Implementation Science - Latest Comments

Author's correction

Kim Holtzer-Goor — 2013-03-14T12:04:50Z

After publication of this article [Holtzer-Goor et al], the authors noted a missing space in Table 6. 'Apart' should read 'a part' resulting in the following quotation: "With respect to glaucoma care, we have started to investigate whether a part of the activities that take place here could be substituted to optometrists who are closer to the patient¿s home."
Besides, the abbreviation 'Nza' in Table 2 and Table 5 remained unexplained. It means Dutch Health Care Authority. The authors apologise for any inconvenience this has caused.

General Comment

Frances Ehrlich — 2012-07-12T16:40:06Z

A very interesting read, pity the logic model was not available to view with the provisional PDF publication. I hope it encourages more evaluators/organisations to publish information on protocols /methods for evaluating research funding programs.

My only comment in relation to the methodology is there was no specific mention of how the various stakeholder groups would be involved in interpreting and making judgements on the evaluation findings. If the principles of utilisation-focused evaluation are to be adopted, this would be a critical element of the evaluation process. I would be very interested to understand more on how the evaluators will facilitate judgements from and amongst the various stakeholder groups, and what, if any, strategies they will employ to encourage use and follow-up after the evaluation.

Think beyond the evidence

Pritpal S Tamber — 2012-07-02T11:25:57Z

Dear Editor,

I applaud the authors¿ summary of research findings in knowledge translation.

I agree that syntheses are the best form of knowledge for clinicians to work from but in many specialities they simply do not exist - sometimes because the primary studies are insufficient to warrant a summary. This is something we encountered at Map of Medicine (at which I was Medical Director) when we created the content. We relied on guidance producers and systematic reviews as the main form of knowledge to work from, but we often found that either specific specialties, topics or parts of topics were insufficiently covered by them. Our solution was to do a light-Delphi process, which we established through professional bodies, such as Royal Colleges and specialist societies (this also leveraged their status as key opinion leaders, another point in your article).

In your list of barriers I was surprised not to see time specifically mentioned. I suspect it's implicit to many of things listed but my experience suggests that it is more important than any other. Most doctors are conscientious individuals who, with more time, would make greater efforts to apply new knowledge into their practice. Indeed, I think most clinicians are hungry for new knowledge, even if only to reduce their medico-legal risk. However, with general practitioners (primary care physicians) in the UK only having, on average, 8 minutes per patient there simply is not the time to acknowledge what one's questions are and then seek answers for them, either intra- or post-consultation.

I had not heard of the Proteus Phenomenon but I suspect we saw an aspect of that playing out in Faculty of 1000 Medicine. We had an option in the service whereby Faculty Members could say whether an article changed their practice. We assumed that it would be used very rarely and that when used it would be for big, blockbuster papers in The Lancet or NEJM. Instead what we found was that the 'changes practice' option was ticked on smaller studies, usually confirmatory ones and not necessarily traditionally-rigorous study designs such as randomised, controlled trials. We found the Faculty often waited until they felt there was sufficient confirmatory evidence before they suggested that practice should change.

In your table 1, I disagree that population health is not relevant to consumers and professionals. I don't know the impact of the global financial crisis in Canada or Australia (where some of the authors are from) but in England there is an attempt to reduce the annual healthcare budget by over 20% by 2015 (the initiative started late 2010). This flies in the face of the increasing expectation of consumers for more healthcare, and faster. While it is politically unpalatable to use the word 'rationing', it's clear that some form of rationing is going to be required to meet the cost-reduction target. That is only likely to happen if both clinicians and the public understand the financial pressures on healthcare and the rising need for out-of-pocket expenses or supplementary insurance.

I also think that industry is increasingly aware of the need to provide value across populations. In England, this is being potentiated by the debate on value-based pricing and the evolving role of the National Institute for Health and Clinical Excellence (NICE). In my work I am hearing of more and more pharmaceutical and device companies asking themselves how their products can offer value beyond the specific intervention they offer.

In behaviour change strategies, I find the role of content to be repeatedly underplayed. All of the interventions listed in table 3 have content at their heart and yet there is little appreciation of what it takes to write compelling content. This is not about great literature, but about consistent messaging, whether delivered in printed, educational materials, through educational meetings or by local opinion leaders. Too often the different channels used do not align. Indeed, I am currently in discussion with a local primary care practice trying to convince them to implement a 'content intervention' across the practice aligned to their two or three primary goals for the year. The idea would be to align all information across all channels and remove all non-aligned content from the practice (leaflets, website info, etc). I have no doubt that this would yield a significant, measurable quality impact.

Much of knowledge translation can come down to messaging and PR (public relations). As you know, there is an industry dedicated to this, with specialist sectors for business-to-business and business-to-consumer companies. I am always surprised that healthcare feels the need to reinvent the wheel through the prism of research and evidence when best practices are established elsewhere. Throughout your article I found elements of what I know PR firms do, such as never delivering more than three messages in 10-15 minutes presentations or having different kinds of people speak to different audiences. Indeed, a physician friend of mine created a service solely dedicated to finding the right kind of key opinion leaders, by topic and geographical area, to speak to different audiences. It¿s interesting that his customers are mainly pharmaceutical companies rather than healthcare providers.

My final comment - which is beyond the scope of your article - is how little strategy there is in how content is delivered. The problems in knowledge translation are not new and yet when a healthcare provider decides it wants to focus on a specific issue it rarely does the work needed to think through what it means for the communications it creates or permits (such as the type of education clinicians should receive). I have always found this baffling. In commercial business it is now established practice to align the brand, its values, the strategy and all communications to all stakeholders and across all channels. I fail to comprehend why healthcare believes itself to be different. It is not.

I want to thank you for your excellent summary. I hope the next time such a summary is written, you ¿ or other authors ¿ are compelled to look beyond research and evidence and find best practices from other industries.

Pritpal S Tamber

THERE ARE 2 TYPOS IN OUR DOCUMENT

Melissa Brouwers — 2012-06-07T14:18:22Z

Dear Colleagues,

re: recommendation regarding structural barriers

We have made a significant typo in the Recommendations Table and the Specific Recommendations statement #3 by mixing up the cancers recommended and not recommended for this intervention. The recommendation should read:

Reducing structural barriers is an effective intervention to increase community access and reduce barriers to breast cancer and CRC screening. There is insufficient evidence to support or refute its role in cervical cancer screening.

We are sorry for the confusion this has caused. We thank our colleagues for pointing out this error and how the recommendations did not align with the conclusions of the companion systematic review.

Sincerely,
Melissa Brouwers
(author of the paper)

Typo in reference

Bruno Rushforth — 2012-06-07T14:17:38Z

Enjoyed reading this article.
Think there is a typo in reference 21. Should this be vol 49 (not 39)?
Thanks.

Update: Acknowledgements

Devin Mann — 2012-06-04T16:45:45Z

Our acknowledgments section was mistakenly not uploaded. It reads as follows:

The authors would like to thank the following people for their invaluable contributions to the work described in this paper. Mr. Daniel Edonyabo for programming the electronic health record tool. Mr. Lucas Romero and Mr. Diego Chiluisa for their help developing the study tools, recruiting participants and executing the study protocols.

Consider a Federation National Societies

Lisa Simpson — 2012-06-04T16:44:30Z

As the president and CEO of AcademyHealth, the premier, U.S. organization for health services research and those who use evidence to improve health and health care, I read your editorial of February 29, 2012 with great interest.

I would tend to agree that no single international organization currently exists to address the issues you raised and I am a firm believer in the value of international exchange and dialogue, having lived in eight countries on five continents! However, I am concerned that your commentary did not adequately reflect the important role that national and regional scientific societies play in both by addressing many of these needs in their host countries and responding to the unique characteristics of their own health systems. For example, AcademyHealth in the United States, the Canadian Association for Health Services and Policy Research (CAHSPR), the Health Services Research Association of Australia and New Zealand, the German Network for Health Services Research, and numerous others provide ¿ to varying degrees - a forum for scientific discourse through conferences, working groups and networking, numerous professional development opportunities and broad dissemination of research findings through traditional and alternative means. Whether these existing organizations and venues already provide ¿ or could in the future provide -- a welcoming enough home for implementation science AND international exchange would seem to be the question. While I would tend to agree that historically, AcademyHealth has not been successful at integrating international exchange or implementation science throughout its programs, I believe that this is now changing.

Recognizing the vital and growing need for more cohesive understanding and application of implementation science, we would suggest that it might be better to create a federation of the various national and regional societies, to develop and share resources and convene meetings in something of a ¿United Nations¿ of implementation science. Thus, the subset of members of national and regional societies engaged in implementation science could be supported to develop a community of discourse and exchange while not losing the important links to other issues and research that provide much of the context for implementation science. As an example, AcademyHealth currently offers a reduced international member rate to enable our peers worldwide to enjoy discounted participation in our programs and access to all our online resources. Among these are programs in each of the areas enumerated in your editorial:

Multi-disciplinary and science based: Membership in AcademyHealth is open to anyone with an interest in developing and using evidence to improve health and health care. Our family of over 4,400 individual and organizational members work in academic and other research settings, delivery systems, and federal and state governments. Thus, our members reflect the full trajectory of research from hypothesis, to testing, analysis, dissemination, translation and implementation. Approximately 55 percent of our members have an M.D. or Ph.D. and more than 55 percent self-identify research as their primary activity.

Provide a forum for scientific exchange: Through in-person and virtual meetings, Interest Groups, official journals and other programs, AcademyHealth provides a forum for scientific exchange, research dissemination and translation. For example, the Annual Research Meeting offers over 120 scientific sessions and more than 800 poster presentations, drawing over 2,000 attendees annually. This year, 26 sessions focus on issues related to implementation of health reform, including quality improvement and delivery systems transformation efforts, as well as translation and dissemination of findings. One example is the session ¿The Science of Improvement and Evaluation¿ chaired by Don Goldmann from the Institute for Healthcare Improvement. Other sessions are focused on disparities reduction, health care costs, the emergence of new data resources, and other relevant topics. Interest Groups encourage topic-based discussion around areas of mutual interest. In 2012, we launched my.academyhealth.org, an online social network that will enable scientific discussion and community building driven by our members and their interests. We would be delighted to have those engaged in implementation science use this platform to communicate, share and challenge us at AcademyHealth to be more responsive to this burgeoning field.

Announce and/or offer relevant training via a website or online mailing group: In 2011, AcademyHealth offered nearly 20 online methods and skill building webinars, in addition to half day workshops and 90 minute methods sessions held in conjunction with the Annual Research Meeting. Our website houses more than three dozen English language webinars that cover methods, data, and content areas relevant to improving health and health care, with several focused on relevant methods for implementation science (e.g. ¿Mixed Methods in Delivery System Settings¿ led by Lucy Savitz, Ph.D., M.B.A.). In addition, we maintain an online calendar of professional development, career listings, scholarships and fellowships, and a website focused on research methods, www.HSRMethods.org, that is freely accessible and draws 48 percent of its subscribers from outside the United States.

Help researchers in any field distribute their work: AcademyHealth is building on its long commitment to dissemination with the launch of the AcademyHealth Translation and Dissemination Institute in 2012, sponsored in part by an investment from our Board of Directors of financial reserves. The institute will actively promote the work of our field, solicit stakeholder input on what research is needed and relevant, and offer programs and scholarships to advance the science of translation and dissemination.

Promote and advocate for our work: AcademyHealth advocates for the funding and data access necessary to generate timely, relevant and rigorous evidence to inform health and health care policy. We also educate policymakers about the impact and value of this work.

We have also just completed an update to our strategic plan with our Board of Directors and identified delivery systems transformation as a priority area for new development. This is now being translated into a series of steps to further embed implementation science in our work and member support. We are also fortunate to have many leaders in implementation science actively engaged in our work, including Lisa Rubenstein and Don Goldmann on our Board of Directors, and Brian Mittman and Lucy Savitz on our Methods Council.

It is with this perspective, and the experience of having worked with our peers around the world, that AcademyHealth urges the editors to consider ways to encourage connections between the various international organizations that already exist to serve the fields of health services research, health policy, and implementation science. This would allow us to focus on building on our strengths and efficiencies at a time when the rapid deployment of implementation science is critical.

Having worked with our international peers in the execution of study tours, the establishment of cross-border student chapters, and the provision of reduced fee international memberships, AcademyHealth has enjoyed the benefits of multinational perspectives and would welcome an opportunity to partner in such an effort.

About the use of GADS as outcome measure

Enric Aragonès — 2012-01-25T10:50:55Z

The Goldberg¿s Anxiety and Depression Scales (GADS) are heteroapplied questionnaires that were derived by latent trait analysis from a standardized psychiatric research interview. They were designed and calibrated to aid general practitioners and other non-psychiatrists in the better recognition of anxiety and depression [1].
These scales were translated and validated as screening tool in Spanish primary care patients by Monton et al. [2] Afterward, these scales were recommended as a screening test by the Program of Preventive Activities and Health Promotion (PAPPS) of the Spanish Society of Family and Community Medicine (semFYC) and they became widely known among Spanish GPs [3].
However, in this research protocol the GADS anxiety sub-scale is proposed to use not as a tool for detection, but as a primary outcome measure by means of monitoring changes in anxiety severity.
As far as we know, this questionnaire is not designed for this purpose and there are no studies examining its operability as an instrument to monitor the symptomatic progression of anxiety or depression symptoms. We have reviewed some systematic reviews of therapeutic interventions for anxiety disorders [4,5,6] and we have seen that there are no clinical trials using the GADS as an outcome measurement.
We advocate using a well validated test to measure the clinical outcomes with reliability. Otherwise, this methodological error may cause difficulties to properly interpret the results of the evaluation, and also difficulties to pass the filters of editors and peer-reviewers when the authors want to publish their report.

1. Goldberg D, Bridges K, Duncan-Jones P, Grayson D. Detecting anxiety and depressionin general medical settings. Br Med J 1988; 297:897-9.
2. Montón C, Pérez-Echevarría MJ, Campos R, et al. Escalas de ansiedad y depresión de Goldberg: una guía de entrevista eficaz para la detección del malestar psíquico. Aten Primaria 1993; 12: 345-9.
3. Tizón García JL, Buitrago Ramírez F, Ciurana Misol R, Chocrón Bentata L, Fernández Alonso C, García Campayo J, Montón Franco C, Redondo Granado MJ. Prevención de los trastornos de salud mental desde la atención primaria. Aten Primaria 2003;32(Supl 2):77-101.
4. Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;(1):CD001848.
5. Kapczinski F, Lima MS, Souza JS, Schmitt R. Antidepressants for generalized anxiety disorder. Cochrane Database Syst Rev. 2003;(2):CD003592.
6. Depping A, Komossa K, Kissling W, Leucht S. Second-generation antipsychotics for anxiety disorders. Cochrane Database Syst Rev. 2010;(12):CD008120.

in support of KT training

David Phipps — 2012-01-25T10:16:56Z

Having recently presented at a knowledge brokers forum in the UK there is international interest in capacity building for knowledge brokering, more than we usually do through individual peer sessions and one off workshops. As valuable as these are for supporting and sustaining knowledge brokering there is a need for accredited knowledge brokering training. 30 years into technology transfer that industry has established a series of accredited training courses for tech transfer. We need the same degree of rigour in training for knowledge brokering. The KTPC session described in the previous comment by Melanie Barwick has been accredited by Univ. Toronto. We need more KTPC across Canada

CPD for KT in Canada

Melanie Barwick — 2012-01-06T09:54:19Z

Interesting to learn how KT Canada is working to expand KT training in Canada. Similar efforts have been undertaken coast to coast since 2004, in KT training for health scientists through the Scientist Knowledge Translation Training course http://tinyurl.com/3uaqob7 (966 people researchers trained to incorporate KT practices into their programs of research) and more recently, the Knowledge Translation Professional Certificate - targeted to KT practitioners http://tinyurl.com/7m7hlux. There is great demand for supports in this area, and this work is very important for building KT capacity.