Implementation Science: An Emerging Field

Bryan J. Weiner, Ph.D.Professor

Department of Health Policy and Management

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A Roadmap for Today’s Talk

• Why implementation science?• What is implementation

science?• What does implementation

science look like? • How do you do implementation

science?• Where can I learn more?

Why Implementation Science?

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A Growing Evidence Base of What Works

And Yet…

• Americans receive “recommended care” approximately 50% of the time (McGlynn et al., 2003).

• Between the health care we have and the care we could have lies not just a gap, but a chasm (IOM, 2001).

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And in Cancer Care…

• Completion rate of 3-dose HPV vaccine:– 33% for teenage girls– 7% for teenage boys

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And in Cancer Care…

• Surgery rate for non-small cell lung cancer:– 14% lower for Blacks than whites

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And in Cancer Care…

• Over-surveillance rate among patients with non-displastic Barrett’s Esophagus

– 65% in a multi-center study

Barriers to Evidence-Based Practice and Policy

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What is Implementation Science?

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What is Implementation Science?

IMPLEMENTATION SCIENCE is the study of methods to promote the use of research findings in healthcare, community, and policy contexts. As a multidisciplinary field, it examines how these findings are disseminated, implemented, and sustained by targeted audiences.

Figure modified from National Cancer Institute Implementation Science Web Portal and Rubenstein et al. 2006.

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Dissemination and Implementation

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

Implementation: the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns in specific settings.

NIH PAR 07-086

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IS as an Emerging Field

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IS as a Translational Science

Modified from Khoury et al.Figure 1—Knowledge integration process.

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IS as a Team Science

What does IS look like?

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Examples of Funded IS Grants

• Implementing evidence to prevent urinary infection and enhance patient safety

• Increasing implementation of evidence-based interventions at low-wage worksites

• Integrating tobacco use treatment guidelines in dental public dental clinics

• Implementing EBAN II: an evidence-based intervention for sero-discorant couples

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Two Examples In My Work

• Examining the implementation, impact, sustainability, and business case of the CCOP, a federally funded provider-based research network

• Increasing colorectal cancer screening rates in community health centers through practice change facilitation and an evidence-informed tool kit

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NCI IS Portfolio Review

Neta et al., (2015). Implementation science in cancer prevention and control: a decade of grant funding by the National Cancer Institute and future directions. Implement Sci, 10(1), 4. doi: 10.1186/s13012-014-0200-2

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NCI Portfolio Review- Implementation Science

• 67 grants included in Implementation Science portfolio review, funded between 2000-2012

Cancer Control Continuum

# of grants

% of grants

Prevention 33 49.3%

Screening 27 40.3%

Cross-cutting 7 10.4%

Survivorship 4 6%

Treatment 3 4.5%

Diagnosis 0 0%

Types of Cancer/ Risk factors

# of grants

% of grants

Tobacco 26 38.8%

Colorectal cancer 20 29.9%

Breast cancer 12 17.9%

Cervical cancer 8 11.9%

Physical activity 6 9%

Diet/nutrition 5 7.5%

Sun safety 5 7.5%

Public health genomics 4 6%

Obesity 3 4.5%

*Numbers may add up to more than 67 (100%) in some cases because a given grant may fit into more than one category.

Neta et al., 2015

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NCI Portfolio Review- Implementation Science

Implementation Science Objectives # of grants % of grants

Implementation 53 79.1%

Dissemination 31 46.3%

Sustainability 26 38.8%

Adoption 20 29.9%

Sustainability Indicators # of grants % of grants

Maintenance 25 37.3%

Capacity building 20 29.9%

Cost analysis 15 22.4%

*Numbers may add up to more than 67 (100%) in some cases because a given grant may fit into more than one category.

Neta et al., 2015

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Funding Trends for NCI-funded IS

Funding trends of NCI-funded implementation science by grant mechanism, fiscal years 2000-2012 (Neta et al., 2015)

How do you do IS?

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When to Do IS

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Study Designs

• Experimental designs – Individual/cluster RCT, MOST, SMART, hybrid

• Quasi-experimental designs – interrupted time series, regression discontinuity

• Observational designs– surveys, focus groups, case studies

• Mixed methods

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Hybrid Designs

Adapted from Curran et al., 2010

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• Provider-directed interventions– Interactive education– Reminders– Decision support– Audit & feedback– Opinion leaders

Implementation Strategies

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• Staff-oriented interventions– Multi-disciplinary teams– Revised roles– Case management

Implementation Strategies

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• Patient-mediated interventions (“pull”)– Education– Navigation– Reminders– Decision aids

Implementation Strategies

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• Regulatory interventions– Accreditation– Licensure– Insurance coverage

Implementation Strategies

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• Financial interventions– Payment changes– Incentives

Implementation Strategies

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• Organizational interventions– Structural changes– Service changes– Quality Improvement

Implementation Strategies

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• Collaboratives / campaigns– Hospital-to-Home Campaign– IHI Breakthrough Series– Vermont Oxford Network– 5 Million Lives Campaign

Implementation Strategies

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Implementation Outcomes

Types of outcomes in implementation research

Adapted from Proctor et al., 2011

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• Implementation in low-resource settings• Reliable, valid, and practical measures• Cost and cost-effectiveness studies• Strategies for scaling up effective programs• Use of simulation models to evaluate

proposed D&I actions, policies, and practices• Theory and research on sustainability• De-implementation

Gaps & Opportunities

Where can I learn more?

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• Sample Grants and Grant Writing Resources• Sources of Evidence• Tools• Measures• Journals • Theories and Frameworks• Conferences and Training• Presentations

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D&I Portal – an NC TraCS Resource

http://tracs.unc.edu/di-portal

Consortium for Implementation Science

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• Advance IS through research, practice, policy, and education/training

• Initial focus: improving health in the US

• Approach:– Identify opportunities and connect investigators– Build cross-institutional research teams– Scientific/technical support for proposals– Facilitate access to internal funds for pilot projects

http://consortiumforis.org/

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The Implementation Network

• http://www.implementationnetwork.com/• Monthly e-newsletter and website• 1500+ members worldwide• Supported by VA QUERI and NCI

• Chief Editor: Wynne Norton, Ph.D.

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• http://www.seattleimplementation.org/sirc-projects/sirc-instrument-project/

• Comprehensive library • Evidence-based assessment • Consensus battery

• Lead Investigator: Cara Lewis, Ph.D.(Indiana University, Bloomington)

SIRC Instrument Review Project

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• Grid-enabled Measures (GEM) D& I Workspacehttps://www.gem-beta.org/public/wsoverview.aspx?wid=11&cat=8

• CFIR Wiki http://www.wiki.cf-ir.net/index.php?title=Main_Page

• SIRC (focus on behavioral therapies)http://www.seattleimplementation.org/

• Implementation Science Journalhttp://www.implementationscience.com/

• VA Enhancing Implementation Science Webinar archiveshttp://www.queri.research.va.gov/meetings/eis/

Other D&I Resources

bryan_weiner@unc.edu919-537-8111

Thank you

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NCI Portfolio Review- Implementation Science

Frameworks/ Models # of grants

% of grants

Diffusion of Innovation 26 38.8%

RE-AIM 23 34.3%

Chronic Care Model 7 10.4%

Organizational Change 7 10.4%

Systems/Network Theories 5 7.5%

Model of Diffusion in Service Orgs 3 4.5%

Methods Used # of grants

% of grants

Quantitative 59 88.1%

Qualitative 54 80.6%

Comparative effectiveness

35 52.2%

Cost analysis 18 26.9%

Simulation models 2 3%

Network analysis 1 1.5%

*Numbers may add up to more than 67 (100%) in some cases because a given grant may fit into more than one category.

Neta et al., 2015

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Funding Trends for NCI-funded IS

Trends in NCI-funded grants in implementation science by funding announcements, fiscal years 2000-2012 (Neta et al., 2015)

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Success Rates

R01s, R21s, R03s R01s only0%

5%

10%

15%

20%

25%

30%

24.3%26.7%

20.2%19.1%

Comparison of funding success rates at NCIDIRH PAR – NCI Cancer Prevention & Control grants

2000-2012

DIRH PAR grants Cancer Prevention & Control grants

Neta et al., 2015

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New Investigator Awards

New Investigator awards0%

10%

20%

30%

40%

50%

43.8%

24.2%

Proportion of New Investigator AwardsDIRH PAR – NCI as a whole, 2000-2012

DIRH PAR NCI

Neta et al., 2015