INTEGRATING RESEACH AND PRACTICE: KEY ISSUES AND FUTURE DIRECTIONS

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INTEGRATING RESEACH AND PRACTICE KEY ISSUES AND
FUTURE DIRECTIONS
Russell E. Glasgow, Ph.D. Kaiser Permanente
Colorado
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Type 2 Translational Research, That isORThe
Road Map Less Taken
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OVERVIEW

• Why Dont We See More Translation of Research
  into Practice?
• What Can We Do to Enhance Research Practice
  Integration?
• Illustrations of RE-AIM for Planning and
  Evaluation
• Application to Health Policy and Environmental
  Change Interventions
• Future Opportunities and Discussion

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BARRIERS TO ADOPTION AND DISSEMINATION
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BARRIERS TO ADOPTION AND DISSEMINATION (cont.)
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BARRIERS TO ADOPTION AND DISSEMINATION (cont.)
Glasgow RE, Marcus AC, Bull SS. Disseminating
effective cancer screening interventions.
Cancer 20041011239-1250
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BARRIERS TO ADOPTION AND DISSEMINATION (cont.)
Glasgow et al. Translation Research in
DiabetesIn Evidence-based Endocrinology VM
Montori (Ed). Humana Press, Totowa, NJ. Pages
241-256, 2005.
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The law of halves a story
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ULTIMATE IMPACT OF MAGIC DIET PILL
Dissemination Step Concept Impacted
50 of Clinics Use Adoption 50
50 of Clinicians Prescribe Adoption 25
50 of Patients Accept Medication Reach 12.5
50 Follow Regimen Correctly Implementation 6.2
50 of Those Taking Correctly Benefit Effective
ness 3.2
50 Continue to Benefit After 6
Months Maintenance 1.6
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MORAL OF THE STORY?
Focus on the Denominator

• (Each step of the dissemination
• sequence, or each RE-AIM
• dimension is important)

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If we want more evidence-based practice, we need
more practice-based evidence. Larry W. Green,
2004
Green LW Ottosen JM. From efficacy to
effectivenessProceedings from NIDDK Conference
From Clinical Trials to Community, 2004
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Behavioral scienceespecially within the U.S.,
has focused primarily in individual
health-related behaviors, without due
consideration of the social context in which
health behaviors occur.Glass McAfee
Glass McAfee, Soc Sci Medicine,
2006621659-1671
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WE NEED MORE STUDIES THAT INTEGRATE RESEARCH INTO
PRACTICE

• Key elements of Practical Clinical Trials
• - Representative Patients
• - Multiple Settings
• - Controls address standard of care other
  alternatives
• - Outcomes or measures relevant to
  clinicians and decision makers

Tunis SR, Stryer DB, Clancy CM JAMA
20032901624-1632 Glasgow RE, Magid DJ, et al.
Med Care 200543(6)551-557
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PROPOSED TRANSLATIONAL RESEARCH MEASUREMENT
PACKAGE
Glasgow, et al. (2003) Diabetes Care
26(8)2451-2456
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BEHAVIOR CHANGE MEASURES

• Brief, practical measures
• Often triangulate when no gold standard
• Focus on sensitivity to change
• Measures of patient, staff, change agents (e.g.,
  family), system and policy changes

Glasgow, et al. Ann Fam Med 2005373-81
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ECONOMIC OUTCOMES Use Standardized Methods

• Assess cost of intervention delivered
• Estimate replication costs
• Optional, more sophisticated analyses of
  cost-effectiveness, cost-utility, cost-benefit,
  return on investment
• Costs are not costs are not costs

Gold, et al. Cost-effectiveness in health and
medicine. New York Oxford Univ. Press, 2003
Meenan, et al. Med Care 199836670-678 Ritzwoll
er, et al. (In press) Economic Analysis of the
Mediterranean Lifestyle Program Diabetes
Educator
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IN DESIGNING FOR PRACTICAL TRIALS, be

• Practical in intervention delivery
• Broad in what you measure
• Transparent (TREND) in reporting
• Summarize results in terms understandable to
  clinicians (NNT) and policy makers

www.hetinitiative.org Des Jarlais, D.C., Lyles,
C., Crepaz, N. Am J Public Health
200494(3)361-366
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RE-AIM AND RELATED GENERALIZATION ISSUES

• The 3 Rs of Integrating Research into Practice
• Representativeness (Reach, Adoption)
• Robustness (Effectiveness across
  subgroupsespecially re disparities)
• Cronbachs generalization across persons,
  time, measures
• Replicability (Implementation) in
  representative settings

Cronbach LH, et al. The dependability of
behavioral measurements Theory of
generalizability for scores and profiles. New
York, John Wiley Sons, 1972 Shadish WR, et al.
Experimental and quasi-experimental design for
generalized causal inference. Boston Houghton
Mifflin, 2002
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RE-AIM TO HELP PLAN, EVALUATE, AND REPORT STUDIES

• R Increase Reach
• E Increase Effectiveness
• A Increase Adoption
• I Increase Implementation
• M Increase Maintenance

Glasgow, et al. Ann Behav Med 200427(1)3-12
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PURPOSES OF RE-AIM

• To broaden the criteria used to evaluate programs
  to include external validity
• To evaluate issues relevant to program adoption,
  implementation, and sustainability
• To help close the gap between research studies
  and practice by
• Informing design of interventions
• Providing guides for adoptees
• Suggesting standard reporting criteria

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RE-AIM DIMENSIONS AND DEFINITIONS
www.re-aim.org
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RE-AIM DIMENSIONS AND DEFINITIONS (cont.)
www.re-aim.org
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RECOMMENDED PURPOSE OF TRANSLATION/EFFECTIVENESS
RESEARCH
To determine the characteristics of interventions
that can

• Reach large numbers of people, especially those
  who can most benefit
• Be widely adopted by different settings
• Be consistently implemented by staff members with
  moderate levels of training and expertise
• Produce replicable and long-lasting effects (and
  minimal negative impacts) at reasonable cost

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USING RE-AIM PROACTIVELY FOR PLANNING AND
PERIODIC SELF-EVALUATION

• Klesges, Estabrooks PA, et al. Ann Behav Med,
  2005, 2966-75
• Dzewaltowski, Glasgow, Klesges, et al. RE-AIM
  A web resource. Ann Behav Med 2004, 2875-80.
• Resources www.re-aim.org...
• especially, re-aim.org/database_quiz/intro.html

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REACH WHICH IS BETTER?
In-office attracted 50 (vs. 41) of eligible
participants
PERCENT
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ADOPTION WHICH IS BETTER?
Linked, separate approach recruited 47 of PCPs
in-office PCP team delivery approach recruited
6 of PCPs
PERCENT
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WHICH PROGRAM IS BETTER?
See www.re-aim.org for displays and evaluation
questions
Glasgow et al. AJPM 30(1)67-73
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NEW RE-AIM SUMMARY METRICS THAT ADDRESS

• Health disparities e.g., who participates and
  who benefits
• Costs and cost-effectiveness
• Effects of different interventionists
• Combining different factors to produce composite
  outcomes

Glasgow, et al. Using RE-AIM Metrics to Evaluate
DiabetesAJPM 200630(1)67-73
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To every complex question, there is a simple
answer and it is wrong. H. L. Mencken
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Application of RE-AIM to Health Policy and
Environmental Change Interventions
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POLICY ISSUES
The first priority is to develop better tools to
assess the effects of policies, to guide policy
development, and to prioritize policy choices.
Schmid TL, Pratt M, Whitmer L, in J Phys Activity
Health 20063(Suppl 1)S20-S29)
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ISSUES IN IDENTIFYING INTENDED POLICY AUDIENCE(S)

• Who makes the Decision or Policy (Adopting
  Organization)
• Who is Responsible for Enforcing the Policy
• Who is Responsible for Following or Adhering to
  the Policy?

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FUTURE DIRECTIONS FOR TRANSLATION AND EXTERNAL
VALIDITYUSING RE-AIM

• Assesses context and representativeness
• Includes multiple dimensions
• Addresses both individual participant and setting
  levels
• Includes quality of life and adverse consequences
  impacts
• Addresses feasibility issues critical for
  dissemination
• Includes sustainability indices

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THE ROAD AHEADDIRECTIONS AND CHALLENGES

• Advice for Clinicians, Decision Makers, and
  Researchers
• - Focus on the Denominator (of settings,
  clinicians, patients)
• - Plan for Generalization and Adaptation
  (dont hope for it)
• - Look for Interfaces with Policy
• - Think like and involve your Target Audience
• - Everything is Contextual (customize and
  document it)

Klesges LM, et al. Ann Behav Med
20052966S-75S Green LW Glasgow RE. Evaluating
the Relevance, GeneralizationEvaluation and
The Health Professions 200629(1)126-153.
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IMPLICATIONS OF CONTEXT

• Cannot study things in isolation
• Interventions effective in one context may not
  work well in different contexts
• Study of contexte.g., organizations, social and
  community environment is important
• Evaluate both anticipated and unanticipated
  outcomes
• Connectedness and contexthow different
  contextual factors fitreinforce or undermine
  each other is critical

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eHEALTH TECHNOLOGIES Integration
with Community and Clinic
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INTEGRATED SELF-MANAGEMENT SUPPORT
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CHALLENGES AND CONCLUSIONS

• The future is multiple (conditions, behaviors,
  interactive modalities)
• The future is complex (and we ignore complexity
  at our peril)
• All models (and designs) are wrong and
  greater tolerance, respect, and creativity is
  needed
• We need to UN-learn much of what we have been
  taught to answer the tough questions

Sterman JD. Syst Dynam Rev 200218501-531
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The significant problems we face cannot be
solved by the same level of thinking that created
them. A. Einstein
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Questions, Counterpoint, Discussion
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CAVEATS AND COMPLEXITIES

• REACH Impact on health disparities and who is
  reached are critical
• EFFECTIVENESS - Policy outcomes should usually
  change over time
• ADOPTION Are there adequate funds for
  enforcement?

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CAVEATS AND COMPLEXITIES (cont.)

• IMPLEMENTATION Consistency across enforcing
  agents and population subgroups
• MAINTENANCE Here as well as throughout,
  contextual factors are critical and qualitative
  as well as quantitative data are helpful