1. Current Status 8th October 2018
ImpleMentAll
Current Status
8th October 2018
Christiaan Vis
VU Amsterdam

2. ImpleMentAll – G.A. 733025 Midterm Workshop Odense, 10 October 2018
Valley of death
% of evidence-based interventions enter routine practice
… after 17 years.
(Grol, et al, 2003, 2013; Westfal, et al, 2007; Balas, et al, 2000, Bauer et al, 2015, Berwick et al, 2002, Corrigan et al, 2001, Institute of Medicine (US) Committee on Quality of Health Care in America, 2001)
Effective clinical innovations are currently developed at unprecedented rates. Their uptake in routine practice remains low, slow and costly [1-3]. Only 14% of new evidence-based interventions enter routine practice [4]. Those who make it, do so only 17 years after establishing their clinical efficacy [2,5,6]. The mere availability of evidence-based clinical innovations is not enough. There is a need for effective strategies to promote their use in routine practice.
1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. The Lancet. 2003;362:1225–30.
2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001.
3. Grol R, Wensing M, and Eccles M. Improving Patient Care: The Implementation of Change in Clinical Practice. Grol R, Wensing M, Eccles M, Davis D, editors. eweb: Oxford, UK: John Wiley & Sons, Ltd; 2005.
4. Westfal JM, Mold J, Fagnan L. Practice-Based Research—“Blue Highways” on the NIH Roadmap. JAMA. 2007;297:403–6.
5. Berwick DM. A User's Manual For The IOM's “Quality Chasm” Report. Health Affairs. 2002;21:80–90.
6. Corrigan PW, Steiner L, McCracken SG. Strategies for disseminating evidence-based practices to staff who treat people with serious mental illness. Psychiatric
ImpleMentAll – G.A Midterm Workshop Odense, 10 October 2018

3. Health problem – common mental disorders
Leading cause of years lived with disability in 146 countries (Vos et al, 2015)
1/3 of EU population is affected (Wittchen, et al., 2011)
Annual costs: 324 mln. Euro / 1 mln. inhabitants (Smit, et al., 2006)
Treated with pharmacotherapy, psychotherapy, and/or electroconvulsive therapy
Care utilization rates for adults range from 35% to 45% in higher income countries (Andrews et al., 2001; Spijker et al., 2001)
Treatment resources are insufficient; international priority (WHO, 2013)

4. Evidence-based medicine – from A to Better (in mental health)
Comparative effectiveness
FP7:
Accelerating uptake
H2020:
ICT4D: proof of concept
FP7:
Upscaling is possible
CIP-ICT-PSP
ImpleMentAll – G.A Midterm Workshop Odense, 10 October 2018

5. Implementation
Implementation: a deliberate and planned process whereby an innovation becomes normal part of daily routine (May, et al. 2016, Proctor 2009)
Implementation science: “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices to improve the quality of health care’’ (Eccles et al., 2009; implementation science journal, aims and scope, 2018)

6. State of the art
> 600 determinants for interventions for chronic conditions (Krause, et al, 2014)
> 60 frameworks, models, and taxonomies of determinants (Tabak, et al, 2012; Nilsen, 2015)
37 eMH specific factors, mostly patient and professional level (Vis, et al., 2018)
Next
Determinants of practices at organisation and system level (Greenhalgh, et al, 2017; Vis, et al, 2018)
Evidence-based implementation strategies: effectiveness and efficiency (Proctor et al, 2013; Powell, et al, 2015)
Requirements
Validated instruments to measure implementation outcomes (Proctor, et al, 2014; Finch, et al, 2013)
Robust methodologies to do research in real-world implementation conditions

7. Context matters Barriers differ per setting and change over time.
Tailoring, a systematic process of:
identification of local determinants
selecting and designing implementation strategies
apply and measure
(Wensing, Bosch, & Grol, 2010; Wensing et al., 2011)
Indications that tailored interventions can change professional practice, but insufficient evidence (Baker et al., 2015)
Importance of context: barriers differ per setting and change over time. And/or their perceived importance and meaning to the people involved and affected by
However, there is insufficient evidence on the most effective approaches to tailoring including identification and prioritization of barriers, selection of strategies and their comparative effectiveness.
In addition, there is no evidence about the cost-effectiveness of tailored interventions compared to other interventions to change professional practice.
Therefore, future research studies should seek to develop and evaluate more systematic approaches to tailoring.
ImpleMentAll – G.A Midterm Workshop Odense, 10 October 2018

8. Tailored implemention
Implementation Effectiveness
Tailored implementation strategies
Normalisation Process Theory and evidence-informed toolkit – ItFits
Runs from 2017 – 2021
11 countries, 16 partners
Budget: 7.1 million Euro
Funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No

9. Implementation object: iCBT
Mood disorders:
Depression, anxiety, eating disorder, psychosomatic symptom disorder
Prevention and treatment
Evidence-based Cognitive Behavior Therapy (CBT):
Psycho-education; Behavioural change techniques; Cognitive restructuring; Relapse prevention
Delivered via ICT:
Online treatment platform (website, app) and/or
Videoconferencing and/or
Blended with face-to-face sessions
MoodBuster (VUA consortium, ICT4D); iFightDepression (EAAD, DF); Get.On; NoDep & Fearfighter (RSD); (BSA, MasterMind); MindWay (GiG)

10. … in 12 sites in 9 countries AL 4 Community MH clinics, Tirana area AU
2 MH clinics reaching south-east Australia DK
Region of South Denmark, nation wide FR
11 MH clinics, Paris area DE
2 MH clinics, nation wide IT
1 MH clinic, Torino area
Kos
4 Community MH clinics, Prizren area NL
2 MH clinics, Amsterdam + Groningen SP
1 MH clinic, Barcelona area

11. ImpleMentAll – G.A. 733025 Midterm Workshop Odense, 10 October 2018
ItFits toolkit
ImpleMentAll – G.A Midterm Workshop Odense, 10 October 2018

12. Research aims
Effectiveness study: does tailored implementation lead to better implementation outcomes than implementation-as-usual?
and
Process evaluation of mechanisms that shape implementation of the ItFits toolkit, within and between settings.
Stepped wedge trial design
Figure 1: Characteristics of the SWT design for the IMA project. Groups are randomised to a cross-over point. a = crossover point; b = time between (2nd and 3rd) crossovers; c = pre-rollout period of 2nd group; d = repeated measurements (every 3 months); e = rollout period of entire study; f = exposure period of group 6.
Implementation-as-Usual (IAU): any existing and ongoing approaches and efforts
Tailored implementation (ItFits-toolkit): systematic and evidence-informed process of prospective tailoring of implementation strategies to local implementation context
Theory based: implementation follows a generic process – Normalisation Process Theory (May, et al., 2009)

13. Analysis and finalisation (7 months)
Trial period
(27 months)
Preparation
(17 months)
Analysis and finalisation (7 months)
Mar ‘21
Jan ‘17
Generic Protocol ready
Nov ‘17
Implementation as usual
Tailoring and tailored implementation
Finalising ItFits
and dissemination
Localisation of protocols
Central data collection infrastructure
ItFits development and piloting
ImpleMentAll – G.A Midterm Workshop Odense, 10 October 2018

14. ImpleMentAll – G.A. 733025 Midterm Workshop Odense, 10 October 2018
Expected output
Implementation practice – the ItFits-toolkit
Automated online implementation toolkit
Lessons learned and case examples
Training materials
Scientific
Effectiveness (and efficiency) of ItFits-toolkit
Validated instruments: Uptake, NoMAD, Organisational Readiness for Change
Process of tailoring and its methods
Case comparison framework (macro/meso)
ImpleMentAll – G.A Midterm Workshop Odense, 10 October 2018