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INTEGRATING RESEACH AND PRACTICE: KEY ISSUES AND FUTURE DIRECTIONS

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Illustrations of RE-AIM for Planning and Evaluation ... RE-AIM AND RELATED GENERALIZATION ISSUES. The '3 Rs' of Integrating Research into Practice ... – PowerPoint PPT presentation

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Title: INTEGRATING RESEACH AND PRACTICE: KEY ISSUES AND FUTURE DIRECTIONS


1
INTEGRATING RESEACH AND PRACTICE KEY ISSUES AND
FUTURE DIRECTIONS
Russell E. Glasgow, Ph.D. Kaiser Permanente
Colorado
2
Type 2 Translational Research, That isORThe
Road Map Less Taken
3
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

4
BARRIERS TO ADOPTION AND DISSEMINATION
5
BARRIERS TO ADOPTION AND DISSEMINATION (cont.)
6
BARRIERS TO ADOPTION AND DISSEMINATION (cont.)
Glasgow RE, Marcus AC, Bull SS. Disseminating
effective cancer screening interventions.
Cancer 20041011239-1250
7
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.
8
The law of halves a story
9
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
10
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
13
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
14
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
15
PROPOSED TRANSLATIONAL RESEARCH MEASUREMENT
PACKAGE
Glasgow, et al. (2003) Diabetes Care
26(8)2451-2456
16
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
17
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
18
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
19
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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
21
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
22
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

23
RE-AIM DIMENSIONS AND DEFINITIONS
www.re-aim.org
24
RE-AIM DIMENSIONS AND DEFINITIONS (cont.)
www.re-aim.org
25
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

26
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
30
ADOPTION WHICH IS BETTER?
Linked, separate approach recruited 47 of PCPs
in-office PCP team delivery approach recruited
6 of PCPs
PERCENT
31
WHICH PROGRAM IS BETTER?
See www.re-aim.org for displays and evaluation
questions
Glasgow et al. AJPM 30(1)67-73
32
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
33
To every complex question, there is a simple
answer and it is wrong. H. L. Mencken
34
Application of RE-AIM to Health Policy and
Environmental Change Interventions
35
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)
36
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

43
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.
44
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

45
eHEALTH TECHNOLOGIES Integration
with Community and Clinic
46
INTEGRATED SELF-MANAGEMENT SUPPORT
47
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
48
The significant problems we face cannot be
solved by the same level of thinking that created
them. A. Einstein
49
Questions, Counterpoint, Discussion
50
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?

51
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
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