Orientation to the Science of Dissemination and Implementation Rinad S. Beidas, PhD, University of Pennsylvania Cara C. Lewis, PhD, Kaiser Permanente Byron J. Powell, PhD, University of North Carolina at Chapel Hill November 30, 2018 11 th Annual Conference on the Science of Dissemination and Implementation
Objective To provide a broad overview of the field of implementation science to whet your appetite for all that is to come. #DIScience2018 @rsbeidas, @caraclewis, @byron_powell 2
Brief Introductions 3
Overview 1. Introduction and Rationale for Implementation Science 2. Introduction to Two Case Studies 3. Implementation Process Models 4. Identifying and Prioritizing Barriers and Facilitators 5. Identifying and Applying Implementation Strategies 6. Evaluating Implementation Efforts 7. Discussion 4
1 2 3 4 5 6 7 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 0.6 year Kumar, 1992 Expert Publication 35% opinion Lack of 0.3 year Balas, 1995 Poyer, 1982 numbers Bibliographic databases Inconsistent 50% 6 - 13 years indexing Antman, 1992 Poynard, 1985 Reviews, guidelines, textbook 9.3 years Implementation Balas & Boren (2000) 6
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 Implementation Practice Does an 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
Health Outcomes Satisfaction What? THE USUAL Function Health status/ Evidence-based symptoms Interventions *IOM Standards of Care Proctor et al. (2009 & 2011) 16
Implementation Service Health Outcomes Outcomes Outcomes* Acceptability Efficiency Satisfaction What? How? Appropriateness Safety Function Effectiveness Feasibility Health status/ Evidence-based Implementation Adoption Equity symptoms Interventions Strategies Fidelity Patient- Penetration centeredness Costs Timeliness Sustainment *IOM Standards of Care Proctor et al. (2009 & 2011) 17
Implementation Service Health Outcomes Outcomes Outcomes* Acceptability Efficiency Satisfaction What? How? Appropriateness Safety Function Effectiveness Feasibility Health status/ Evidence-based Implementation THE IMPLEMENTATION PATHWAY Adoption Equity symptoms Interventions Strategies Fidelity Patient- Penetration centeredness Costs Timeliness Sustainment *IOM Standards of Care Proctor et al. (2009 & 2011) 18
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 Courtesy of Geoff Curran 19
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” 20
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) 21
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.& ! 22
Types of Theories/Frameworks Nilsen (2015) 23
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1 2 3 4 5 6 7 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 26
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” 29
Timeline of Data Collection 21 agencies 19 agencies 22 agencies 26 sites 23 sites 28 sites Pre- 249 130 247 EPIC therapists therapists therapists 30
EPIS Framework Aarons et al. (2011); Beidas et al. (2013) 31
? 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. 32
Case Study 2 Randomized trial comparing to approaches to implementing measurement-based care in community mental health Lewis et al. Implementation Science (2015) 10:127 DOI 10.1186/s13012-015-0313-2 Implementation Science STUDY PROTOCOL Open Access Implementing measurement-based care (iMBC) for depression in community mental health: a dynamic cluster randomized trial study protocol Cara C. Lewis 1,2* , Kelli Scott 1 , C. Nathan Marti 3 , Brigid R. Marriott 1 , Kurt Kroenke 4 , John W. Putz 5 , Peter Mendel 6 and David Rutkowski 7 33
Measurement Based Care (MBC) ● MBC is the systematic evaluation of patient symptoms prior to or during a clinical encounter to inform treatment ● 3 components of MBC fidelity 1. Administer 2. Review Data 3. Discuss Measure 34
iMBC: Implementing Measurement Based Care ● Aim 1: To compare the effect of standardized versus tailored MBC implementation on 1a: Clinician- 1b: Client-level level outcomes outcomes 35
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