1. Implementation Science: An Emerging Field Bryan J. Weiner, Ph.D. Professor Department of Health Policy and Management

2. A Roadmap for Today’s Talk Why implementation science? What is implementation science? What does implementation science look like? How do you do implementation science? Where can I learn more? 2

3. Why Implementation Science? 3

4. A Growing Evidence Base of What Works 4

5. And Yet… Americans receive “recommended care” approximately 50% of the time (McGlynn et al., 2003). Between the health care we have and the care we could have lies not just a gap, but a chasm (IOM, 2001). 5

6. And in Cancer Care… Completion rate of 3-dose HPV vaccine: –33% for teenage girls –7% for teenage boys 6

7. And in Cancer Care… Surgery rate for non-small cell lung cancer: –14% lower for Blacks than whites 7

8. And in Cancer Care… Over-surveillance rate among patients with non-displastic Barrett’s Esophagus –65% in a multi-center study 8

9. Barriers to Evidence-Based Practice and Policy 9

10. What is Implementation Science? 10

11. 11 What is Implementation Science? IMPLEMENTATION SCIENCE is the study of methods to promote the use of research findings in healthcare, community, and policy contexts. As a multidisciplinary field, it examines how these findings are disseminated, implemented, and sustained by targeted audiences. Figure modified from National Cancer Institute Implementation Science Web Portal and Rubenstein et al. 2006.

12. Dissemination and Implementation Dissemination: the targeted distribution of information and intervention materials to a specific public health audience or clinical practice audience Implementation: the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns in specific settings. NIH PAR 07-086 12

13. IS as an Emerging Field 13

14. IS as a Translational Science Modified from Khoury et al. Figure 1—Knowledge integration process. 14

15. IS as a Team Science 15

16. What does IS look like? 16

17. Examples of Funded IS Grants Implementing evidence to prevent urinary infection and enhance patient safety Increasing implementation of evidence- based interventions at low-wage worksites Integrating tobacco use treatment guidelines in dental public dental clinics Implementing EBAN II: an evidence-based intervention for sero-discorant couples 17

18. Two Examples In My Work Examining the implementation, impact, sustainability, and business case of the CCOP, a federally funded provider-based research network Increasing colorectal cancer screening rates in community health centers through practice change facilitation and an evidence- informed tool kit 18

19. NCI IS Portfolio Review 19 Neta et al., (2015). Implementation science in cancer prevention and control: a decade of grant funding by the National Cancer Institute and future directions. Implement Sci, 10(1), 4. doi: 10.1186/s13012-014-0200-2

20. NCI Portfolio Review- Implementation Science 67 grants included in Implementation Science portfolio review, funded between 2000-2012 20 Cancer Control Continuum # of grants % of grants Prevention3349.3% Screening2740.3% Cross-cutting710.4% Survivorship46% Treatment34.5% Diagnosis00% Types of Cancer/ Risk factors # of grants % of grants Tobacco2638.8% Colorectal cancer2029.9% Breast cancer1217.9% Cervical cancer811.9% Physical activity69% Diet/nutrition57.5% Sun safety57.5% Public health genomics46% Obesity34.5% *Numbers may add up to more than 67 (100%) in some cases because a given grant may fit into more than one category. Neta et al., 2015

21. NCI Portfolio Review- Implementation Science 21 Implementation Science Objectives# of grants% of grants Implementation5379.1% Dissemination3146.3% Sustainability2638.8% Adoption2029.9% Sustainability Indicators# of grants% of grants Maintenance2537.3% Capacity building2029.9% Cost analysis1522.4% *Numbers may add up to more than 67 (100%) in some cases because a given grant may fit into more than one category. Neta et al., 2015

22. Funding Trends for NCI-funded IS 22 Funding trends of NCI-funded implementation science by grant mechanism, fiscal years 2000-2012 (Neta et al., 2015)

23. How do you do IS? 23

24. When to Do IS 24

25. Study Designs Experimental designs –Individual/cluster RCT, MOST, SMART, hybrid Quasi-experimental designs –interrupted time series, regression discontinuity Observational designs –surveys, focus groups, case studies Mixed methods 25

26. Hybrid Designs Adapted from Curran et al., 2010 26

27. Provider-directed interventions –Interactive education –Reminders –Decision support –Audit & feedback –Opinion leaders 27 Implementation Strategies

28. Staff-oriented interventions –Multi-disciplinary teams –Revised roles –Case management 28 Implementation Strategies

29. Patient-mediated interventions (“pull”) –Education –Navigation –Reminders –Decision aids 29 Implementation Strategies

30. Regulatory interventions –Accreditation –Licensure –Insurance coverage 30 Implementation Strategies

31. Financial interventions –Payment changes –Incentives 31 Implementation Strategies

32. Organizational interventions –Structural changes –Service changes –Quality Improvement 32 Implementation Strategies

33. Collaboratives / campaigns –Hospital-to-Home Campaign –IHI Breakthrough Series –Vermont Oxford Network –5 Million Lives Campaign 33 Implementation Strategies

34. 34 Implementation Outcomes Types of outcomes in implementation research Adapted from Proctor et al., 2011

35. Implementation in low-resource settings Reliable, valid, and practical measures Cost and cost-effectiveness studies Strategies for scaling up effective programs Use of simulation models to evaluate proposed D&I actions, policies, and practices Theory and research on sustainability De-implementation 35 Gaps & Opportunities

36. Where can I learn more? 36

37. Sample Grants and Grant Writing Resources Sources of Evidence Tools Measures Journals Theories and Frameworks Conferences and Training Presentations 37 D&I Portal – an NC TraCS Resource http://tracs.unc.edu/di-portal

38. Consortium for Implementation Science 38 Advance IS through research, practice, policy, and education/training Initial focus: improving health in the US Approach: –Identify opportunities and connect investigators –Build cross-institutional research teams –Scientific/technical support for proposals –Facilitate access to internal funds for pilot projects http://consortiumforis.org/

39. The Implementation Network http://www.implementationnetwork.com/ Monthly e-newsletter and website 1500+ members worldwide Supported by VA QUERI and NCI Chief Editor: Wynne Norton, Ph.D. 39

40. http://www.seattleimplementation.org/sirc- projects/sirc-instrument-project/ http://www.seattleimplementation.org/sirc- projects/sirc-instrument-project/ Comprehensive library Evidence-based assessment Consensus battery Lead Investigator: Cara Lewis, Ph.D. (Indiana University, Bloomington) 40 SIRC Instrument Review Project

41. Grid-enabled Measures (GEM) D& I Workspace https://www.gem-beta.org/public/wsoverview.aspx?wid=11&cat=8 CFIR Wiki http://www.wiki.cf-ir.net/index.php?title=Main_Page SIRC (focus on behavioral therapies) http://www.seattleimplementation.org/ Implementation Science Journal http://www.implementationscience.com/ VA Enhancing Implementation Science Webinar archives http://www.queri.research.va.gov/meetings/eis/ 41 Other D&I Resources

42. bryan_weiner@unc.edu 919-537-8111 Thank you

43. NCI Portfolio Review- Implementation Science 43 Frameworks/ Models# of grants % of grants Diffusion of Innovation 2638.8% RE-AIM 2334.3% Chronic Care Model 710.4% Organizational Change 710.4% Systems/Network Theories 57.5% Model of Diffusion in Service Orgs 34.5% Methods Used# of grants % of grants Quantitative5988.1% Qualitative5480.6% Comparative effectiveness 3552.2% Cost analysis1826.9% Simulation models23% Network analysis11.5% *Numbers may add up to more than 67 (100%) in some cases because a given grant may fit into more than one category. Neta et al., 2015

44. Funding Trends for NCI-funded IS 44 Trends in NCI-funded grants in implementation science by funding announcements, fiscal years 2000-2012 (Neta et al., 2015)

45. Success Rates 45 Neta et al., 2015

46. New Investigator Awards 46 Neta et al., 2015