Dissemination and implementation strategies What works Anne Sales

Dissemination and implementation strategies: What works? Anne Sales Ph. D RN salesann@umich. edu

Acknowledgements • No conflicts to declare • Co-editor-in-chief of Implementation Science, implementationscience. com • Online, open access journal hosted by Bio. Med Central (Springer) • I am not an expert in dissemination science or the practice of dissemination • Resource to consider: • • • http: //www. innovations. ac. uk/btg/resour ces/publications/dissemination. pdf Focuses on dissemination of educational materials May be relevant to QSEN

Defining implementation science (IS) • As defined by the Annual NIH Conference on Implementation and Dissemination, implementation is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings. Research on implementation addresses the level to which health interventions can fit within realworld public health and clinical service systems. • Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice. It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidencebased interventions. • http: //www. fic. nih. gov/News/Events/implementationscience/Pages/faqs. aspx

Current definitions Implementation science is the science of planned human behavior change under organizational constraints.

Implementation science is a rapidly evolving field • Key issue in implementation is behavior change – Changing behavior of professionals and others delivering health services – In health care, people generally take actions or behave under constraints • Organizational policy and culture • Context for behavior

Different streams have converged to create our current understanding of implementation science Evidencebased medicine • Systematic reviews • Guidelines Health services research • Variation studies • Outcomes research Psychology and other cognate theories • Theories • Frameworks 1950 s-1960 s Contemporaneous streams: Diffusion of Innovation, Quality Improvement, Improvement Science 1980 s 1990 s 2000 s forward

Why worry about implementation science? • Doesn’t everyone providing health care services just do the right thing? • My 5 moments for hand hygiene: – before touching a patient, – before clean/aseptic procedures, – after body fluid exposure/risk, – after touching a patient, and – after touching patient surroundings – http: //www. who. int/gpsc/5 ma y/background/5 moments/en/

Most people want a “magic bullet” • Simple ways to get things done – – Implement anything Anywhere Any time With any group

1995 2004

Defining implementation science (IS) • As defined by the Annual NIH Conference on Implementation and Dissemination, implementation is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings. Research on implementation addresses the level to which health interventions can fit within realworld public health and clinical service systems. • Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice. It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidencebased interventions. • http: //www. fic. nih. gov/News/Events/implementationscience/Pages/faqs. aspx

Current definitions Implementation science is the science of planned human behavior change under organizational constraints.

What is evidence based practice? • “the conscientious use of current best evidence in making decisions about patient care” (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000).

Why worry about systematic approaches to implementing evidence based practices? • Consistent principles for • Appears to take more designing interventions effort than intuiting an intervention or using • Based on evolving the ISLAGIATT principle knowledge and – May not be as much standards “fun” • More rational and • Not clear that this replicable basis than results in better intuition alone outcomes It Seemed Like A Good Idea At The Time

Effectiveness of implementation strategies • Dependent on a number of factors – What should be transferred? • Evidence based practices, where evidence requires synthesis over a body of literature rather than single studies – To whom are you transferring? • Multiple audiences, often requiring multiple strategies • Consumers (patients); healthcare professionals; policy makers; regulatory bodies; industry; research funders; researchers; educators Grimshaw et al. Implementation Science 2012, 7: 50 Implementation Science http: //www. implementationscience. com/content/7/1/50

• • How to transfer research knowledge or implement evidence based practices Requires planning Knowledge of the audience Identifying barriers to implementation Deciding on professional behavior change strategies – Link to assessed barriers – Cochrane Effective Practice and Organization of Care group (EPOC) has conducted reviews of over 300 reviews of effectiveness of strategies

Not all strategies are equal Intervention Number of studies Printed educational materials Median absolute improvement of 4. 3%, range -8. 0% to 12 RCTs, 11 non randomized +9. 6% Educational meetings 81 RCTs Median absolute improvement of 6. 0%, range +1. 8% to +15. 3% Educational outreach 69 RCTs Median absolute improvement in prescribing 4. 8% (IQR +3. 0 to +6. 5%), other behaviors 6. 0% (IQR +3. 6 to +16. 0%) Local opinion leaders 18 RCTs Median absolute improvement 12. 0% (+6. 0 to +14. 5%) Audit and feedback 118 RCTs Median absolute improvement 5. 0% (+3. 0 to +11%) Computerized reminders 28 RCTs Median absolute improvement 4. 2% (+0. 8 to +18. 8%) 26 RCTs Pooled odds ratio of 1. 52 (95% CI 1. 27 to 1. 82, p<. 001, over 12 of 26 studies) Tailored interventions Effect sizes Source: Grimshaw et al. Implementation Science 2012, 7: 50 Implementation Science http: //www. implementationscience. com/content/7/1/50

Should interventions include multiple strategies (Multifaceted)

61 frameworks and counting • 2012 systematic review of the literature in dissemination and implementation sciences found over 100 frameworks – 61 identified as being potentially useful in either dissemination or implementation or both – Level of focus (individual, organizational, social) identified • Policy interventions would likely be at social level, above individual and probably organizational – But not all frameworks are equal • Some are consolidations of the literature at previous points in time – Consolidated Framework for Implementation Research (CFIR) – Theoretical Domains Framework (TDF)

Different kinds of frameworks are useful at different points in implementation research • Process frameworks – Describing – Guiding the process • Determinant frameworks – Understanding – Explaining what influences implementation • Evaluation frameworks – How well the process worked Nilsen, Implementation Science 2015 http: //www. implementationscience. com/content/10/1/53

What barriers and facilitators exist to evidence based practices? DETERMINANTS FRAMEWORKS

Multiple determinants frameworks in implementation research • Greenhalgh et al. 2005 -7 – – – • Michie et al. 2005 -2014 – – • Theoretical Domains Framework (TDF) Consolidates 33 health psychology/behavior change theories Damschroder et al. 2009 and forward – – • Milbank Quarterly review Book Reviewed and consolidated framework components across health and social service organizations Consolidated Framework for Implementation Research (CFIR) Largely built off Greenhalgh et al. work but incorporated other frameworks and models as well Flottorp et al. 2013 – – – Tailored Implementation for Chronic Disease (TICD) Checklists consolidating over 12 different models and frameworks Included Greenhalgh, TDF, CFIR and others • Mostly used as checklists – – – Assess barriers and facilitators to implementing specific evidence based practices Typically collect data using qualitative semistructured interviews TICD includes both individual and organizational level determinants

Focus on the TICD • Most recent consolidation • Seven domains of frameworks – Guideline factors – Includes most of the major prior determinants frameworks • TDF, CFIR, Greenhalgh • Nine other frameworks or checklists – Individual health professional factors – Patient factors – Professional interactions – Incentives and resources – Capacity for organizational change – Social, political and legal factors • 57 different constructs within these 7 domains

Systematizing design of implementation interventions • Systematic analysis of barriers (and enablers) through pilot work or literature review • Use of determinants frameworks to map barriers to behavior change techniques or strategies for change – Individual level • Map to Behavior Change Techniques (http: //www. ncbi. nlm. nih. gov/pubmed/23512568) – Organizational level (and possibly above) • Map to implementation strategies (work ongoing)

Designing interventions • Current leading edge in implementation research – Linking barriers to techniques (at individual level) – Linking barriers to strategies (at higher level) – Designing interventions from strategies (broad) and techniques (micro) as indicated

Effective implementation strategies • Effective Practice and Organization of Care Group – EPOC– part of the Cochrane Collaboration – 78 systematic reviews and/or meta-analyses of strategies • From specific intervention modalities – Opinion leaders, audit with feedback, printed educational materials among others • To other approaches to changing organization of care – Approaches to changing culture, models of nursing care among others • Other reviews through other groups and sources • We know a lot about a number of ways to implement evidence based practice – Maybe…

Implementation strategies • 73 broader, more macro approaches – Quite variable in level – Linkage to 39 CFIR constructs currently in progress – Example • Audit and provide feedback • Mandate change Reference: Powell et al. Implementation Science (2015) 10: 21 DOI 10. 1186/s 13012 -0150209 -1

Behavior change techniques • 93 techniques for changing behavior – Operate through specific psychological or social theory • Emphasize specific behavior within practices – Generally validated through both theory and empirical test – Linked to TDF – Examples • Self-monitoring of behavior (linked to Motivation and Goals) • Instruction on how to perform a behavior (linked to Knowledge) Reference: Michie, S. , Richardson, M. , Johnston, M. , Abraham, C. , Francis, J. , Hardeman, W. , Eccles, M. P. , Cane, J. & Wood, C. E. (2013). The Behavior Change Technique Taxonomy (v 1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions. Annals of Behavioral Medicine, 46(1), pp. 8195. doi: 10. 1007/s 12160 -013 -9486 -6

Summary • Implementing evidence based practices is complex • Dissemination is probably simpler, but effective dissemination is complex also • We have a number of useful approaches – But none work all of the time, for everyone, in all settings • This is as true in educational work as in care delivery

Questions or comments? • salesann@umich. edu

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