Co-Hosted by the National Institutes of Health and AcademyHealth Orientation to the Science of Dissemination and Implementation
Orientation to the Science of Dissemination and Implementation Cara C. Lewis, PhD, Kaiser Permanente Washington Rinad S. Beidas, PhD, University of Pennsylvania Byron J. Powell, PhD, Washington University in St. Louis Meghan Lane-Fall, MD, MSHP, University of Pennsylvania Annual Conference on the Science of Dissemination and Implementation in Health December 4, 2019
Objective To provide a broad overview of the field of implementation science. Don’t forget the resource guide! @caraclewis, @rsbeidas, @byron_powell, @mlanefall 3
Brief Introductions 4
Overview Introduction and Rationale for Implementation Science 1. 2. Introduction to Two Case Studies 3. Implementation Frameworks: Overview 4. Identifying and Prioritizing Barriers and Facilitators 5. Identifying and Applying Implementation Strategies 6. Evaluating Implementation Efforts 7. Discussion 5
Orientation to the Science of Dissemination and Implementation Introduction and Rationale for Implementation Science
Original Research 18% variable Dickersin, 1987 Negative Submission results 46% 0.5 year Koren, 1989 Kumar, 1992 Acceptance It takes 17 years to turn 14 0.6 year Kumar, 1992 Expert Publication percent of original research to 35% opinion Lack of 0.3 year Balas, 1995 Poyer, 1982 numbers the benefit of patient care Bibliographic databases Inconsistent 50% 6 - 13 years indexing Antman, 1992 Poynard, 1985 Reviews, guidelines, textbook 9.3 years Implementation Balas & Boren (2000) 7
From Bench to Bedside? Credit Cynthia Vinson 8
Quality Gaps Persist 9
Prioritization of D&I Science 10
Dissemination Research – The scientific study of targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to understand how to best spread and sustain knowledge and the associated evidence-based interventions Implementation Research – The scientific study of the use of strategies to adopt and integrate evidence- based health interventions into clinical and community settings to improve patient outcomes and benefit population health. NIH PAR-18-007 11
“Make it happen” Implementation “Help it happen” Dissemination “Let it happen” Diffusion Greenhalgh et al. (2004); Lomas (1993) 12
Multidisciplinary Influences Intervention Effectiveness/Process Research Healthcare/Behavioral Improvement Science Economics Adult Education/ Medical Anthropology Learning Organization & Social Psychology Management, Marketing 13
Implementation Research Generalizable knowledge Sustainment Making an Implementation intervention work Preparation Real-world relevance knowledge Local Exploration 4 Phases: Aarons et al., 2011 Does an Implementation Practice intervention Effectiveness work? studies Traditional Translational Efficacy Could an studies Pipeline intervention work? Preintervention 14 Time Brown et al., ARPH 2017
Effectiveness vs. Implementation Evaluate Quality, Quantity, System to Support System to Support Speed of Adoption and Delivery Adoption and Delivery Delivery with Fidelity w Fidelity Evaluate Intervention Intervention Health Outcomes Credit H. Brown and J.D. Smith
Service Implementation Health Outcomes Outcomes* Outcomes Efficiency Acceptability Satisfaction What? How? THE USUAL Safety Appropriateness Function Effectiveness Feasibility Health status/ Evidence-based Implementation THE IMPLEMENTATION Equity Adoption symptoms Interventions Strategies PATHWAY Patient- Fidelity centeredness Penetration Timeliness Costs Sustainment *IOM Standards of Care Proctor et al. (2009 & 2011) 16
Plain Language The intervention/practice/innovation is THE THING ● Implementation strategies are the stuff we do to try to help ● people/places DO THE THING Main implementation outcomes are HOW WELL they DO ● THE THING Curran, G. M. (In Press). Implementation Science Made Too Simple. Implementation Science Communications 17
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Orientation to the Science of Dissemination and Implementation Introduction to Two Case Studies
Case Study 1 Naturalistic observational study of use of evidence-based practice over time in large public mental health system 20
2007 2011 2012 2016
Adm Policy Ment Health (2016) 43:909–926 DOI 10.1007/s10488-016-0733-6 ORIGINAL PAPER Applying the Policy Ecology Framework to Philadelphia’s Behavioral Health Transformation Efforts Byron J. Powell 1,2 • Rinad S. Beidas 2 • Ronnie M. Rubin 3 • Rebecca E. Stewart 2 • Courtney Benjamin Wolk 2 • Samantha L. Matlin 4 • Shawna Weaver 3 • Matthew O. Hurford 5 • Arthur C. Evans 3 • Trevor R. Hadley 2 • David S. Mandell 2 Hosting events Designating Systematically Enhanced Training & highlighting organizations contracting for rates for EBP Consultation EBP as “EBP EBP delivery delivery champions agencies” 23
Timeline of Data Collection 21 agencies 19 agencies 22 agencies 26 sites 23 sites 28 sites Pre- 249 130 247 EPIC therapists therapists therapists 24
? Research Questions What drives clinician Does use of CBT behavior in a large increase over the 5 system implementing year period? EBP? What are stakeholder Establishing temporal perspectives on relationship between barriers and facilitators constructs of interest to implementation of to move towards EBP? mechanisms. 25
Case Study 2 Hybrid trial of implementing standardized handoffs two surgical intensive care units 26
ICU nurses (2°) What OR ICU provider Surgeon to ICU handoffs should look like ICU nurse (1°) Anesthetist Respiratory therapist
Research questions organized by the EPIS framework Adapted from Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38(1):4-23.
Setting: Ø Penn Medicine health system Ø 2 mixed surgical ICUs Participants: Ø Patients admitted from OR to ICU Ø Clinicians Ø Surgeons (all ranks) Ø Anesthesia staff (all ranks and roles) Ø ICU nurses Ø ICU ordering providers Ø Clinical leadership Timeline: Ø Contextual inquiry: June 2014 – October 2014 Ø Intervention go-live: June 2015 Ø Post-intervention: July 2015 – January 2016 Ø Sustainment: February 2016 - present
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Orientation to the Science of Dissemination and Implementation Implementation Frameworks: Overview
Proliferation of Frameworks “Frameworks are like toothbrushes. Everyone has one and no one wants to use anyone else’s.” -Christian Schunn (2001) Schunn is cited as saying this in Gorman et al. (2003), “Spherical Horses and Shared Toothbrushes” 33
Common Element: Multiphase Adoption EBP Delivered Training/ Decision with Fidelity Coaching Begins P reparation I mplementation S ustainment E xploration Phase Phase Phase Phase Aarons et al. (2011) 34
Common Element: Multilevel Four!Levels!of!Change!for!Assessing! Assump9ons!about!Change ! Performance!Improvement ! Reimbursement,&legal,&and& Larger&System/&Environment & regulatory&policies&are&key & Organiza4on & Structure&and&strategy&are&key & Coopera4on,&coordina4on,&&&shared& Group&/&Team & knowledge&are&key & Knowledge,&skill,&and&exper4se&are& Individual & key & Shortell,&S.&M.&(2004).&Increasing&value:&a&research&agenda&for&addressing&the&managerial&and&organiza4onal&challenges&facing&health&care& delivery&in&the&United&States.& Medical(Care(Research(and(Review ,& 61 (3&suppl),&12SS30S.& ! Ferlie,&E.&B.,&&&Shortell,&S.&M.&(2001).&Improving&the&quality&of&health&care&in&the&United&Kingdom&and&the&United&States:&a&framework&for& change.& Milbank(Quarterly ,& 79 (2),&281S315.& ! 35
Types of Theories/Frameworks Nilsen (2015) 36
Case Study 1: EPIS Framework Aarons et al. (2011); Beidas et al. (2013) 37
Proctor EK et al, Adm Policy Ment Health. 2009 Jan; 36(1) Case Study 2: Proctor framework Lane-Fall MB et al, adapted from Proctor
Conceptual model with constructs & measures
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Orientation to the Science of Dissemination and Implementation Identifying and Prioritizing Barriers and Facilitators
Assessing Barriers/Facilitators Determinants Methods “Factors that might prevent or ● Literature search enable improvements in ● Informal consultation practice (barriers, enablers, ● Surveys facilitators, problems & needs, ● Interviews, focus groups, or disincentives or incentives)” ethnographic methods (Flottorp et al., 2013) ● Mixed methods approaches 42
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