State of the Science for Implementation Research: - PowerPoint Presentation

State of the Science for Implementation Research:The role of context and strategies Laura J. Damschroder, MS, MPH March 6, 2018Prepared for the Committee on Fostering Healthy Mental, Emotional, and Behavioral (MEB) Development.The views expressed in this presentation are our own and do not reflect the position or policy of our respective institutions listed above.

OutlineRole of theoryRole of context in implementation2

Preparing for, explaining implementation 3 Program Benefits Theory underlying implementation Theory underlying clinical innovation Barriers and facilitators Why did/will it work? Establishing “ external validity ” as a priority, without compromising internal validity Embrace and understand CONTEXT +

Importance of theoryProvides common terms & definitionsBasic building block: theoretical constructsProvides organizing framework to guide researchSystematically build scientific knowledge base ContextMechanisms of actionRelationships Efficiently build collective knowledge 4 Colquhoun, H., Leeman , J., Michie , S., Lokker , C., Bragge , P., Hempel , S., … Grimshaw , J. (2014). Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies. Implementation Science, 9, 51. Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. Quality & safety in health care. Feb 11 2011.

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So many models, frameworks, theories…6

7 61 frameworks identified Tabak , R. G., E. C. Khoong, D. A. Chambers, and R. C. Brownson. 2012. “Bridging research and practice: models for dissemination and implementation research.” American Journal of Preventive Medicine 43(3): 337-50.

CFIR: 5 domains8 Core Components Adaptable Periphery Intervention (unadapted )

CFIR: Intervention characteristics(8 constructs)9Damschroder, L. J., D. C. Aron, R. E. Keith, S. R. Kirsh, J. A. Alexander, and J. C. Lowery. 2009. “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.” Implement Sci 4..

CFIR: 5 domains10 Core Components Adaptable Periphery “…I was impressed with the evidence and I know from our own patients who have been successful with a similar program” Intervention (unadapted )

CFIR: 5 domains11 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved

CFIR: Characteristics of individuals (5 constructs)12Damschroder, L. J., D. C. Aron, R. E. Keith, S. R. Kirsh , J. A. Alexander, and J. C. Lowery. 2009. “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.” Implement Sci 4..

CFIR: 5 domains13 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved “I’ve heard one physician…say, ‘Aw it doesn’t work, they re-gain the weight anyway’”

CFIR: 5 domains14 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved Outer setting

CFIR: Outer setting(4 constructs)15Damschroder, L. J., D. C. Aron, R. E. Keith, S. R. Kirsh , J. A. Alexander, and J. C. Lowery. 2009. “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.” Implement Sci 4..

CFIR: 5 domains16 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved Outer setting “It will help us meet national performance measures…”

CFIR: 5 domains17 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved Outer setting Inner setting

CFIR: Inner setting(14 sub/constructs)18Damschroder, L. J., D. C. Aron, R. E. Keith, S. R. Kirsh , J. A. Alexander, and J. C. Lowery. 2009. “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.” Implement Sci 4..

CFIR: 5 domains19 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved Outer setting Inner setting “…the health coaching just fits right in with our disease prevention and health promotion programs, and it's such a complement…”

CFIR: 5 domains20 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved Outer setting Inner setting Process

CFIR: Process(8 sub/constructs)21Damschroder, L. J., D. C. Aron, R. E. Keith, S. R. Kirsh , J. A. Alexander, and J. C. Lowery. 2009. “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.” Implement Sci 4..

CFIR: 5 domains22 Core Components Adaptable Periphery Intervention (unadapted ) Adaptable Periphery Core components Intervention(adapted)IndividualsInvolved Outer setting Inner setting Process “… I didn't even know that was available to my patients.”

Use of theory to guide implementation23Sales A, Smith J, Curran G, Kochevar L. Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice. J. Gen. Intern. Med. Feb 2006;21 Suppl 2:S43-49.Bartholomew, L. K., Parcel, G. S., & Kok, G. (1998). Intervention mapping: a process for developing theory- and evidence-based health education programs. Health Educ Behav, 25(5), 545-563. Assess targeted EBP change and context 1 Use theory to guide assessment

Telephone lifestyle coaching programCoaching to support lifestyle change for VeteransEat wiselyBe physically activeBe tobacco freeStrive for a healthy weight Manage stressLimit alcoholStrong evidence-baseClinically relevant benefits at 6 months after baseline 9,357 Veterans referred over 19 month period 24

Variable referral rates25 .28 Referral Rate Time (months) since launch

Outcomes26 Rate of enrollment X Medical Center Proctor, E., H. Silmere , R. Raghavan, P. Hovmand, G. Aarons, A. Bunger, R. Griffey, and M. Hensley, Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health, 2011. 38(2): p. 65-76.

Use of theory to guide implementation27Sales A, Smith J, Curran G, Kochevar L. Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice. J. Gen. Intern. Med. Feb 2006;21 Suppl 2:S43-49.Bartholomew, L. K., Parcel, G. S., & Kok, G. (1998). Intervention mapping: a process for developing theory- and evidence-based health education programs. Health Educ Behav, 25(5), 545-563. Assess targeted EBP change and context Who needs to do what differently? Which barriers/ facilitators need to be addressed? 1

28www.CFIRGuide.org

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Coding and rating: compatibilityNegative Rating – e.g., Only providers could refer to TLC in some sites“Our nurses are specifically forbidden to write orders …everything that gets written has to be written by a physician[…] this has formed a really labor intensive situation for practitioners.” 31 -2

Coding and rating: compatibilityPositive Rating – e.g., Perceived compatibility with clinical initiatives“…this …really helps the patient to have ownership for their processes and their living, and it definitely blends very nicely with the health coaching.” 32 +2

Analysis: compatibility33 Correlation: 0.55 (p=0.08)

Compatibility +1 -1 +1 +1 -1 +1 -1 +1 +2 +2 +2 *0.552 0.0783

Explaining variation in referral rates35 .28 Referral Rate Time (months) since launch

State of science: use of theoryLittle reporting of methods or logic for selecting theory or its componentsMost studies use theory superficiallyIn background/discussion sectionsFew studies clearly define and assess outcomes and link outcomes to implementation process“…the single greatest need for … implementation models is rigorous, prospective use of the framework to guide implementation projects.”2 36 For example:1. Damschroder, L., D. Aron, R. Keith, S. Kirsh, J. Alexander, and J. Lowery. 2009. “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.” Implement Sci 4(1): 50. 2. Helfrich, C. D., L. J. Damschroder, H. J. Hagedorn, G. S. Daggett, A. Sahay, M. Ritchie, T. Damush, M. Guihan, P. M. Ullrich, and C. B. Stetler . 2010. “A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework.” Implement Sci 5(1): 82.

Assessment of CFIR’s valueIs terminology and language coherent?Terminology and language of constructs appear to be coherentDoes CFIR promote comparison of results across contexts and studies over time?Too early to tell but progressing in the right directionDoes the CFIR stimulate new theoretical developments?Generally poor integration of the CFIR into empirical studies stymies progress 37

RecommendationsConsider how to use most meaningfully across different phases of implementationUse prospectively to develop implementation approaches and monitor progress, as well as retrospective explanationIntegrate CFIR into all phases of research e.g., data collectionReport how CFIR constructs were selected and assessedLink constructs with proximal implementation outcomes 38

Use of theory to guide implementation39Sales A, Smith J, Curran G, Kochevar L. Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice. J. Gen. Intern. Med. Feb 2006;21 Suppl 2:S43-49.Bartholomew, L. K., Parcel, G. S., & Kok, G. (1998). Intervention mapping: a process for developing theory- and evidence-based health education programs. Health Educ Behav, 25(5), 545-563. Assess targeted EBP change and context Develop tailored implementation strategy Who needs to do what differently? Which barriers/ facilitators need to be addressed? What strategies can be used to address barriers & facilitators? 1 2

What works where and why?40 Contact: Laura.Damschroder@va.gov Questions?