Methods and Metrics Issues in Delivery System Research

JEFF ALEXANDERThe University of Michigan

The Challenge and Promise of Delivery System Research: A Meeting of AHRQ Grantees, Experts, and

StakeholdersDoubletree Dulles – Sterling, Virginia

February 16, 2011

Framing the issues around a common theme

Striking a balance between depth and breadth

Pushing the envelope without being unrealistic

Examples from proposals

Challenges

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Can it work? Will it work?

When will it work (for which patients and settings)?

What is necessary for it to work?

Is it worth it? Value

How can we put it into practice? Implementation research

What do We Want to Know about Delivery System Effectiveness?

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Manner in which a given DSC is implemented and practiced is influenced by range of factors surrounding the specific change

These factors constitute the social system or social context of change

These factors may explain why, when, and how a DSC works (or not)

Delivery System Change

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“Experimentalists have pursued too single-mindedly the question of whether a [social] program works at the expense of knowing why it works.”

Pawson and Tilley (1997)

“….. although the OXO model seeks generalizable knowledge, in that pursuit it relies on – it depends on – removing most of the local details about “how” something works and about the “what” of contexts.”

Berwick (2008)

Limits of Experimentalism

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Modeling intervention context Assessing intervention fidelity and

sustainability Incorporating time in delivery system

models Measuring readiness for change Assessing complex, multi-component

interventions

Five Methods and Metrics Issues

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Interventions can display different strengths, causal directions, and base rates depending on the ecological conditions under which the processes or programs are observed

Measure context as an analytic variable in our models- not as study setting descriptions

Analytic techniques for assessing contextual effects are robust- concepts and measures of context are not

Modeling Intervention Context

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Measurement of treatment fidelity provides a means for determining whether key program components were delivered as specified by the program logic model/theory

Sustainability- are intervention components active long enough to produce the desired effect on individuals?

Fidelity and sustainability follow from interrelationships among a range of internal and external factors that constitute the social system that surrounds the intervention- not just individual attitudes.

Assessing Intervention Fidelity and Sustainability

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Time as an important analytic concept in its own right, not simply as an element of the research design

Individual growth trajectories Organizational/ system level developmental

trajectories

Time

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Not all delivery systems/organizations are good candidates for interventions and change

Readiness for change a precursor to the successful implementation of complex changes in health care settings

Readiness measured as collective motivation and collective capability

Readiness for Change

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How the combined effects of multiple intervention elements affect outcomes

How, and the extent to which, individual elements of the intervention contribute to these collective efforts

Mixed methods designs are difficult to implement in a manner that creates synergistic benefits from the use of different forms of data collection and analysis.

Complex, Multi-Component

Interventions

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Don’t reject traditional designs- complement them

Consider methods and metrics challenges as a package of related issues

Increase the synergistic value of mixed methods research

Time as an analytic variable Robust theoretical frameworks to guide the

application of analytic methods and measures

General Recommendations

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From DSC Model to PracticeGOAL: To increase the adoption, reach and impact of DSC

Science PushInvestigation, improvement and communication of DSC for widespread use

Delivery CapacityBuilding the capacity of relevant systems to deliver improved care

Market Pull/DemandBuilding a market and demand for DSC

Increase the number of systems providing evidence-based DSCIncrease the number of practitioners providing evidence-based DSCIncrease the number of individuals receiving evidence-based DSC

ULTIMATE GOAL:Improve patient

health and well being

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Thank you

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