1. Dissemination and Implementation Ellen Goldstein, MA Kevin Grumbach, MD Translating Practice into Evidence: Community Engaged Research

2. Institute of Medicine Definition of “T2” Translational Research “the translation of results from clinical studies into everyday clinical practice and health decision making” “from bedside to community” Westfall et al further distinction: –“T2” as translation to patients –“T3” as translation to practices

3. Dissemination and Implementation are Key Aspects of T2 and T3 Translation

4. Definitions Dissemination is the targeted distribution of information and intervention materials to a specific public health or clinical practice audience Implementation is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings –“Scaling up” of interventions Source: Schillinger et al, CTSI CEP An Introduction to Effectiveness, Dissemination and Implementation Research http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf

5. The Process of Dissemination and Implementation is Itself Researchable Dissemination research is the systematic study of how the targeted distribution of information and intervention materials to a specific public health audience can be successfully executed so that increased spread of knowledge about the evidence- based public health interventions achieves greater use and impact of the intervention

6. The Process of Dissemination and Implementation is Itself Researchable Implementation research is the systematic study of how a specific set of activities and designed strategies are used to successfully integrate an evidence-based public health intervention within specific settings (e.g., primary care clinic, community center, school)

7. And 1 More Concept Diffusion research is the systematic study of the factors necessary for successful adoption by stakeholders and the targeted population of an evidence-based intervention which results in widespread use (e.g., state or national level) and specifically includes the uptake of new practices or the penetration of broad scale recommendations through dissemination and implementation efforts, marketing, laws and regulations, systems-research and policies.

8. What is Fundamentally at Issue Does the world change because a study demonstrating the efficacy of an intervention is published in a peer- reviewed journal?

9. Why focus on Dissemination? This is how science makes a difference in people’s health. Your results shouldn’t be hard to find or top secret

10. Traditional academic culture While there are clear guidelines for grant submission, human subject protections, research methods… There’s no standard expectation or training on dissemination outside academic circles

11. Value of Good Dissemination Impact on public and individual health Develop new partners Generate new ideas

12. Risks of Poor Dissemination Outraged Public Outraged Partners Outraged Participants No impact on health

13. Ethical issues Public dollars Citizen participants Health disparities

14. Dissemination Planning

15. Audiences Study Participants General Public Clinicians Community agencies Policymakers

16. Purpose Why are you sharing this information at this time and with this audience? –Tailor this field for each audience –Is this the right time to disseminate? –Assess the cost/ benefit of publicity

17. Content What you learned – process data –Recruitment –Baseline data What you learned – outcome data –Positive and negative results So what? –Implications for health, clinical care, programs, policy –Recommendations

18. Messaging crafting take-home messages/ sound bites Redefine “media moment” Context of data within body of research Working with community to refine message Right findings to the right audience Statistics and stories, depending on audience

19. Channels - venues Media Presentations –Conferences –inservices, grand rounds –community meetings Websites/ blogs/ Facebook/ webinars Written reports for lay audiences Policy briefs

20. Skills Language sensitivity Working with the media Working with community stakeholders

21. Logistics Timeline Budget Messenger Support (i.e. UCSF News Office, community or clinical outreach)

22. T2 Clinical practiceClinical practice Public health practicePublic health practice Behavior changeBehavior change DisparitiesDisparities T1 Discovery

23. Implementation Science Gap between discovery and application Many efficacious interventions not widely implemented (or implemented effectively) in practice –Team care of depression in primary care settings –Parteras and birth outcomes –Hand washing –Aspirin for patients at risk of cardiovascular disease

24. “The lack of “fit” (mismatch) between an intervention/research design on the one hand and the realities inherent to the ultimate target practice setting and the information needed by policymakers on the other hand, leads to low adoption and implementation” Research culture emphasizing internal validity to much greater degree than external validity Schillinger et al, CTSI CEP An Introduction to Effectiveness, Dissemination and Implementation Research http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf http://ctsi.ucsf.edu/files/CE/edi_introguide.pdf

25. The Challenge to Move From Innovation to Implementation “All breakthrough, no follow through” –Steven Woolf, Department of Family Medicine, Virginia Commonwealth University ; Washington Post, 2006

26. A Case Study

27. Mike Potter Flu Shot-Colorectal Cancer Screening Study at SFGH FHC Question: –What if everyone aged 50-80 who got a Flu Shot each year also completed a Home Fecal Occult Blood Test? Intervention: –Have nursing staff give hemoccult kits and ed to patients during flu shot clinics at FHC

28. Initial Randomized Clinical Trial at FHC to Prove “Efficacy”: Does the intervention work? 2009

29. Did the Flu shot-FOBT intervention become standard of care at FHC in 2009 after this terrific study was published? No Why not? –Differences between an RCT and sustainable implementation in routine clinic operations –(More on this story later…)

30. Many Factors for Translating Innovation into Sustainable, Scalable Implementation Incentives and rewards Organization and culture Feasible incorporation into routine practice Competing demands Buy in of leadership and team Time frame Institutionalization rather than reliance on single champion

31. “Getting a new idea adopted, even when it has obvious advantages, is often very difficult.” – Everett Rogers, Diffusion of Innovations

32. Rogers EM. Diffusion of Innovations. New York, NY: Free Press Adopter Categorization on the Basis of Innovativeness

33. Glasgow RE-AIM Framework R Reach E Effectiveness A Adoption I Implementation M Maintenance Glasgow, et al. Ann Behav Med 2004;27(1):3-12

34. Flu Shot-FOBT Reprise Dr. Potter’s sustained effort in implementation –Kaiser Permanente Flu-FIT Program –SF DPH Clinics Chinatown “adaptation” pilot System-wide adoption –…including FHC –Research in the science of implementation

35. Dissemination Plan Session #5 Homework: Complete Dissemination Plan Worksheet for two different non- academic audiences for your study –It’s helpful to separate the two audiences by a blank line or shading.