1. Implementation Science – What Is It and How Could It Impact Global Health in Primary Care? Jeff Markuns, MD, EdM, FAAFP Malwina Carrion, MPH Boston University Global Health Collaborative October 1, 2015

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Jeff Markuns and Malwina Carrion have indicated they have no relevant financial relationships to disclose.

3. Objectives On completion of this presentation, participants should be able to: Describe implementation science Explain the importance and relevance of implementation science to global health Apply principles of implementation science to global health programs in primary care 3

4. Improve access to primary care globally How? –medical education & training –improving health systems management –increasing access to high quality clinical services –promoting policy supports –advancing research and evaluation Every person deserves a well-trained primary care provider 4

6. Why implementation science? 6

7. Tenth Annual Report to Congress on PEPFAR 2013

8. Strategic Investments for Impact: Global Fund Results Report 2012, Full Report

9. PIH 2013 Annual Report

11. Introduction to IS Definition according to NIH Fogarty: –Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice Definition according to Eccles and Mittman (2006): –Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care 11

12. Introduction to IS Efficacy vs Effectiveness Traditional research = efficacy Implementation science = effectiveness 12

13. Introduction to IS 13

14. Introduction to IS “The use of effective interventions without implementation strategies is like serum without a syringe; the cure is available but the delivery system is not.’” Source: Fixsen, Blase, Duda, Naoom & Van Dyke, 2010 “Often, the rate-limiting step isn’t the discovery; it’s implementation ‘potholes.’” Source: UNC Gillings School of Public Health 14

15. Basics of IS Bridge the gap between knowledge and practice Interdisciplinary Focus on long-term changes and sustainability Many types of frameworks –Multiple Levels –Multiple phases Source: Tabak et al, 2012 15

16. Stages of Implementation Exploration Installation Initial Implementation Full Implementation Program Sustainability Source: Fixsen, Naoom, Blase, Friedman, & Wallace, 2005 16

17. Stages of Implementation Exploration (Initial Decision) –Needs assessment –Appropriateness of chosen model –Resources and reporting requirements –Implementation drivers 17 Bertram, 2014

18. Core Intervention Components a) model definition b) theory bases supporting those elements and activities c) the practice model’s theory of change d) target population characteristics e) alternative models Source: Bertram et al, 2015 18

19. Stages of Implementation Installation (Project Planning) –Implementation Team –Consensus on approach –Resource gathering/accessibility –Staffing 19

20. Stages of Implementation Initial Implementation (Practice Session) –Introduction of new practice –Reduce resistance and awkwardness –Data collection systems –Continuous improvement and feedback cycle 20

21. Stages of Implementation Full Implementation –Universal acceptance –Monitoring and evaluating fidelity –Systematic approach to adjustments –Process evaluation –Full integration into existing system(s) –Ongoing orientation and training –Continuous improvement and feedback cycle 21

22. Stages of Implementation Program Sustainability –Share results –Prioritize maintaining funding –Continue improvement and feedback cycle –Maintain quality and fidelity –Maintain training 22

23. Stages of Implementation 23

24. Drivers of Implementation 24 Source: Bertram, 2014

25. Types of IS Programs Comparisons of multiple evidence-based interventions Identification of strategies to promote the integration of evidence into policy and program decisions Identification of approaches to scale-up effective interventions Development of innovative approaches to improve healthcare delivery Setting up an impact evaluation for a population based intervention Source: NIH, Fogarty International Center 25

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27. 3760 patients pre, 3820 post Complications reduced from 27.3/100 patients to 16.7/100 patients Proportion of patients with one or more complications decreased from 15.4% to 10.6% In-hospital mortality decreased from 1.5% to 0.8% 27

28. 101 hospitals –109,341 procedures pre, 106,370 post Risk of death within 30 days 0.71% vs 0.65% Surgical complications 3.86% vs 3.82% Implementation of surgical checklists was NOT associated with significant reductions in operative mortality or complications 28

29. Surgical checklists in LICs Relative risk of mortality improved Following implementation of WHO SSC, largest decrease in complications (74.3%) was in LICs and MICs Usage still poor, with compliance as low as 12% Pulse oximetry availability a barrier 29 Surgical safety checklists in developing countries. Vivekanantham S et al. Intl J Surg 2014

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31. Other Examples of IS Programs Male circumcision in Africa –Different attitudes and beliefs around sex, circumcision, and HIV meant circumcision programs had to implemented differently in different countries US President's Emergency Plan for AIDS Relief (PEPFAR) – second phase –First phase focused on emergency situations –Since a baseline has been reached, second phase focuses on sustainability and long-term success by using an IS framework Clean needle programs for injection drug users –Police harassment levels meant different levels of coverage needed 31

32. Benefits to IS in research Clear next steps Emphasis on real value for the real world Addresses gaps Continuous evaluation, adaptation, and training Interdisciplinary teams 32

33. Challenges to IS in research Paradigm shift Multiple frameworks Unfamiliarity in all areas ‘Scientific rigor’? Interdisciplinary teams 33

34. Tensions in IS Bias towards positive results (outcome reporting, publication, and confirmation bias) Politicians like evidence (politician’s syllogism) Fidelity vs local context –Evidence-based approaches implemented with high fidelity result in better population-based outcomes –Evidence is often tainted (or even wrong), and high fidelity implementation isn't always possible or even desirable (esp. in LMICs) 34

35. IS for Global Health and Family Medicine Typically takes years to decades One key to success is integration Universal issues with basic core Improve health = improve x, y, z Family medicine requires comprehensive system change 35

36. Questions? 36

37. Questions How do we balance vertically-oriented programs against the need for whole person care in primary care? What do you think of this tension between “high fidelity” and “local context’? 37

38. Summary Implementation science is a rising discipline coming to a program near you There is a growing group of ‘implementation scientists’ looking to determine the “best” way of implementing health interventions Tension exists between “high fidelity” and “local context” Consider the role of implementation science in your own program 38

39. Resources for Implementation Science WHO TDR Implementation Research Toolkit ( http://www.who.int/tdr/publications/topics/ir-toolkit/en/ ) National Implementation Research Network (nirn.fpg.unc.edu) The Consortium for Implementation Science (http://consortiumforis.org/) –Joint partnership between RTI International and the UNC Gillings School of Global Public Health Global Implementation Initiative (GII) (http://globalimplementation.org/) –Goal is to “promote and establish coherent and collaborative approaches to implementation practice, science, and policy” NIH Fogarty International Center's Implementation Science resource site ( http://www.fic.nih.gov/researchtopics/pages/implementationscience.aspx)implementation) http://www.fic.nih.gov/researchtopics/pages/implementationscience.aspx)implementation Center for Research in Implementation Science and Prevention (CRISP) University of Colorado ( http://www.ucdenver.edu/academics/colleges/medicalschool/programs/crisp/Pages/default.aspx ) 39