Translation of Research Into Practice (TRIP)

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Translation of Research Into Practice (TRIP)

• Jim Mold, M.D., M.P.H.
• Department of Family and Preventive Medicine
• OUHSC OKC

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The Challenge

• It has been estimated that it takes an average of
  17 years to turn 14 of original research
  findings into changes in care that benefit
  patients.
• Balas and Boren. Yearbook of Medical Informatics
  2000 65-70

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Translational Steps

• Basic Science/Possibilities
• 1
• Clinical Applications/Efficacy
• 2
• Practical Applications/Effectiveness

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The Opportunity

• Practice-based research networks are ideally
  positioned to address the second translational
  step.
• Funding available to find out how to TRIP (NIH,
  AHRQ, CDC, RWJF, etc.)
• Possible to combine research and quality
  improvement

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The Opportunity

• The research community suddenly understands the
  need for primary care and primary care research
• Academic researchers and funding agencies are
  just beginning to see that research and practice
  must inform each other
  (bidirectional not unidirectional)

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Examples

• Beta blockers after MI
• ACEIs in patients at high risk for CV events
• Beta blockers for CHF with low LVEF
• Tight blood glucose control in hospitalized
  patients
• Evidence-based guidelines (DM, preventive
  services, etc.)

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Theories

• Knowledge gap
• Research findings not relevant
• Research findings not applicable
• Research findings not important
• Research findings difficult to apply given
  current primary care systems, processes, and
  resources
• New methods must be developed to make
  full/accurate implementation possible

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Strategies

• Traditional CME necessary but not sufficient
• Academic detailing works for the pharmaceutical
  companies
• Targeting opinion leaders sometimes works
• Performance feedback minimally effective
• Feedback with benchmarking slightly more
  effective

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Strategies

• Community-Based Participatory Research
• Best practices identification of exemplars and
  dissemination of their methods
• QI Collaboratives
• Practice enhancement assistants
• Technology development and assistance

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OKPRN Approach

• Multi-component Intervention
• Performance feedback with benchmarking
• Best practices
• Academic detailing
• Practice enhancement assistants
• Technology development and assistance

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OKPRN TRIP Projects

• Diabetes (OFMQ)
• Diabetes (AHRQ)
• Mammography (AHRQ)
• CRC (NIH)
• Preventive services (AHRQ)
• Health Behaviors (RWJF)

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Lessons Learned and Questions

• Some research findings may not be applicable,
  effective, or feasible.
• What evidence is sufficient to warrant TRIP?
• In what form does this evidence need to be
  assembled and presented?
• Who needs to present it and in what forum?

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Lessons Learned and Questions

• Some practices are readier and abler than others
  to adopt new research findings.
• How do we assess readiness and ability to change?
• Who within the practice must be involved in the
  change process and in what ways?
• Are there some common barriers that could be
  overcome within a TRIP intervention?

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Lessons Learned and Questions

• Feedback with benchmarking sometime works but
  often doesnt.
• Are there ways to enhance the effectiveness of
  feedback with benchmarking?
• How important is confidentiality in this process?
• What information should always be included in the
  report?

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Lessons Learned and Questions

• The best practices concept is popular with
  clinicians, but there are significant questions
  about how to do it and its effectiveness for
  creating change.
• What is the most cost effective way to identify
  exemplars?
• What are the best ways to spread the wisdom of
  exemplars to others?
• How can we better help practices adopt best
  practice methods?
• What are the potential hazards involved in this
  approach?

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Lessons Learned and Questions

• Virtually all of the academic detailing in OKPRN
  has been done by me. While I always enjoy it and
  rarely encounter resistance, were not sure how
  effective it has been.
• Whos the best person to do this?
• Is it better to do it one-on-one or should it be
  done with small groups of clinicians/practices?

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Lessons Learned and Questions

• Collaboratives count on friendly competition
  between practices to motivate them to change.
  The PEA approach doesnt include this.
• How effective and important is competition
  between practices as a motivator?
• Should we add some luncheon meetings for small
  geographically clustered groups of practices to
  our intervention?

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Lessons Learned and Questions

• While the PEA concept has been very popular,
  there are still big questions about how PEAs can
  help practices.
• How often should PEAs come to a practice? For
  how long?
• What should they do while there?
• What commitment should be required of the
  practice with respect to PEAs?
• Are PDSA cycles useful? Should PEAs teach the
  practice to do them or continue to coordinate
  them?

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Lessons Learned and Questions

• Technology development and assistance seems to
  have been one of our most effective strategies
  for accomplishing change in practices.
• Should we do even more of this?
• How should we be involved in implementation and
  modifications of electronic health records?
• What is the future of PDAs in primary care?

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Additional Thoughts and Questions?