Tuesday, December 7, 2010

Research Priority: Implementing What Works

Dissemination and implementation of research findings into practice is necessary to achieve a return on investment in our research enterprise and to apply research findings to improve outcomes in the broader community. In a thoughtful review of the application of discovery to prevention of cancer, Bowen and colleagues note, “Our previous 30 years have taught us that dissemination does not just happen if we wait for it. New information is often needed to make it happen. Let’s consider this a call to action to gather the new information in support of making it happen” (Bowen, Sorensen et al. 2009). The challenges in dissemination and implementation research are broad and apply far beyond health and health care systems. In fact, early examples come from other fields such as education in which research has addressed the application of new knowledge to improve outcomes in children’s learning (Huberman AM, Levinson NS et al. 1981; Crandall 1989; Huberman M 1991). This rapidly expanding field improving the speed with which we translate discoveries to broader application in the health care delivery systems still requires a more uniform understanding of the principles, methods, and applications to achieve the potential to improve outcomes in a more timely manner.

First, some question arise from the review that Bowen and colleagues (Bowen, Sorensen et al. 2009) conducted in the context of prevention science.
  • How will we gather this information?
  • Will it be applicable to our setting?
  • What methods should we use to decide what to disseminate or implement?
  • Which strategies will give us the greatest impact on population health?
  • What outcomes should be tracked to know if we are making progress?
  • How long will it take to show progress, or when will it be observed?

Moving from discovery to application brings society the full return on our collective investment in research. Given the crisis in funding of research and health services more broadly, we cannot afford the luxury of reinventing approaches developed in other fields (such as education) nor can we wait decades to apply discoveries and delay the return on investment in our research. For example, in 2010, the United States spent over $32 billion on health-related research (Office of Management and Budget 2010.). It is estimated that between 9 and 25% of this amount was expended on prevention research (Farquhar 1996; Harlan 1998)—i.e., the direct and immediate application of effective intervention strategies to benefit the public’s health (Institute of Medicine 1997). Farquhar has estimated that 10% or less of prevention research is focused on dissemination (Farquhar 1996). Despite this low priority, the NIH maintains an active program in “dissemination” research, but across all funding sources in 2002—federal and foundations—spending on health services research represented only 1.5% of biomedical research funding (Woolf 2008). As the CTSA program has fostered community based participatory research with additional growing emphasis on comparative effectiveness and systems level interventions to improve health outcomes, greater emphasis in these areas should be encouraged rather than threatened through funding cuts.

What are the outcomes for progress in dissemination and implementation of discoveries? These can be counted as more effective health services, better prevention, or in non-health settings - better schooling for our children, greater highway safety, or employment opportunities. The methods and issues may appear to differ across fields of study. Like statistics, which has a long history of development in agriculture (the leading industry of the time – Cochran wrote on meta-analysis of results from agriculture trial plots in 1937 and helped define modern approaches (Cochran 1937)), dissemination and dissemination research also grew from agriculture to guide thinking in this field (Rogers 1993). Now, with health care consuming an ever-increasing portion of national and state budgets in the developed world, methods to maximize our societal benefit must be refined and accessible to end users – and will likely be developed and refined most quickly in the context of health and wellness. In fact, data from OECD indicate that the average ratio of health expenditure to GDP has risen from 7.8% in 2000 to 9.0% in 2008, and is at 16.0% for the US and 10.4% for Canada. (OECD 2010) There is no shortage of academic research but how do we sift through studies and draw inference to disseminate and implement programs and policies more broadly?

Delay in adoption of scientific discoveries is not a new event. Penicillin was discovered by Fleming in 1928 (though others are attributed with noticing the effect of mold on bacteria in research laboratories). Use of penicillin was not implemented for more than 15 years, when an Australian Rhodes Scholar, Howard Florey, then in the Pathology Department at Oxford, evaluated penicillin in humans and with a team of scientists developed methods for mass production leading to widespread military use for infected soldiers (Bickell 1996). Only after the War did civilian use become available, first in Australia and then more broadly. The time delay from discovery to clinical application is typical of the lag we still see today. Of course, war has a long history for development of new methods in trauma surgery and other areas of clinical medicine, but our focus is broader application of scientific advances.

How can improving the methods for dissemination and implementation help us move more quickly to build on research findings and apply them to improve health? The challenge of implementation extends along the continuum from discovery of biologic phenomena to clinical application in research settings and the broader application in the population at large. A range of approaches to describing this continuum have been developed. Green and colleagues (Green, Ottoson et al. 2009) describe a leaky pipeline from research to practice. Across these approaches to defining stages of translation and application, some common themes emerge; discovery on its own does not lead to use of knowledge; evidence of impact does not lead to uptake of new strategies; and maintenance of change is often overlooked leading to regression of system level changes back to a prior state.The lag from discovery to application (implementation of effective programs and practices) may vary across disciplines. Examples from public health include the gap from perfecting the Papanicolaou test in 1943 to the establishment of screening programs in all US states in 1995, and the delay from the 1964 Surgeon General’s repot on smoking in 1964 to effective state wide tobacco control programs (Brownson and Bright 2004). Of course early applications will be in place to varying degrees before full widespread programs are implemented and sustained.

A frequently quoted statement about the total attrition in the funnel and the lapse between research and medical practice indicates that it takes 17 years to turn 14% of original research to the benefit of patient care, and is attributed to Balas & Boren (Balas and Boren 2000). The leakage or loss of medical-clinical research from the pipeline at each stage from completed research through submission, publication, indexing, and systematic reviews that produce guidelines and textbook recommendations for best practices, to the ultimate implementation of those practices in health care settings all contribute to these estimates. Changing technologies and priorities of publishing, bibliographic data management, and systematic reviews and disseminating evidence-based guidelines will lead to different estimates over time and in different fields.

Our challenge is to improve approaches to summarize the evidence, identify strategies to implement programs and practices that will most efficiently improve the health and wellbeing of the population. Its time for greater emphasis in these areas to garner the full return on our past investment in biomedical research across the continuum from prevention to detection, treatment, and community outcomes.

Literature Cited 
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  2. Bickell, L. (1996). Howard Florey: The Man Who Made Penicillin (Australian Lives series.
  3. Bowen, D. J., G. Sorensen, et al. (2009). "Dissemination research in cancer control: where are we and where should we go?" Cancer Causes Control 20(4): 473-485.
  4. Brownson, R. C. and F. S. Bright (2004). "Chronic disease control in public health practice: looking back and moving forward." Public Health Rep 119(3): 230-238.
  5. Cochran, W. (1937). "Problems arising in the analysis of a series of similar experiments." J R Stat Soc Suppl 4: 102-118.
  6. Crandall, D. (1989). "Implementation Aspects of Dissemination." Science Communication 11(1): 79-106.
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  8. Green, L. W., J. M. Ottoson, et al. (2009). "Diffusion theory and knowledge dissemination, utilization, and integration in public health." Annu Rev Public Health 30: 151-174.
  9. Harlan, W. R. (1998). "Prevention research at the National Institutes of Health." Am J Prev Med 14(4): 302-307.
  10. Huberman AM, Levinson NS, et al. (1981). "Interorganizational Arrangements. An approach to education practice improvement." Knowledge: Creation, Diffusion, Utilization 3(1): 5-22.
  11. Huberman M (1991). "Research utilization: The state of the art." Knowledge, Technology & Policy 7(4): 13-33.
  12. Institute of Medicine (1997). Linking Research to public health practice. A review of the CDC's program of Centers for Research and Demonstration of Health Promotion and Disease Prevention. Washington, DC, National Academy Press.
  13. OECD (2010). OECD Health Data 2010: Statistics and Indicators.
  14. Office of Management and Budget (2010.). Budget: Department of Health and Human Services. . Washington, DC, The Executive Office of the President.
  15. Rogers, E. (1993). Diffusion of innovations. London, The Free Press.
  16. Woolf, S. H. (2008). "The meaning of translational research and why it matters." JAMA 299(2): 211-213.

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