When you visit a physician or mental health professional, you’re getting the most up-to-date treatment available, right?
Well, probably not. One commonly cited statistic from the American Medical Informatics Association is that it takes as long as 17 years for research findings to enter medical or mental health practice, and even then, only a fraction makes it in.
“In almost every case, it’s the exception to the rule that health-care research innovations get translated into the real world,” says psychologist Russell Glasgow, PhD, senior scientist at Kaiser Permanente’s Institute for Health Research in Denver. “And if they do, it takes a really long time, and they usually don’t end up getting translated as the original research or researchers had intended.”
Researchers in the emerging field of dissemination and implementation science are working to improve those odds. At different organizational and system levels, from community health centers to national health-care systems, these investigators are designing and testing strategies to overcome the barriers that keep evidence-based practices from trickling down to the real-world settings where they’re needed most.
For patients with diabetes, that barrier may be not having convenient access to education programs that teach them how best to manage their disease. For patients who don’t speak English, the hurdle may be not having health information in their native tongues. For child-welfare workers, the obstacle may be failing to receive the encouragement or support they need to properly implement evidence-based approaches.
Then there is the challenge of taking proven treatments and making sure they reach large numbers of people rather than a select few.
“Until we figure out effective strategies to get evidence-based practices integrated so they can help people, they’re not much better than a nice publication,” says the National Institute of Mental Health’s David Chambers, DPhil, who directs the institute’s dissemination and implementation research arm.
The dissemination and implementation science field has caught fire in the last decade, as part of the movement toward reforming health-care quality and cost. Despite its youth, it is gaining both credibility and funding: NIMH alone supports more than $20 million worth of projects in these areas. Other National Institutes of Health institutes are devoting significant amounts of funding to the area as well, says Chambers. What’s more, NIH has established a study section devoted to dissemination and implementation science made up of experts in the field, a development that will allow grant applications to be judged within the field rather than across areas. The move will also enable a more considered review of applications than has been possible in the past, which in turn should lead to better work, Chambers says.
While dissemination and implementation science overlap — in fact, the two aspects are sometimes contained in the same project — they tend to have different foci, Chambers adds. Implementation science looks to improve our knowledge of how to embed particular evidence-based practices within specific service settings — the psychology, sociology and anthropology of intervention uptake. Dissemination research tests ways to best transmit information about such practices to a broad range of audiences, an arena that can tap psychology, design and systems engineering, for example.
Some of these projects may also use nontraditional clinical research designs so that promising interventions can be used in a timely fashion, Glasgow says.
“Our job isn’t just to create new knowledge, it’s to improve the health-care delivery system,” he says. “Sometimes that means proceeding with the best available information and learning from experience, even though we’d prefer to wait for something a lot more definitive.”
While dissemination and implementation science are multidisciplinary by nature, psychologists with strong research backgrounds and an interest in systems change have much to contribute, adds psychologist Gregory Aarons, PhD, an implementation researcher and associate professor at the University of California, San Diego.
“It’s a great area for psychologists to work in because it’s all about behavior change: how to get clinicians — physicians, psychologists, social workers — to make their practices more consistent with research evidence,” he says.
Given the increased call for accountability in mental health and health care as health-care reform moves forward, he adds, the field can only keep growing.
Interventions with promise
Dissemination and implementation scientists are involved in a variety of projects that focus both on improving the quality of patient care and on making care accessible to more patients. Here are some examples:
Bringing the hospital to the patient. Researchers at the Johns Hopkins Medical School have been working for 15 years on an innovation called Hospital at Home, which brings hospital-level care — including physicians, nurses and equipment — into the homes of older adults who would otherwise be hospitalized for common conditions, including chronic obstructive pulmonary disorder, congestive heart failure and pneumonia. The intervention addresses the fact that the hospital environment can create more problems for older adults than the ones they came in for, including infections, delirium and anxiety, says principal investigator Bruce Leff, MD.
“At home, you’re in your own environment, you’re comfortable, you’re not subject to unnecessary procedures,” he says. “As a result, you’re more likely to improve and less likely to experience complications.”
Studies show the model lowers costs, provides better quality care, improves patient and provider satisfaction, and causes fewer clinical complications than hospital stays. A 2009 meta-analysis of 10 randomized controlled trials in the Canadian Medical Association Journal (Vol. 180, No. 2) finds the model significantly lowers mortality rates at six months post-stay, as well.
The team has tested and implemented the model at a number of sites, including several Medicare managed-care organizations and Veterans Administration medical centers. They’re also disseminating the intervention more widely, and a number of large health-care organizations are picking up on it on their own terms. The VA, for instance, has provided a number of grants to start new Hospital at Home programs at VA medical centers with the capabilities of deploying the model effectively, Leff says.
One challenge, however, is the lack of a bona fide payment model for Hospital at Home within the fee-for-service Medicare system, Leff adds. But as new health-care models emerge that promote the care of whole patient populations and reward efficient, high-quality care, “I think we’ll begin to see imaginative solutions develop,” he says. “Hospital at Home is one of those solutions.”
Reaching more diabetes patients. Kaiser Permanente’s Colorado office has in place a diabetes-education group that is effective but used by few. Glasgow and his colleagues decided to explore whether mailing a low-cost DVD to patients could help more of them without sacrificing the quality of care.
The team assigned 180 Type-2 diabetes patients to one of two interventions: a traditional class or a DVD created by Kaiser that covered the same content. In one condition, participants could choose either to watch the DVD or attend the class, while in the other, they were randomly assigned to one intervention or the other.
After six months, all of the DVD and class participants showed similarly strong improvements in managing their diabetes and blood glucose levels. But people who were given the choice — as might actually happen with one’s insurance company or health plan — were four times more likely to pick the DVD, the team found. The research, published in Chronic Illness (Vol. 5, No. 4), demonstrates that a low-cost, convenient option can be as effective as a more expensive, time-intensive one. As intriguingly, it shows that this type of real-world research is a practical way of testing an intervention that can in turn improve care, Glasgow believes.
“We wouldn’t have found that out using a more traditional design,” he says.
Keeping care workers on board. Public sector social service workers often have notoriously high attrition rates. So if they’re asked to adopt an evidence-based practice that could reduce their perceived job autonomy, they could view it as an extra imposition and be even more inclined to leave unless the practice is properly implemented, says Aarons.
In conjunction with a statewide effectiveness trial being conducted by psychologist Mark Chaffin, PhD, and colleagues at the University of Oklahoma Health Sciences Center, Aarons and colleagues tested the effectiveness of a range of implementation approaches among Oklahoma child-welfare workers adopting an evidence-based child neglect intervention called SafeCare. The team randomized workers into four conditions: SafeCare training without monitoring; SafeCare training plus positive, encouraging monitoring; care as usual without monitoring; and care as usual with the supportive monitoring.
They found that workers trained in SafeCare who received supportive monitoring were less likely to leave their teams than those who received SafeCare without monitoring or who practiced standard care and received monitoring (Journal of Consulting and Clinical Psychology, Vol. 77, No. 2). This is an encouraging result because it suggests a way to implement or disseminate evidence-based practices in public sector settings on a wider scale, Aarons says.
“The study supports the idea that if done well, implementation can lead to both positive organizational outcomes and ultimately to better client outcomes,” he says.
Helping people with schizophrenia through computer-based group therapy. In the 1980s, marriage and family therapist Carol Anderson, PhD, developed a cutting-edge psychoeducation and therapy intervention for people with schizophrenia and their families. Despite more than 30 randomized controlled trials showing its effectiveness, it has languished virtually unused due to cost, treatment and travel barriers.
Armando Rotondi, PhD, a health systems engineer at the University of Pittsburgh and a research health scientist at the VA, wanted to see if a group telehealth version could address those barriers while maintaining fidelity to the treatment and making it available to many. With an NIMH grant and help from Anderson, he developed online interfaces that help circumvent cognitive problems experienced by people with schizophrenia, such as a tendency to feel overwhelmed by too much information. The intervention’s therapy aspect, for instance, uses a static bulletin board format where people can post a question to a therapist and receive an answer, rather than using an interactive chat room. The site’s psychoeducational articles are presented so people can get the gist in the first paragraph without having to read further unless they want to. The system also allows family members to hold therapy groups and access information.
Patients took to the design, used it regularly and by the end of a year reported far fewer symptoms, such as hallucinations and hearing voices, according to a study in press at Psychiatric Services. Rotondi attributes that finding to a newfound ability for patients to communicate with one another and with their therapists about ways to control symptoms and manage their medications. In addition, both patients and family members reported much greater knowledge about the condition, the study found.
Next, Rotondi will conduct a larger efficacy study to confirm that the format works with a larger sample. Then, he hopes to disseminate it. “There are a number of elements that make this format much more cost-effective than in-person treatment, and much more likely that community treatment centers can offer it,” he says.
Overcoming cultural and language barriers to care. Psychologist Karen Emmons, PhD, a professor at Harvard and an implementation researcher at the Dana Farber Cancer Institute, is testing whether a rigorously designed phone-reminder system can increase the rate of compliance for cancer screenings among a vulnerable population: low-income Hispanic clients with an extremely high no-show rate due to cultural, language and other barriers.
She implemented the intervention in four linked community health centers in Lawrence, Mass. Her challenge was both to relieve overburdened staff of having to make these calls — which were generally ineffective — and in their place, substitute an automated call system that tailors messages according to patient factors, such as language and gender. The system can also automatically link a patient to an appointment center or place multiple calls if the patient isn’t home.
Emmons is also testing whether patients are more likely to keep their appointments when they also have a “prevention care coordinator,” a trained staff member who knows the system and can help patients address any hurdles, misunderstandings or complications. The study design will make it possible to determine whether adding this “human touch” will significantly increase screening rates over technology alone. Given the number of calls the system is able to place, the intervention is likely to lead to significant cost savings compared to using staff, she adds.
Improving addiction care for veterans. The Department of Veterans Affairs is a standard-bearer in implementation science, home to 10 Quality Enhancement Research Initiative (QUERI) centers devoted to implementing evidence-based practices throughout the VA. One QUERI center, for instance, houses a treatment initiative devoted to helping the approximately 150,000 veterans who receive specialty care for substance use disorders.
Over a 10-year period, the QUERI program promoted a number of changes based on learning from what didn’t work and applying new strategies accordingly, says Daniel Kivlahan, PhD, clinical coordinator of the center. For example, the VA stopped requiring clinicians to use a well-validated but cumbersome assessment measuring addiction severity and psychosocial problems to follow up with patients. Instead, with support from QUERI implementation consultants, the VA is implementing a five-minute standardized instrument that captures patterns of use and information about risk and protective factors known to influence recovery, such as depression and family and community support for recovery.
The project also is evolving to focus more on monitoring clients’ individual responses to treatment, using the shorter assessment instrument — the direct result of finding that simply keeping patients in treatment wasn’t always improving their outcomes, says Kivlahan. In addition, the VA is now working to integrate data from this assessment into individual electronic medical records so it can inform patient care in systematic, easily accessible ways.
“A lot of people get frustrated, even cynical about changing things in a big bureaucracy,” Kivlahan says. “But when systems-oriented investigators — many of them psychologists — participate in these processes, the system does respond.”
Tori DeAngelis is a writer in Syracuse, N.Y.
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