See the article below.
Ironically, the NIH reported on this fact over 20 years ago…
It Takes an Average of 17 Years for Evidence to Change Practice—the Burgeoning Field of Implementation Science Seeks to Speed Things Up
JAMA. Published online April 5, 2023. doi:10.1001/jama.2023.4387
Colorectal cancer screening with an at-home stool test is more convenient than with a colonoscopy, but an abnormal result on the former still requires a follow-up with the latter.
However, studies have shown that in safety-net health care systems, only around half of patients with an abnormal at-home stool test result get a follow-up colonoscopy within a year, University of Washington gastroenterologist Rachel Issaka, MD, MAS, noted in an interview with JAMA.
Issaka, not surprisingly, would like to raise that proportion. To accomplish her goal, she needed to find out why people were skipping their follow-up colonoscopy and what might help change their behavior and, possibly, save their life.
So she turned to the relatively new field of implementation science.
Put simply, “implementation science is really trying to close that gap between what we know and what we do,” Issaka explained. Or, as the National Cancer Institute’s David Chambers, DPhil, described his field, “implementation science is about bringing the best possible care to everyone.”
Chasm might be a better word to describe the gap between research and practice. A frequently cited estimate puts that gap at 17 years on average, and even then, only 1 in 5 evidence-based interventions make it to routine clinical practice.
“To some degree, the interventions do vary greatly in terms of their complexity,” Chambers acknowledged in an interview. “Some interventions may be easier to administer.”
In historically marginalized populations, the evidence-to-practice gap is often even more yawning, said general internist Nathalie Moise, MD, MS, director of implementation science research at Columbia University’s Center for Behavioral Cardiovascular Health.
“The hope of implementation science is that we can synthesize what works for whom and for where and for what disease and close that 17-year gap,” Moise told JAMA.
Implementing and “Deimplementing”
Clinical psychologist Rinad Beidas, PhD, was puzzled when she saw children with anxiety who weren’t receiving the standard treatment of cognitive behavioral therapy. “Why aren’t clinicians in the community using evidence-based practices?”
But her “light bulb moment” came after the death of someone close to her by suicide with a firearm and the birth of her son, Beidas recalled in an interview. She was surprised that her child’s pediatrician never asked whether she had a firearm in her home and, if so, how it was stored, even though the American Academy of Pediatrics recommended that pediatricians do so.
Her personal experience led Beidas to become the principal investigator for the ASPIRE trial, which stands for Adolescent and Child Suicide Prevention in Routine Clinical Encounters.
The aim of the trial is to determine the most effective way to implement a National Institute of Mental Health–funded, evidence-based firearm storage program in pediatric primary care. Pediatricians are supposed to deliver the program, which is endorsed by the American Academy of Pediatrics, during well-child visits. Families receive counseling about preventing children from handling firearms without a parent’s permission and are offered a free cable lock for safe storage.
ASPIRE is just one example of how implementation science has been developing steadily in recent years, said Beidas, chair of the Department of Medical Social Sciences at the Feinberg School of Medicine at Northwestern University. The journal Implementation Science, of which she is an associate editor, was launched in 2006, and the National Institutes of Health (NIH) held its first conference on the subject in 2007, she said.
“The reason I came to Feinberg is because they wrote it into their strategic plan,” noted Beidas, who joined the Northwestern faculty in 2022 after serving as founding director of the University of Pennsylvania Implementation Science Center.
Using electronic health record documentation, the ASPIRE pilot study, published in December 2022, found that pediatricians were more likely to deliver the firearm storage program to non-Hispanic White patients and their families than to those in other racial groups. In addition, some clinicians were more likely to deliver the program to parents of boys than of girls.
Beidas’ team recently completed the expanded ASPIRE trial, in which they compared 2 implementation approaches. Both involved a “nudge,” or prompt, from an electronic health record during the pediatrician visit, but 1 added a trained professional to teach physicians how to deliver the firearms safety program.
Narrowing the gap between research and practice also sometimes entails “deimplementing” overused practices.
For example, although 3 national guidelines discourage the use of continuous pulse oximetry monitoring of children hospitalized with bronchiolitis who aren’t receiving supplemental oxygen, the practice remains prevalent, Beidas and her coauthors noted in a recent article.
Continuously monitoring hospitalized patients with the common viral respiratory illness who are breathing room air may identify brief, self-limited periods of lower oxygen saturation that don’t require treatment, they wrote. Monitoring such children is associated with increased oxygen administration, prolonged hospital stays, and unnecessary monitor alarms. The article described the study protocol for Eliminating Monitor Overuse, a clinical trial comparing 2 deimplementation strategies at multiple hospitals around the US.
Funding agencies increasingly have been issuing requests for implementation science proposals. Both the NIH’s National Heart, Lung, and Blood Institute (NHLBI) and National Cancer Institute (NCI) have arms devoted to implementation science, and the NCI has established the Implementation Science Centers in Cancer Control Network.
Lost in Translation
Many effective treatments lose something in translation to the real world.
For example, some evidence-based psychotherapeutic interventions require 6, 12, or 18 sessions, a commitment that may be impractical for many patients, Chambers noted.
He offered another illustration: “Colorectal cancer screening is a great example of where there are multiple modalities and good guidelines,” but, “particularly in certain areas of the country, there are inequities in screening rates.”
Data from the US Centers for Disease Control and Prevention (CDC) and other sources suggest that colorectal cancer screening rates vary from county to county, Chambers explained. “Context matters” when it comes to figuring out how to shrink the gap between evidence and practice, he said, because the reasons for low screening rates may vary from one community to another.
That’s why implementation scientists seek input from community members and patients as well as from health systems, physicians, and policy makers. By waiting to do so until after all the research on efficacy has been completed, though, “we’re actually setting ourselves up for failure,” Beidas said.
So-called hybrid studies, such as the ASPIRE trial, investigate both the effectiveness of an intervention and its implementation. Dave Clark, DrPH, MPH, chief of the NHLBI’s implementation science branch, is working on one such study, the Maternal Health Community Implementation Project (MHCIP), which is testing community-based implementation strategies to increase the use of evidence-based interventions for improving maternal health.
The NIH has funded 4 MHCIP community coalitions, made up of research organizations and community partners such as regional WIC—Special Supplemental Nutrition Program for Women, Infants, and Children—clinics in Georgia, Louisiana, and New York, Clark said in an interview. “We asked for communities that had very disproportionately high morbidity and mortality.”
Involving partners such as the WIC clinics—“we wanted to go where the target audience is”—helps ensure “that we’re not just dictating to people but making sure we’re working with them as partners,” Clark explained.
COVID Has Highlighted the Need
Data show that lifesaving vaccines and treatments for COVID-19 aren’t being used as widely as they should be. Although clinical trials have demonstrated that the vaccines reduce the risk of serious illness, hospitalization, and death, nearly 31% of the US population have not completed their primary series of shots, according to the CDC.
In addition, a January Nature news article reported that US physicians have prescribed Paxlovid (a combination of nirmatrelvir and ritonavir) to only 13% of people with new COVID-19 cases, even though studies have shown that treatment with the antiviral drug reduces the chance of hospitalization or death among high-risk individuals who start it within 3 days of symptom onset.
“For me, COVID really highlights the fact that implementation science should be a thing,” Beidas said.
She pointed to a November 2021 editorial in Science about the gap between research and practice in preventing and treating COVID-19. The editorial, she said, “suggests implementation science is on the map.”
“COVID-19 has shown the world that ‘knowing what to do’ does not ensure ‘doing what we know,’” wrote the editorial’s authors, implementation science pioneer Enola Proctor, PhD, a professor emerita of social work, and infectious disease specialist Elvin Geng, MD, MPH, director of the Center for Dissemination and Implementation at the Institute for Public Health, both at Washington University in St Louis.
“There is no better time for science to establish a new lane, one devoted to ensuring that our nation’s health discoveries are used to improve population health,” they wrote. Quoting another often-cited statistic, Proctor and Geng noted that in the US, people receive only about 55% of clinical interventions known to benefit their health. They called for the NIH to support networks for implementation research similar to the AIDS Clinical Trials Group and to devote at least 10% of its budget to this work.
Early in the pandemic, authors from the University of Washington and the King County and Washington state health departments wrote about how implementation science could be used to expand effective uptake of evidence-based COVID-19 interventions, including face masks and ventilation.
Implementation science, they argued, and “public health, medical, and governmental communities can work together to inform a stronger response to the COVID-19 pandemic.”
Two-and-a-half years after that perspective piece was published, though, coauthor Bryan Weiner, PhD, told JAMA that “there’s a real missed opportunity” for implementation science in the COVID-19 response.
“The science is often clouded out by the misinformation and disinformation that goes on,” said Weiner, a professor in the departments of global health and health services at the University of Washington.
Getting Treatments to Patients
Monoclonal antibody treatments for COVID-19 first became available in the US in November 2020. Currently, none are authorized to treat the disease because they’re ineffective against the SARS-CoV-2 Omicron subvariants now circulating in the US. When they still worked, though, clinical trials and real-world experience showed that the intravenous infusions reduced hospitalizations for high-risk patients with COVID-19 by 70% to 80%.
The problem was that these highly effective treatments weren’t being used, especially among members of racial and ethnic minorities.
“We don’t know that it’s due to explicit racism,” Bethany Kwan, PhD, MSPH, a social psychologist at the University of Colorado School of Medicine, noted in an interview. “It’s more the underlying system.”
To illustrate her point, she referred to a rumor circulating in Colorado that the state was going to set up a lottery system for distributing monoclonal antibodies. Although that was never the plan, both physicians and patients believed it to be true, so they didn’t bother trying to get the treatment, she said. Another common misconception was that only the “rich and famous,” like then-President Donald Trump, could access monoclonal antibodies, Kwan said.
“Once people develop an attitude or belief about something, it’s really hard to change,” Kwan noted.
To learn why patients weren’t being referred to treatment with neutralizing monoclonal antibodies or were having trouble accessing it, she and her coauthors interviewed 38 frontline clinicians with experience caring for outpatients with COVID-19.
Sure enough, the researchers found that a persistent belief that monoclonal antibodies were in short supply hindered referrals. Given what the clinicians said, “simplifying patient access by linking testing with delivery of treatments that reduce morbidity and mortality will be critical for the ongoing response to COVID-19 and in future pandemics,” Kwan and her coauthors wrote in the journal Medicine.
To ensure more equitable use of monoclonal antibodies, they developed a model in which an urgent care center administered the treatment. Part of Denver’s safety-net health system, the center was located at the intersection of 4 neighborhoods with high concentrations of medically underserved people.
The Denver safety-net health system worked with the state public health department to maintain a stable supply of monoclonal antibodies, and eligible patients who tested positive on a rapid test were immediately offered the treatment. Over 17 months, approximately 2500 patients received monoclonal antibodies, and the percentages who were Black or Hispanic patients were comparable with the demographics of those who had tested positive for COVID-19 in the country, Kwan and her coauthors recently reported.
Because monoclonal antibodies currently aren’t authorized to treat COVID-19, “the systems for delivering treatments are no longer relevant,” Kwan acknowledged. “The main thing that is still being used in Colorado that came out of this process is the concept of test to treat.”
The NIH–funded Colorado COVID-19 Community Engagement Alliance is now talking to people in the state about why they haven’t gotten the bivalent vaccine, she said. In late March, the percentage of Coloradans who’d received the shot stood at almost 28%—considerably higher than the 16.4% of the overall US population but still less than a third of Colorado residents.
One reason for the low uptake has been a lack of awareness, due in part to the vaccine’s name, Kwan said. “The bivalent?” some Coloradans have asked. “What in the world does that mean?”
A Step-by-Step Science
The pandemic has highlighted the need for implementation science in multiple areas of health care, not only for COVID-19.
“A lot of implementation happens in primary care,” Columbia’s Moise, first author of a recent American Heart Association statement on using implementation science to reduce cardiovascular disease disparities, said in an interview. “Clinics have been overwhelmed by COVID-19. It becomes really tough to follow guidelines.” Plus, she added, “there are a lot of competing priorities making it really difficult.”
For example, guidelines recommend that patients with cardiovascular disease be screened and, if necessary, treated for depression, a condition that leads to poorer outcomes in this population. The NIH and other funders have long recognized and invested heavily in understanding the link between depression and heart disease and effective interventions, Moise said.
Studies have found that up to 1 in 5 people with cardiovascular disease screen positive for depression, she said. Patients with depression are more likely to smoke, not exercise, and eat an unhealthful diet—all cardiovascular disease risk factors.
But, as Moise and her coauthors noted in a recent article, few patients with cardiovascular disease receive optimal treatment for depression. They’re even less likely than individuals without cardiovascular disease to receive treatment for their depression, even though interventions such as antidepressants, cognitive behavioral therapy, and cardiac rehabilitation have all been shown to be effective, Moise said.
Using implementation and behavioral science methods, she and her colleagues identified common barriers to depression screening and treatment for patients with cardiovascular disease. They developed a strategy called “iHeart DepCare” to minimize those barriers that they are now evaluating in a hybrid effectiveness-implementation trial at a dozen clinics.
“Implementation science is very step by step,” explained Moise, who earned a certificate in the field at the University of California, San Francisco. “You see this gap, and then you do all this quality work to see why it’s not happening.”
The iHeart DepCare tool features animated YouTube videos, in English and in Spanish, to help patients understand that they shouldn’t feel embarrassed about depression and that it could lead to a worsening of their cardiovascular disease if left untreated. “Not everybody’s ready” to be screened and treated for depression, Moise said, but if they are, their physicians are alerted.
Such tools aren’t enough, though, Moise pointed out. “You still need to change the health care system,” by, for example, reducing the long wait times patients might encounter when trying to schedule an appointment for a mental health specialist.
For Lack of a Ride
University of Washington gastroenterologist Issaka and her collaborators asked patients, clinicians, and other stakeholders about barriers to follow-up colonoscopy after an abnormal stool test result, and possible fixes. They heard a variety of reasons, including fear about the procedure and difficulty navigating complex health systems.
For some, though, the main obstacle was getting a ride home after a colonoscopy. “For people who lack social connection, transportation is a significant barrier,” Issaka explained. Because most people are sedated for a colonoscopy, they can’t drive themselves home afterward or take a bus, she noted.
“I do think that White, high socioeconomic clinicians just have no clue that there are people out there who lack transportation options,” said Issaka’s University of Washington colleague Weiner, who collaborated on the research.
Their findings led to the design of a pilot program that enables the colonoscopy health care team to arrange nonemergency medical transportation for patients screened at Harborview Medical Center, a safety-net health care system, and track their ride home. A member of the health care team makes sure patients get into the rideshare vehicle safely. The Washington State Healthcare Authority signed a contract with a rideshare company last summer, and for now, a grant covers the cost of the trips.
The program focuses on patients who’ve already shown they’re interested in screening because they took the effort to get a stool test, Issaka said, but it could also be beneficial for patients whose primary screening is a colonoscopy.
If the pilot study proves the intervention to be safe, acceptable, and feasible, Issaka would like to expand it to other outpatient procedures that require sedation, such as lung cancer screening that leads to a biopsy.
Because data from the pilot study have not yet been published, Issaka said she could not share how many patients have gotten a ride. She did say that when asked afterward about their experience, every single one said they would recommend it. “Many have said they would not have done their colonoscopy had it not been for this program.”
