briefs

Skills

• Language sensitivity

• Working with the media

• Working with community stakeholders

Logistics

• Timeline

• Budget

• Messenger

• Support (i.e. UCSF News Office, community or clinical outreach)

T2

•Clinical Clinical practicepractice

•Public health Public health practicepractice

•Behavior Behavior changechange

•DisparitiesDisparities

T1 DiscoveryT1 Discovery

Implementation Science• Gap between discovery and application

• Many efficacious interventions not widely implemented (or implemented effectively) in practice – Team care of depression in primary care settings– Parteras and birth outcomes– Hand washing– Aspirin for patients at risk of cardiovascular disease

• “The lack of “fit” (mismatch) between an intervention/research design on the one hand and the realities inherent to the ultimate target practice setting and the information needed by policymakers on the other hand, leads to low adoption and implementation”

• Research culture emphasizing internal validity to much greater degree than external validity

Schillinger et al, CTSI CEP An Introduction to Effectiveness, Dissemination and Implementation Research http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf

The Challenge to Move From Innovation to Implementation

• “All breakthrough, no follow through” – Steven Woolf, Department of Family Medicine, Virginia

Commonwealth University ; Washington Post, 2006

A Case Study

Mike PotterFlu Shot-Colorectal Cancer

Screening Study at SFGH FHC

• Question:– What if everyone aged 50-80 who got a

Flu Shot each year also completed a Home Fecal Occult Blood Test?

• Intervention:– Have nursing staff give hemoccult kits and

ed to patients during flu shot clinics at FHC

Initial Randomized Clinical Trial at FHC to Prove “Efficacy”:Does the intervention work?

52.9% 54.5%57.3%

84.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Controls Intervention

% Up to date for CRC screen

PrePost

20092009

Did the Flu shot-FOBT intervention become standard of care at FHC in

2009 after this terrific study was published?• No

• Why not?– Differences between an RCT and

sustainable implementation in routine clinic operations

– (More on this story later…)

Many Factors for Translating Innovation into Sustainable,

Scalable Implementation• Incentives and rewards• Organization and culture• Feasible incorporation into routine practice• Competing demands• Buy in of leadership and team• Time frame• Institutionalization rather than reliance on single

champion

• “Getting a new idea adopted, even when it has obvious advantages, is often very difficult.”– Everett Rogers, Diffusion of Innovations

Rogers EM. Diffusion of Innovations. New York, NY: Free Press

Adopter Categorization on the Basis of Innovativeness

Glasgow RE-AIM Framework

R Reach

E Effectiveness

A Adoption

I Implementation

M Maintenance

Glasgow, et al. Ann Behav Med 2004;27(1):3-12

Flu Shot-FOBT Reprise

• Dr. Potter’s sustained effort in implementation– Kaiser Permanente Flu-FIT Program– SF DPH Clinics

• Chinatown “adaptation” pilot• System-wide adoption

– …including FHC

– Research in the science of implementation

Dissemination Plan Session #5 Homework:

• Complete Dissemination Plan Worksheet for two different non-academic audiences for your study– It’s helpful to separate the two audiences

by a blank line or shading.