Dissemination,Implementation, and Improvement Science Research in Population Health: Opportunities for Public Health and CTSAs

Importance

The complex, dynamic nature of health systems requires dissemination, implementation, and improvement (DII) sciences to effectively translate emerging knowledge into practice. Although they hold great promise for informing multisector policies and system‐level changes, these methods are often not strategically used by public health.

Objectives and Methods

More than 120 stakeholders from Southern California, including the community, federal and local government, university, and health services were convened to identify key priorities and opportunities for public health departments and Clinical and Translational Science Awards programs (CTSAs) to advance DII sciences in population health.

Main Outcomes

Participants identified challenges (mismatch of practice realities with narrowly focused research questions; lack of iterative learning) and solutions (using methods that fit the dynamic nature of the real world; aligning theories of change across sectors) for applying DII science research to public health problems. Pragmatic steps that public health and CTSAs can take to facilitate DII science research include: employing appropriate study designs; training scientists and practicing professionals in these methods; securing resources to advance this work; and supporting team science to solve complex‐systems issues.

Conclusions

Public health and CTSAs represent a unique model of practice for advancing DII research in population health. The partnership can inform policy and program development in local communities.     

Interdisciplinary Priorities for Dissemination,Implementation, and Improvement Science: Frameworks,Mechanics, and Measures

Much of dissemination, implementation, and improvement (DII) science is conducted by social scientists, healthcare practitioners, and biomedical researchers. While each of these groups has its own venues for sharing methods and findings, forums that bring together the diverse DII science workforce provide important opportunities for cross‐disciplinary collaboration and learning. In particular, such forums are uniquely positioned to foster the sharing of three important components of research. First: they allow the sharing of conceptual frameworks for DII science that focus on the use and spread of innovations. Second: they provide an opportunity to share strategies for initiating and governing DII research, including approaches for eliciting and incorporating the research priorities of patients, study participants, and healthcare practitioners, and decision‐makers. Third: they allow the sharing of outcome measures well‐suited to the goals of DII science, thereby helping to validate these outcomes in diverse contexts, improving the comparability of findings across settings, and elevating the study of the implementation process itself.     

Concocting that Magic Elixir: Successful Grant Application Writing in Dissemination and Implementation Research

Background

This paper reports core competencies for dissemination and implementation (D&I) grant application writing and provides tips for writing a successful proposal.

Methods

Two related phases were used to collect the data: a card sorting process among D&I researchers and an expert review among a smaller set of researchers. Card sorting was completed by 123 respondents. In the second phase, a series of grant application writing tips were developed based on the combined 170 years of grant review experience of the writing team.

Results

The card sorting resulted in 12 core competencies for D&I grant application writing that covered the main sections in a grant application to the US National Institutes of Health: (a) specific aims that provide clear rationale, objectives, and an overview of the research plan; (b) significance that frames and justifies the importance of a D&I question; (c) innovation that articulates novel products and new knowledge; and (d) approach that uses a relevant D&I model, addresses measurement and the D&I context, and includes an analysis plan well‐tied to the aims and measures.

Conclusions

Writing a successful D&I grant application is a skill that can be learned with experience and attention to the core competencies articulated in this paper.     

Engaging the Community in the Dissemination,Implementation, and Improvement of Health‐Related Research

To help maximize the real‐world applicability of available interventions in clinical and community healthcare practice, there has been greater emphasis over the past two decades on engaging local communities in health‐related research. While there have been numerous successful community–academic partnered collaborations, there continues to be a need to articulate the common barriers experienced during the evolution of these partnerships, and to provide a roadmap for best practices that engage healthcare providers, patients, families, caregivers, community leaders, healthcare systems, public agencies and academic medical centers. To this end, this paper presents a summary of a forum discussion from the 2014 Southern California Dissemination, Implementation and Improvement (DII) Science Symposium, sponsored by the University of California Los Angeles (UCLA) Clinical Translational Science Institute (CTSI), University of Southern California (USC) CTSI, and Kaiser Permanente. During this forum, a diverse group of individuals representing multiple constituencies identified four key barriers to success in community‐partnered participatory research (CPPR) and discussed consensus recommendations to enhance the development, implementation, and dissemination of community health‐related research. In addition, this group identified several ways in which the over 60 NIH funded Clinical and Translational Science Institutes across the country could engage communities and researchers to advance DII science.     

Evaluation Guidelines for the Clinical and Translational Science Awards (CTSAs)

The National Center for Advancing Translational Sciences (NCATS), a part of the National Institutes of Health, currently funds the Clinical and Translational Science Awards (CTSAs), a national consortium of 61 medical research institutions in 30 states and the District of Columbia. The program seeks to transform the way biomedical research is conducted, speed the translation of laboratory discoveries into treatments for patients, engage communities in clinical research efforts, and train a new generation of clinical and translational researchers. An endeavor as ambitious and complex as the CTSA program requires high‐quality evaluations in order to show that the program is well implemented, efficiently managed, and demonstrably effective. In this paper, the Evaluation Key Function Committee of the CTSA Consortium presents an overall framework for evaluating the CTSA program and offers policies to guide the evaluation work. The guidelines set forth are designed to serve as a tool for education within the CTSA community by illuminating key issues and practices that should be considered during evaluation planning, implementation, and utilization. Additionally, these guidelines can provide a basis for ongoing discussions about how the principles articulated in this paper can most effectively be translated into operational reality.     

Using AI to Understand Key Success Features in Evolving CTSAs

A vital role for Clinical and Translational Science Award (CTSA) evaluators is to first identify and then articulate the necessary change processes that support the research infrastructures and achieve synergies needed to improve health through research. The use of qualitative evaluation strategies to compliment quantitative tracking measures (e.g., number of grants/publications) is an essential but under‐utilized approach in CTSA evaluations. The Clinical and Translational Science Institute of Southeast Wisconsin implemented a qualitative evaluation approach using appreciative inquiry (AI) that has revealed three critical features associated with CTSA infrastructure transformation success: developing open communication, creating opportunities for proactive collaboration, and ongoing attainment of milestones at the key function group level. These findings are consistent with Bolman & Deal''s four interacting hallmarks of successful organizations: structural (infrastructure), political (power distribution; organizational politics), human resource (facilitating change among humans necessary for continued success), and symbolic (visions and aspirations). Data gathered through this longitudinal AI approach illuminates how these change features progress over time as CTSA funded organizations successfully create the multiinstitutional infrastructures to connect laboratory discoveries with the diagnosis and treatment of human disease.     

Public Health in the Emergency Department: Overcoming Barriers to Implementation and Dissemination

This article is the outcome of a consensus building workshop entitled, "Overcoming Barriers to Implementation and Dissemination" convened at the 2009 Academic Emergency Medicine Consensus Conference, 'Public Health in the ED: Surveillance, Screening, and Intervention." The participants were asked to address potential methods for overcoming barriers to the dissemination and implementation in the emergency department (ED) of evidenced-based practices to improve public health. The panel discussed three broad areas of interest including methods for disseminating evidence-based practices, barriers encountered during the process of implementation, and the importance of involvement in activities outside the ED including engagement in policy development and improvement. Four recommendations were discussed in detail and consensus was reached. The recommendations included 1) researchers and advocates should disseminate findings through multiple forums beyond peer-reviewed publications when an ED-based public health intervention has enough evidence to support integration into the routine practice of emergency care; 2) local barriers to implementation of public health interventions should be recognized and well understood from multiple perspectives prior to implementation; 3) innovation must be put into place and adapted based on local institutional context and culture as barriers and the best methods for overcoming them will vary across institutions; and 4) use of legislation, regulation, and incentives outside of the ED should support and strengthen ED-based interventions. For each area of interest, research dimensions to extend the current understanding of methods for effectively and efficiently implementing evidence-based public health interventions in the ED were discussed and consensus was achieved.     

Evaluating the Development,Implementation and Dissemination of a Multisite Card Study in the WWAMI Region Practice and Research Network

Background

Practice‐based research networks (PBRNs) promote the conduct of research in real‐world settings by engaging primary care clinicians as champion research collaborators. Card studies are brief surveys administered to patients or clinicians at the point of care. The objective of this paper is to describe the design and evaluation of a card study methodology that the WWAMI Region Practice and Research Network (WPRN) used to develop research partnerships across multiple member sites.

Methods

We used a collaborative model to develop, implement and disseminate the results of a network‐wide card study to assess patient preferences for weight loss in primary care. After the card study data collection was completed, we conducted individual and focus group interviews and a brief survey of participating practice champions.

Results

Increased research engagement and personal and professional developments were the primary motivators for participating in the development of the card study. Increasing research activity at practices and learning information about patients were motivators for implementing the study. Their participation resulted in champions reporting increased confidence in collaborating on research projects as well as the development of new clinical services for patients.

Discussion

This collaborative model positively influenced research capacity in the WPRN and may be a useful strategy for helping PBRNs conducted translational research.     

Science Cafés: Engaging Scientists and Community through Health and Science Dialogue

Engagement of the community through informal dialogue with researchers and physicians around health and science topics is an important avenue to build understanding and affect health and science literacy. Science Cafés are one model for this casual interchange; however the impact of this approach remains under researched. The Community Engagement Key Function of the Clinical and Translational Science Institute of Southeast Wisconsin hosted a series of Science Cafés in which topics were collaboratively decided upon by input from the community. Topics ranged from Personalized Medicine to Alzheimer''s and Dementia to BioMedical Innovation. A systematic evaluation of the impact of Science Cafés on attendees'' self‐confidence related to five health and scientific literacy concepts showed statistically significant increases across all items (Mean differences between mean retrospective pre‐scores and post‐scores, one tailed, paired samples t‐test, n = 141, p < .0001 for all items). The internal consistency of the five health and scientific literacy items was excellent (n = 126, α = 0.87). Thematic analysis of attendees'' comments provides more nuance about positive experience and suggestions for possible improvements. The evaluation provides important evidence supporting the effectiveness of brief, casual dialogue as a way to increase the public''s self‐rated confidence in health and science topics.     

Understanding the Supports of and Challenges to Community Engagement in the CTSAs

Background

The Clinical and Translational Science Award (CTSA) program has raised the profile and the available funding for engagement in biomedical research. Such increased funding and attention may address known barriers to engagement. However, little work has been done to describe experiences across multiple CTSAs, especially how the CTSA structure supports or challenges engagement.

Objective

We sought to understand the supports and challenges experienced by multiple CTSAs as they pursued community engagement. This knowledge may help guide future efforts to support and enhance community engagement in biomedical research.

Methods

We conducted semi‐structured, in‐depth interviews with CTSA community engagement core leaders and staff from the 2006 cohort of CTSAs (n = 12).

Results

A total of 17 interviews with respondents from nine institutions identified three support themes, including: funding, existing relationships with communities, and leadership and a partnership approach at the institution. Six challenge themes arose: need for capacity development, lack of positive relationships with communities, lack of leadership, funding constraints, time and staff constraints, and unsustainable models.

Conclusion

The CTSAs have brought much‐needed attention to community engagement in research, but more can be done to adequately support engagement. Challenges remain that need to be addressed to achieve the potential benefits of engagement.     

Facilitating Emergency Care Research Networks: Integration into the Clinical Translational and Science Award (CTSA) Infrastructure

Emergency care research (ECR) does not fit neatly into the traditional National Institutes of Health (NIH) funding model, because emergency research involves undifferentiated disease presentations involving multiple disciplines and time-sensitive interventions. A task force of emergency care researchers and other stakeholders was convened to discuss the present and future state of clinical research networks. Integration of ECR with the Clinical Translational and Science Award (CTSA) program through a multidisciplinary emergency care research network (ECRN) would obviate the duplication of research efforts by disease-specific or institute-specific multicenter networks and reduce startup and maintenance costs. Strategies to enhance integration must include the training of emergency physician investigators in biostatistical and epidemiologic methods, as well as educating collaborative investigators in emergency care–related methodologies. Thus, an ECRN would be of great benefit to CTSA awardees and applicants and should be considered a priority.     

Values in Translation: How Asking the Right Questions Can Move Translational Science Toward Greater Health Impact

The speed and effectiveness of current approaches to research translation are widely viewed as disappointing given small gains in real population health outcomes despite huge investments in basic and translational science. We identify critical value questions—ethical, social, economic, and cultural—that arise at moments throughout the research pathway. By making these questions visible, and promoting discussion of them with diverse stakeholders, we can facilitate handoffs along the translational pathway and increase uptake of effective interventions. Who is involved with those discussions will determine which research projects, populations, and methods get prioritized. We argue that some upfront investment in community and interdisciplinary engagement, shaped by familiar questions in ethics, social justice, and cultural knowledge, can save time and resources in the long run because interventions and strategies will be aimed in the right direction, that is, toward health improvements for all. Clin Trans Sci 2012; Volume 5: 445–451     

A Distributed Model: Redefining a Robust Research Subject Advocacy Program at the Harvard Clinical and Translational Science Center

The Harvard Clinical and Translational Science Center (“Harvard Catalyst”) Research Subject Advocacy (RSA) Program has reengineered subject advocacy, distributing the delivery of advocacy functions through a multi‐institutional, central platform rather than vesting these roles and responsibilities in a single individual functioning as a subject advocate. The program is process‐oriented and output‐driven, drawing on the strengths of participating institutions to engage local stakeholders both in the protection of research subjects and in advocacy for subjects’ rights. The program engages stakeholder communities in the collaborative development and distributed delivery of accessible and applicable educational programming and resources. The Harvard Catalyst RSA Program identifies, develops, and supports the sharing and distribution of expertise, education, and resources for the benefit of all institutions, with a particular focus on the frontline: research subjects, researchers, research coordinators, and research nurses.     

Development,Implementation, and Evaluation of an Interprofessional Course in Translational Research

The advancement of research from basic science discovery to clinical application requires the extensive collaboration of individuals from multiple disciplines, therefore the ability to work as an effective interprofessional team is essential for researchers in clinical and translational science (CTS). Courses that build interprofessional skills are a key component in CTS education, but the development of these courses poses numerous administrative and educational challenges. This paper describes the processes of designing, implementing, and evaluating an innovative graduate‐level course that combines online lectures and in‐class facilitated group discussions to promote interprofessional interactions. The course offers students the opportunity to interact with and learn from individuals in a variety of disciplines, and it requires students to engage in interprofessional group work to meet the course objectives. During the past 4 years, 96 students from the schools of medicine, pharmacy, nursing, public health, and health and rehabilitation sciences at a large urban university have completed the course. The course has been well‐received, with 87% of students rating its overall quality as excellent, good, or satisfactory. The course offers educators a model to teach graduate students the skills that are essential for becoming effective CTS researchers. Clin Trans Sci 2012; Volume #: 1–7     

Models of Interinstitutional Partnerships between Research Intensive Universities and Minority Serving Institutions (MSI) across the Clinical Translational Science Award (CTSA) Consortium

Health disparities are an immense challenge to American society. Clinical and Translational Science Awards (CTSAs) housed within the National Center for Advancing Translational Science (NCATS) are designed to accelerate the translation of experimental findings into clinically meaningful practices and bring new therapies to the doorsteps of all patients. Research Centers at Minority Institutions (RCMI) program at the National Institute on Minority Health and Health Disparities (NIMHD) are designed to build capacity for biomedical research and training at minority serving institutions. The CTSA created a mechanism fostering formal collaborations between research intensive universities and minority serving institutions (MSI) supported by the RCMI program. These consortium‐level collaborations activate unique translational research approaches to reduce health disparities with credence to each academic institutions history and unique characteristics. Five formal partnerships between research intensive universities and MSI have formed as a result of the CTSA and RCMI programs. These partnerships present a multifocal approach; shifting cultural change and consciousness toward addressing health disparities, and training the next generation of minority scientists. This collaborative model is based on the respective strengths and contributions of the partnering institutions, allowing bidirectional interchange and leveraging NIH and institutional investments providing measurable benchmarks toward the elimination of health disparities.     

Implementation Science: Incorporating Obstructive Sleep Apnea Screening and Capnography Into Everyday Practice

PurposeThis article describes the implementation and maintenance of obstructive sleep apnea (OSA) screening and capnography monitoring.DesignA quality improvement project.MethodsA multidisciplinary team provided staff education to three perianesthesia care units. Using the STOP-Bang screening tool, five or more positive responses indicated high risk for OSA. A postanesthesia care unit audit tool tracked STOP-Bang scores, capnography use, hypoventilation events, nursing interventions, and respiratory complications.FindingsAmong 314 patients with OSA, 36% were identified as high risk. Nurses used capnography on 76% of OSA patients and were able to readily identify hypoventilation and intervene. Respiratory complications occurred in 10.8% (n = 34) requiring a higher level of care. Postimplementation, all six postanesthesia care units employ this best practice.ConclusionsPerianesthesia nurses found OSA screening and capnography easy to incorporate into nursing practice. This process can reduce respiratory complications in the surgical patient with OSA. An Evidence-Based Practice Fellowship Program facilitated this practice change.     

Clinical and Translational Research Capacity Building Needs in Minority Medical and Health Science Hispanic Institutions

A preliminary needs assessment was conducted among faculty and students of three minority medical and health science institutions comprising the Puerto Rico Clinical and Translational Research Consortium (PRCTRC). The Web‐based survey was focused on evaluating the training interests in the clinical and translational research core areas and competencies developed by the National Institutes of Health‐Clinical and Translational Sciences Award. The survey was the result of a team effort of three PRCTRC key function''s leaderships: Multidisciplinary Training and Career Development, Tracking and Evaluation and Community Research and Engagement. The questionnaire included 45 items distributed across five content areas including demographics, research training needs, training activities coordination and knowledge about the services offered by the PRCTRC. Analysis of research needs includes a sample distribution according to professor, assistant/associate professor and graduate students. The thematic area with highest response rate among the three groups was: “Identify major clinical/public health problems and relevant translational research questions,” with the competency “Identify basic and preclinical studies that are potential testable clinical research hypothesis.” These preliminary results will guide the training and professional development of the new generation of clinical and translational researchers needed to eliminate health disparities.     

Bridging the divide: a survey of nurses' opinions regarding barriers to, and facilitators of, research utilization in the practice setting

Background. Many researchers have explored the barriers to research uptake in order to overcome them and identify strategies to facilitate research utilization. However, the research–practice gap remains a persistent issue for the nursing profession. Aims and objectives. The aim of this study was to gain an understanding of perceived influences on nurses’ utilization of research, and explore what differences or commonalities exist between the findings of this research and those of studies that have been conducted in various countries during the past 10 years. Design. Nurses were surveyed to elicit their opinions regarding barriers to, and facilitators of, research utilization. The instrument comprised a 29‐item validated questionnaire, titled Barriers to Research Utilisation Scale (BARRIERS Scale), an eight‐item scale of facilitators, provision for respondents to record additional barriers and/or facilitators and a series of demographic questions. Method. The questionnaire was administered in 2001 to all nurses (n = 761) working at a major teaching hospital in Melbourne, Australia. A 45% response rate was achieved. Results. Greatest barriers to research utilization reported included time constraints, lack of awareness of available research literature, insufficient authority to change practice, inadequate skills in critical appraisal and lack of support for implementation of research findings. Greatest facilitators to research utilization reported included availability of more time to review and implement research findings, availability of more relevant research and colleague support. Conclusion. One of the most striking features of the findings of the present study is that perceptions of Australian nurses are remarkably consistent with reported perceptions of nurses in the US, UK and Northern Ireland during the past decade. Relevance to clinical practice. If the use of research evidence in practice results in better outcomes for our patients, this behoves us, as a profession, to address issues surrounding support for implementation of research findings, authority to change practice, time constraints and ability to critically appraise research with conviction and a sense of urgency.