Funded by the VA HSR&D (Project# SDR 10-012)

Spotlight on Women Cyberseminar Series
Using Implementation Implementation Science Science to Improve Improve Wome

in VA: Applying QUERI Frameworks and Appr

Brian S. Mittman Mittman, PhD

Director, VA Center for Implementation

Practice and Research Research Support Support

VA Greater Los Angeles Healthcare Syste

July 7, 2011
O tli u ne

3⁄4 Part 1: Introduction: Introduction: overview overview of implementation implementation Part 2: Policy/practice foundations of implementatio

implementation science

Part 3: Implementation Implementation science science frameworks frameworksPart 4: Implementation research resources and future

di i rect ons
Poll question: Audience Compositi

1. Have you served as PI or key investigator investigator for a VA

implementation study?

– Yes, and it was funded– Yes, but it was not funded

– No
Increased investment investment and activity activity in

implementation and implementation

research are critical to achievement o

VA – and soci l eta – goals in h lh ea t and

health care:

 Quality, outcomes: gaps in life expec

quality of life, gender/racial equity, u

effective care, prevention

 Cost: % of US GDP devoted to healthc

 Obesity, substance abuse, etc.
What is implementation research

A typi l ca sequence

1. Development of new evidence, innovation2. Initial Initial efforts efforts to promote promote implementation implementation3. Measurement of adoption and implementatio

(q y) uality) g pa s

4. Research to develop and evaluate

implementation ( ) QI p g ro rams to increase

implementation
Innovation in medical treatmen
Advocacy for adoption
Guidance for adoption
Incentives for adoption
Assessment of adoption rates

(US 2002‐03; UK 2005)
Trials of implementation program
Trials of implementation program
O tli u ne

Part 1: Introduction: Introduction: overview overview of implementation implementation sci

sci

3⁄4 Part 2: Policy/practice foundations of implementa

implementation science

Part 3: Implementation Implementation science science frameworks frameworksPart 4: Implementation research resources and future

di i rect ons
Policy/practice foundations of

implementation, implementation rese

1. The implementation gap2. The quality chasm
The imp e e tat o plementation gap

(second translational roadbloc

Basic / Lab 

Research

Clinical 

Research

Improve

Health

Basic / Lab 

Research

Clinical 

Research Imp

H
The Implementation Gap:

A component of the Cli i l Clinical R h esearch C

• AAMC Cl l inica Research Summit: Cl l inica Researc

A National Call to Action (Nov 1999)

• IoM Clinical Research Roundtable (2000‐2004)
The “Quality Chasm” in US healthcare d

• Institute of Medicine (1999, 2001)• US and international q y ualit measurement studies
Quality comparisons: VA vs. othe
Gaps and shortcomings in the typical seq

Enhancing Enhancing implementation implementation and the value a

effectiveness of implementation research

Changes are needed in each phase of activity:1. Development of new evidence, innovation

2. Efforts to promote adoption

3. Measurement of adherence, adoption

4. Studies evaluating strategies to increase

adoption
O tli u ne

Part 1: Introduction: Introduction: overview overview of implementation implementation sci

sci

Part 2: Policy/practice foundations of implementatio

implementation science

3⁄4 Part 3: Implementation Implementation science science frameworks frameworksPart 4: Implementation research resources and future

di i rect ons
Implementation research definit

Implementation research is the scientific study ofmethods to promote the systematic uptake of res

findings and other evidence‐based practices into 

practice practice, and, hence, to improve improve the quality quality and

effectiveness of health services.

It includes includes the study of influences influences on healthcare healthcare

professional and organizational behavior.

Eccles and Mittman, 2
Implementation research goa

1. Develop reliable strategies for improving heal

related processes and outcomes; facilitate

widespread adoption of these strategies

2. Produce insights and generalizable knowledge

regarding implementation processes, barriers,

facilitators, strategies

3. Develop Develop, test and refine implementation implementation theo

theo

and hypotheses; methods and measures
Refined research‐implementation pipe

Implementation research research and clinical clinical res

res

/

Clinical Science

Health Behavior

Promotion Research

Translational

Basic Pre Clinical

Implemen- t ti

Clinical

Effective

Pre-ClinicalResearch

Basic

Science

tation

Research Health Behavior

Health Services

-ness Studies

Basic/Lab Science Health Services Research
Gaps in the research‐implementation pip

Pre‐implementation studies

Clinical

Efficacy Studies

IntImStu

Health Behavior Effectiveness Studies

Document and

diagnose gaps

Observational

Health Services

Practice Guidelines

studies of 

implementation
Gaps in the research‐implementation pip

Phased implementation trials

Clinical

Efficacy Studies

IntervenImplemStudies

Health Behavior Effectiveness Studies

Document and

diagnose gaps

Observational

Health Services

Practice Guidelines

studies of 

implementation

Phase 1 

Pilot Projects

Phase 2 

Small-Scale 

Efficacy Trials

Phase 3

Large-Sca

Effectivene

Trials
Features of implementation phenomena

• Heterogeneity of settings, interventions, effects• Context dependence, weak main effects

• Process and mechanism (vs. outcome/impact) focus

• Protocol‐driven intervention adaptation• External validity vs. internal validity• Representative sampling paradox

• Sustainability Sustainability, scale‐up/spread up/spread potential potential, economic economic

evaluation
O tli u ne

Part 1: Introduction: Introduction: overview overview of implementation implementation sci

sci

Part 2: Policy/practice foundations of implementatio

implementation science

Part 3: Implementation Implementation science science frameworks frameworks3⁄4 Part 4: Implementation research resources and fut

di i rect ons
National, international resourc

 NIH Conference on the Science of Dissemination and

Implementation (2007, 2009, 2010, 2011)

 NIH PARs

 NIH‐ and AHRQ‐funded training programs

 Journals: Implementation Science, Translational Beha

Medicine, special issues of general and specialty journ

 CTSAs (selected) PBRNs VA QUERI Knowledge Translation Canada, other CIHR programs
Local resources

Health Sciences: Main Campu

• Community Health,

Health Behavior

• Psychology, Sociology

Anthropology Politica

p

Health Behavior

• Health Services,

Management

Anthropology, PoliticaScience, Economics

• Management, Educat

• GIM, Family/Prev

Medicine , Subspec

ll d

Public Policy

• Nursing, Dentistry, Allied
Critical resources

• Practice‐based research network or alternative lab• Social/behavioral science expertise• Management, leadership leadership skills, skills, training, training, aptitude aptitude• Local, regional and national policy/practice engag• Academic recognition
New opportunities

• AAMC implementation science initiative• Standing study section at NIH; ongoing and new P

• Evolution Evolution of CSTAs and “type 2 translation translation” focus

• Comparative Effectiveness Research, Patient‐Cent

Outcomes Research Institute Institute (PCORI): (PCORI):CER studies of prevention, “delivery system interv
New directions

• Social/behavioral science theory: identify, refine, g

of existing existing theory (and develop develop new theory? theory?)

• Increased study of natural experiments, processes• Challenges of evaluating “complex social intervent

implications for expt’l, obsv’l research approaches

• Methods for synthesizing diverse, complex eviden• Partnership Partnership research: research: bridging bridging science science and practic

practic

balancing internal vs. external validity