Dissemination and Implementation

Ellen Goldstein, MAKevin Grumbach, MD

Translating Practice into Evidence: Community Engaged Research

Institute of MedicineDefinition of “T2” Translational Research

• “the translation of results from clinical studies into everyday clinical practice and health decision making”

• “from bedside to community”

• Westfall et al further distinction:– “T2” as translation to patients– “T3” as translation to practices

Dissemination and Implementation are Key Aspects of T2 and T3

Translation

Definitions• Dissemination is the targeted distribution of

information and intervention materials to a specific public health or clinical practice audience

• Implementation is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings– “Scaling up” of interventions

Source: Schillinger et al, CTSI CEP An Introduction to Effectiveness, Dissemination and Implementation Research http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf

The Process of Dissemination and Implementation is Itself Researchable

• Dissemination research is the systematic study of how the targeted distribution of information and intervention materials to a specific public health audience can be successfully executed so that increased spread of knowledge about the evidence-based public health interventions achieves greater use and impact of the intervention

The Process of Dissemination and Implementation is Itself Researchable

• Implementation research is the systematic study of how a specific set of activities and designed strategies are used to successfully integrate an evidence-based public health intervention within specific settings (e.g., primary care clinic, community center, school)

And 1 More Concept

• Diffusion research is the systematic study of the factors necessary for successful adoption by stakeholders and the targeted population of an evidence-based intervention which results in widespread use (e.g., state or national level) and specifically includes the uptake of new practices or the penetration of broad scale recommendations through dissemination and implementation efforts, marketing, laws and regulations, systems-research and policies.

What is Fundamentally at Issue

• Does the world change because a study demonstrating the efficacy of an intervention is published in a peer-reviewed journal?

Why focus on Dissemination?

• This is how science makes a difference in people’s health.

• Your results shouldn’t be hard to find or top secret

Traditional academic culture

• While there are clear guidelines for grant submission, human subject protections, research methods…

• There’s no standard expectation or training on dissemination outside academic circles

Value of Good Dissemination

• Impact on public and individual health

• Develop new partners

• Generate new ideas

Risks of Poor Dissemination

• Outraged Public

• Outraged Partners

• Outraged Participants

• No impact on health

Ethical issues

• Public dollars

• Citizen participants

• Health disparities

Dissemination Planning

•

Audiences

• Study Participants• General Public• Clinicians• Community agencies• Policymakers

Purpose

• Why are you sharing this information at this time and with this audience?

– Tailor this field for each audience– Is this the right time to disseminate?– Assess the cost/ benefit of publicity

Content

• What you learned – process data– Recruitment– Baseline data

• What you learned – outcome data– Positive and negative results

• So what?– Implications for health, clinical care,

programs, policy– Recommendations

Messagingcrafting take-home messages/ sound bites

• Redefine “media moment”• Context of data within body of research • Working with community to refine

message• Right findings to the right audience• Statistics and stories, depending on

audience

Channels - venues

• Media• Presentations

– Conferences– inservices, grand rounds– community meetings

• Websites/ blogs/ Facebook/ webinars• Written reports for lay audiences• Policy briefs

Skills

• Language sensitivity• Working with the media• Working with community stakeholders

Logistics

• Timeline• Budget• Messenger• Support (i.e. UCSF News Office,

community or clinical outreach)

Implementation Science• Gap between discovery and application

• Many efficacious interventions not widely implemented (or implemented effectively) in practice – Team care of depression in primary care settings– Parteras and birth outcomes– Hand washing– Aspirin for patients at risk of cardiovascular disease

• “The lack of “fit” (mismatch) between an intervention/research design on the one hand and the realities inherent to the ultimate target practice setting and the information needed by policymakers on the other hand, leads to low adoption and implementation”

• Research culture emphasizing internal validity to much greater degree than external validity

Schillinger et al, CTSI CEP An Introduction to Effectiveness, Dissemination and Implementation Research http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf

Reasons for Lack of Fit• Context

– Relevant question?– Relevant population?– Motivation to change– Motivation not to change

• Intervention– Feasible to adopt?– Sustainable?– Adaptable without sacrificing effectiveness?– Affordable, cost-effective?

Implementation Science Case Study

• AJ Dietrich et al. Translation of an Efficacious Cancer-Screening Intervention to Women Enrolled in a Medicaid Managed Care Organization. Ann Fam Med 2007;5:320

• “Practical Clinical Trial” of prevention care management program

• Initial RCT of PCM intervention demonstrated its efficacy

• Implementation study designed to investigate adaption and scaling up of intervention integrated into routine operations of a quality improvement unit of a Medicaid Managed Care Organization

Dissemination Plan Session #5 Homework:

• Complete Dissemination Plan Worksheet for two different non-academic audiences for your study– It’s helpful to separate the two audiences

by a blank line or shading.