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Introduction to Dissemination and Implementation . · PDF file ·...
Transcript of Introduction to Dissemination and Implementation . · PDF file ·...
Introduction to Dissemination and Implementation Science.
Cynthia A. Vinson, PhD, MPA Acting Deputy Director for Implementation Science Division of Cancer Control and Population Sciences
November 5, 2014
Objectives
1. Discuss why dissemination and implementation science research is needed
2. Define dissemination and implementation (D&I) research
3. Describe who should be involved
4. Highlight D&I approaches and methods
5. Discuss what makes a good D&I study
Why Do We Need Implementation Science Research?
Most common type of research?
6
Overview Key Features Global Health Discussion IS Applications
T2
T3
T4
T1
Modified from Glasgow RE et al; J Acquir Immune Defic Syndr. 2013;63 Suppl 1:S26-31.
Glasgow, Vinson et al. AJPH 2012.
Discoveries
(e.g. new risk factors,
biomarkers)
Promising Application
(e.g. new vaccine)
Practice and
control programs
Evidence-based
guideline/policy
Reducing the
Burden of Disease
Knowledge Integration
T0
Continuum of Translational Research
Focus of
Implementation
Science – T3 and T4
From: http://kirstyevidence.wordpress.com/2014/09/06/implementation-science/?blogsub=confirming#blog_subscription-2
The Language of D&I
Health Services
Health Services Research
A Sea of Terms (and Circles)
Implementation Science
Implementation
Research
Dissemination
Research
Quality
Improvement
Science
QI
Health
Communication
Research
PEPFAR Definition
• Implementation Science (IS): the study of methods to improve the uptake, implementation and translation of research findings into routine and common practices (the ‘know-do’ or ‘evidence to program’ gap)
• Scope: improve program effectiveness and optimize efficiency, including the effective transfer of interventions from one setting to another
Padian, N. S., C.B. Holmes, S.I. McCoy, R. Lyerla., Bouey, P. D., & Goosby, E. P. (2011).
“Implementation science for the US president's emergency plan for AIDS relief (PEPFAR).” Journal
of Acquired Immune Deficiency Syndromes 56(3): 199-203
Implementation research for the control of infectious diseases of poverty: strengthening the evidence base for the
access and delivery of new and improved tools, strategies, and interventions. World Health Organization, 2011
WHO /TDR Definition
• Implementation involves evidence-supported, systematic, and planned efforts within a system (or organization) to institutionalize an intervention and to ensure its intended effects and impacts.
• Implementation research asks: “What is happening in the design, implementation, administration, operation, services, and outcomes of social programs? Is it what is expected or desired? Why is it happening the way it is?
• Implementation research does not isolate the effects from the context, thus distinguishing itself from clinical trials and impact evaluations.
NIH’s Definitions
– Dissemination: the targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread knowledge and the associated evidence-based interventions.
– Implementation: the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings.
The Trans-NIH D&I Funding Announcement (International Investigators Eligible)
• R01 - PAR 13-055 ($500k per annum up to five years)
R03 - PAR 13-056 ($50K per annum up to two years)
R21 - PAR 13-054 ($275K up to two years)
• Participating Institutes: NIMH, NCI, NIDA, NIAAA,
NIAID, NHLBI, NINR, NIDDK, NINDS, NIDCD,
NIDCR, NCCAM, NHGRI*, NIA* & Office of Behavioral
& Social Sciences Research
• Standing review committee, Dissemination and Implementation
Health Research
• Three submission dates per year: February, June, October
*New Institute Added to PAR in 2013
http://cancercontrol.cancer.gov/funding_apply.html#is
Possible Dissemination
Research Topics
Analysis of factors influencing the creation, packaging, transmission and reception of valid health research knowledge
Experimental studies to test the effectiveness of individual and systemic dissemination strategies, focusing on relevant outcomes (e.g., acquisition of new knowledge, maintenance of knowledge, attitudes about the dissemination strategies, use of knowledge in practice decision-making)
Studies testing the utility of alternative dissemination strategies for service delivery systems targeting rural, minority, and/or other underserved populations
Studies on how target audiences are defined, and how evidence is packaged for specific target audiences
Possible Implementation
Research Topics
Studies of efforts to implement prevention, early detection, and diagnostic interventions, as well as treatments or clinical procedures of demonstrated efficacy into existing care systems to measure the extent to which such procedures are utilized, and adhered to, by providers and consumers
Studies on the fidelity of implementation efforts, including the identification of components of implementation that will enable fidelity to be assessed meaningfully
Longitudinal and follow-up studies on the factors that contribute to the sustainability of research-based improvements in public health and clinical practice
Possible D&I Research Topics
Studies of the capacity of specific care delivery settings (e.g., primary care, schools, community health settings) to incorporate D&I efforts within current organizational forms
Studies that focus on the development and testing of theoretical models for D&I processes
Development of outcome measures and suitable methodologies for D&I approaches that accurately assess the success of an approach to move evidence into practice (i.e., not just clinical outcomes)
What do these have in common?
TRUTH
BEAUTY
INSANITY
PORNOGRAPHY
CONTACT LENSES
D&I RESEARCH
…in the eye of the beholder
Adapted from Melissa Brouwers (KT Canada)
Q3. Is this a D&I Research Project?
• Chemotherapy: The objective of this study is to
determine the most effective chemotherapy
regimen (as measured by overall survival) for
individuals with stage III colon cancer who have not
been previously treated.
Q3. Is this a D&I Research Project?
• Tool for Health Systems Guidance: The
objective of this study is to develop a measurement
instrument designed to evaluate the methodological
quality of health systems guidance documents.
Q3. Is this a D&I Research Project?
• AF+Media vs. Media alone cRCT: The
objective of this cluster randomized control trial is to
determine if small media combined with audit &
feedback are superior to small media alone at
increasing primary care providers' rates of flu
vaccination of their elderly patients in their practice.
Do differences exist as a function of type of primary
care provider (physician, nurse practitioners vs.
others)?
• # Patients Using ER: Using clinical databases, the
objective of this study is to examine the proportion
of patients who visit the emergency department
within 2 weeks of death and to compare patterns of
practice across 14 local health integrated networks
(i.e. health regions).
Q3. Is this a D&I Research Project?
…And The Survey Said…
Ch
em
oth
er
ap
y O
ptio
ns
To
ol fo
r H
ea
lth S
ys
tem
G
uid
an
ce
A&
F +
Me
dia
vs
. Me
dia
a
lon
e c
RC
T
# P
atie
nts
us
ing
ER
Green = no Blue = yes Orange = not sure
Interpretation
• Even amongst the old-timers, differences of opinion (…in the eye of the beholder)
• Benefit: Likely an appetite for a broad range of ideas
• Challenge: Variety of opinions on your review committees (funding, publication)
Who Should be Involved in D&I Research?
“Successful implementation research begins and ends with successful
collaborations”
Community
Overview of D&I Methods/Approaches
What Approaches are Appropriate
• “Question is King”
• Examples of types approaches:
– Pragmatic Trials
– Effectiveness-Implementation Hybrid Trials
– Quality Improvement Studies
– Participatory Action Research
• Qualitative, Quantitative and Mixed Methods
Pragmatic (Practical) Trials: Key Contextual
Characteristics
• Multiple, heterogeneous settings
• Representative populations
• Comparison conditions are real-world alternatives
• Multiple outcomes important to decision and policy makers
Thorpe KE et al., Can Med Assoc J, 2009, 180: E47-57
Tunis SR et al. Practical clinical trials…JAMA 2003;290:1624-1632
Glasgow RE et al. Practical clinical trials…Med Care2005;43(6):551-557
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Key differences between Traditional Randomized Control
Trials (RCT) & Pragmatic Controlled Trials (PCT)
Traditional RCT tests a
hypothesis under ideal
conditions
PCT compares treatments
under everyday clinical
conditions
GOALS To determine causes and
effects of treatment
To improve practice and inform
clinical & policy decisions
DESIGN Tests the intervention against
placebo using rigid study
protocols & minimal variation
Tests two or more real-world
treatments using flexible
protocols & local customization
PARTICIPANTS Highly defined & carefully
selected
More representative because
eligibility criteria are less strict
MEASURES Require data collection
outside routine clinical care
Brief and designed so data can be
easily collected in clinical
settings
RESULTS Rarely relevant to everyday
practice
Useful in everyday practice,
especially clinical decision
making
Hunter, C. “Dissemination and Implementation Research in Diabetes and Obesity”
TIDIRH 2014 July 2014.
Effectiveness-Implementation Hybrid Trials
Efficacy
Studies
Effectiveness
Studies
Implementation
Research
Improved
processes,
outcomes
Hybrids
“go” in
here
Types of Hybrids
Clinical Effectiveness
Research
Implementation Research
Hybrid Type I
Hybrid Type II
Hybrid Type III
Test clinical intervention, observe/gather information on implementation
Test clinical intervention, study implementation intervention
Test implementation intervention, observe/gather information on clinical intervention outcomes.
From Curran G., Bauer, M., Stetler, C., Mittman B.
A different view of Hybrids
Focus Implementation?
Clinical
Intervention?
Yes No
Yes Hybrid Type II Hybrid Type I
No Hybrid Type III Observational Research
From Curran G., Bauer, M., Stetler, C., Mittman B.
Plan, Do, Study, Act Cycle
P D Plan Do A S Act Study
PLAN for changes to bring about improvement
• Customer/supplier mapping Flowcharting
• Pareto analysis • Brainstorming • Nominal group techniques • Evaluation Matrix • Cause-and-effect diagrams
DO changes on small scale first to trial them
• Small group leadership skills
• Experiment Design • Conflict Resolution • On-lab training
ACT to get the greatest benefit from changes
STUDY changes to see if they are working and investigate selected processes • Data check sheets • Graphical analysis • Control charts • Key performance indicators
• Process mapping • Process standardization • Control reference
information formal training for standard processes
Peters, D.H., Tran, N.T., Adam, T., Implementation Research in Health: A Practical Guide, 2013.
Quality Improvement Studies
Participatory Action Research
Participatory Action Conventional
What’s the research for? Action Understanding what’s
possible
Who’s the research for? Local People Institutional, personal, and
professional
Whose knowledge counts
most?
Local people’s Scientist’s
Who chooses the topic? Local priorities Funding agency,
institutional agenda,
professional interests
Methodology chosen for
what reason?
Empowerment and learning Disciplinary convention,
“objectivity”, “truth”
Who takes part in the stages of research?
Problem Identification Local people Researcher
Data collection Local people Researcher, data collector
Interpretation Local concepts and
frameworks
Disciplinary theories and
frameworks
Analysis Local people Researcher
Presentation of findings Locally accessible
and useful
By researcher to academics
and funding agency
Action on findings Integral to process Usually separate or may not
happen
Who takes action? Local people, with
or without external
support
External agency
Who owns results? Shared Researcher or funder
Emphasis of process or
outcomes?
Process Outcomes
What Makes a Good D&I Study?
Q1. We asked D&I Scientists:
In your experience as a REVIEWER of D&I
research grant proposals, please identify the
one or two key components you believe
define a stellar D&I research proposal.
Adapted from Melissa Brouwers (KT Canada)
…And The Survey Said…
• Potential to make an impact/real world problem (soon)
• Strong theory, concepts, frameworks
• Well-chosen intervention and/or implementation plan
– sound justification, innovative, tested pragmatically, aimed to change behavior
• Tests an intervention or competing interventions
…And The Survey Said…
Logical step to research enterprise/strong
rationale
Evaluation – process and outcome (e.g.
clinical outcomes) measures contradictions across respondents
Compelling description of performance gap
Pilot data collected to justify request pilot primary data, systematic review, or both
…And The Survey Said…
• Advances Implementation Science
• Rigorous assessment of implementation
strategy
• Good team
– integrated, D&I scientists
• Good fundamental methods
Q2. We asked D&I Scientists:
In your experience as a REVIEWER of D&I
research grant proposals, please identify the one
or two common problems seen in these
proposals.
Adapted from Melissa Brouwers (KT Canada)
…And The Survey Said…
• Applicants simply do not understand D&I
(almost all) – superficial
– not an integrated approach with decision makers
– conference presentation or publication does NOT = D&I
– not embedded in a real world context
– window dressing (use D&I theory but do NOT
understand it)
– no respect for the science of D&I
…And The Survey Said…
• Poor justification
– failure to build on what is already known
– little knowledge of extant literature
– no pilot data
• D&I interventions not designed appropriately
D&I Research Training Opportunities
• Dec. 8-9, 2014 - 7th Annual Conference on the Science
Dissemination & Implementation: Transforming Health Systems
to Optimize Individual and Population Health (Bethesda, MD) –
registration currently open
• June-December 2014- Implementation Science-Principles and
Practice (World Cancer Congress Master’s Course) –
registration closed
• Summer 2015 - Annual Training Institute on Dissemination and
Implementation Research in Health
• Monthly IS Advanced Topic Webinars (see our website)
Questions?