The REAIM Framework applied to the Prevention and Management of Chronic Disease

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• The RE-AIM Framework applied to the Prevention
  and Management of Chronic Disease
• Paul Estabrooks, PhD
• Kaiser Permanente Colorado

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Outline

• Context, definitions, core concepts, state of the
  science
• Applying RE-AIM Use in prevention and
  self-management of chronic disease
• Future Directions

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Context

• Well documented gap between best-practices
  discovered through research and those delivered
  in practice.
• Partial cause Many practitioners do not believe
  current research is applicable to their clinical
  context.
• Almost total focus on efficacy
• Linear automatic process?
• efficacy ? effectiveness ? dissemination

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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

Glasgow, et al. Ann Behav Med 200427(1)3-12
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RE-AIM Dimensions and Definitions
www.re-aim.org
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RE-AIM Dimensions and Definitions
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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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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RE-AIM LITERATURE REVIEW Controlled Studies
1996-2000
Glasgow, et al., 2004, Ann Behav Med, 28(2)75-80
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Percent of studies reporting Individual Level
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Percent of studies reporting Setting Level
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Summary and Conclusions of Review

• Data are seldom reported on external validity.
  Particular attention is need to the
  representativeness of participants, settings, and
  intervention staff.
• Should report on reach, adoption, implementation,
  and maintenance, in addition to effectiveness.
• The actions and representativeness of
  intervention settings and agents are as important
  as the behavior and representativenss of
  subjectsand have received far less investigation.

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DIABETES PRIORITY PROGRAMA Randomized
Effectiveness Trial

• OBJECTIVE Work with both primary care offices
  and patients to improve the quality of diabetes
  care
• SETTINGS Family practice and internal medicine
  physicians across the state of Colorado conducted
  the study in their offices

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Diabetes Priority Program

• KEY OUTCOMES Accomplishment of NCQA/ADA
  Provider Recognition Program criteria on a)
  medical / lab checks and activities b)
  patient self-management / behavior change
  counseling
• DESIGN Nested design with practices matched and
  randomized to 1) Computer-assisted Quality
  Improvement Intervention or 2) Touchscreen
  Computer Assessment Control

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Reach

• 75 of contacted eligible type 2 DM patients
  participated.
• Participants similar to non-participants on
  gender, comorbid conditions, and matched state
  of Colorado BRFSS diabetes sample
• Participants, compared to non-participants were
  higher income (57 vs 41 lt 30,000) and more
  educated

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Effectiveness
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Robustness of Effectiveness

• Analyses conducted to identify patient
  characteristics associated with outcomes
• Of 12 demographic and medical characteristics,
  only 1 interacted with intervention
• Less educated patients in intervention condition
  improved more than those in usual care on
  behavioral counseling composite

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Adoption

• 5 of primary care physicians from non-managed
  care programs throughout Colorado participated,
  despite insurance cost reduction and computer
  incentives
• They were representative of non-participants on
  all measures we had (size of practice, of
  diabetes patients, use of diabetes care QI
  strategies, gender, specialty, years in practice)

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Implementation
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Simple Questions for Dissemination

• Who comes? (Reach and Representativeness)
• What Outcomes are Produced? (Effectiveness)
  (Intended and Unintended)
• Where Will Program Work? (Adoption and
  Representativeness)
• How Consistently is Program Delivered?
  (Implementation)
• How Long Will Effects Last? (Maintenance)

Dzewaltowski, Glasgow, Klesges, Estabrooks, Brock
(2004) Ann Beh Med 28(2)235-245
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More Complex Dissemination Questions

• What parts of the protocol are less applicable or
  not consistently implemented?
• How does success come about at multiple levels?
• How much does it cost, what types of costs, and
  how does the value produced compare to
  alternative uses?
• What factors influence adaptation,
  implementation, and institutionalization?

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The 3 Rs of Dissemination Research
Representativeness who participates at patient,
setting, and staff levels
Robustness are results replicable across
subgroups of - settings (large vs small high
vs low resource) - patients (high vs. low
literacy race/ ethnicity)
Re-Invention how is program modified and
adopted over time?
Rotheram-Borus, et al (2004) Interventions that
are CURRESIn Facilitating pathways
Care, treatment, and preventionNew York,
Springer. Rogers, E.M. (2003) Diffusion of
Innovations (5th Edition) New York Free Press
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NEW RE-AIM METRICS

• 1) Individual Level Impact (RE) Reach x
  Composite Effectiveness
• a) Reach Participation rate
• Median ES differential characteristics
• b) Composite Effectiveness
• Median ESkey outcomes - Median
• ESnegative outcomes/QOL Median
• ES differential impact

Glasgow, et al. (2006) Evaluating the Overall
Impact of Health Promotion Programs Health
Education Research, In press.
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NEW RE-AIM METRICS

• 2) Efficiency
• Cost of Intervention (over control)
• Reach x Composite Effectiveness
• 3) Setting Level Impact (AI)
• Adoption x Implementation
• Multi-level Adoption (rate and robustness at
  setting and clinician levels) x Composite
  Implementation

Glasgow, et al. (2006) Evaluating the Overall
Impact of Health Promotion ProgramsHealth
Education Research, In press.
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If we want more evidence-based practice, we need
more practice-based evidence. L. W. Green, 2004