From Research to Daily Clinical Practice: What Are the Challenges in “Translation”?

Multiple predictively equivalent risk models for handling missing data at time of prediction: With an application in severe hypoglycemia risk prediction for type 2 diabetes

The presence of missing data at the time of prediction limits the application of risk models in clinical and research settings. Common ways of handling missing data at the time of prediction include measuring the missing value and employing statistical methods. Measuring missing value incurs additional cost, whereas previously reported statistical methods results in reduced performance compared to when all variables are measured. To tackle these challenges, we introduce a new strategy, the MMTOP algorithm (Multiple models for Missing values at Time Of Prediction), which does not require measuring additional data elements or data imputation. Specifically, at model construction time, the MMTOP constructs multiple predictively equivalent risk models utilizing different risk factor sets. The collection of models are stored and to be queried at prediction time. To predict an individual's risk in the presence of incomplete data, the MMTOP selects the risk model based on measurement availability for that individual from the collection of predictively equivalent models and makes the risk prediction with the selected model. We illustrate the MMTOP with severe hypoglycemia (SH) risk prediction based on data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study. We identified 77 predictively equivalent models for SH with cross-validated c-index of 0.77 ± 0.03. These models are based on 77 distinct risk factor sets containing 12-17 risk factors. In terms of handling missing data at the time of prediction, the MMTOP outperforms all four tested competitor methods and maintains consistent performance as the number of missing variables increase.

The Logic Behind a Multimethod Intervention to Improve Adherence to Clinical Practice Guidelines in a Nationwide Network of Primary Care Practices

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Assessing organizational readiness for depression care quality improvement: relative commitment and implementation capability

Background

Depression is a major cause of morbidity and cost in primary care patient populations. Successful depression improvement models, however, are complex. Based on organizational readiness theory, a practice’s commitment to change and its capability to carry out the change are both important predictors of initiating improvement. We empirically explored the links between relative commitment (i.e., the intention to move forward within the following year) and implementation capability.

Methods

The DIAMOND initiative administered organizational surveys to medical and quality improvement leaders from each of 83 primary care practices in Minnesota. Surveys preceded initiation of activities directed at implementation of a collaborative care model for improving depression care. To assess implementation capability, we developed composites of survey items for five types of organizational factors postulated to be collaborative care barriers and facilitators. To assess relative commitment for each practice, we averaged leader ratings on an identical survey question assessing practice priorities. We used multivariable regression analyses to assess the extent to which implementation capability predicted relative commitment. We explored whether relative commitment or implementation capability measures were associated with earlier initiation of DIAMOND improvements.

Results

All five implementation capability measures independently predicted practice leaders’ relative commitment to improving depression care in the following year. These included the following: quality improvement culture and attitudes (p = 0.003), depression culture and attitudes (p <0.001), prior depression quality improvement activities (p <0.001), advanced access and tracking capabilities (p = 0.03), and depression collaborative care features in place (p = 0.03). Higher relative commitment (p = 0.002) and prior depression quality improvement activities appeared to be associated with earlier participation in the DIAMOND initiative.

Conclusions

The study supports the concept of organizational readiness to improve quality of care and the use of practice leader surveys to assess it. Practice leaders’ relative commitment to depression care improvement may be a useful measure of the likelihood that a practice is ready to initiate evidence-based depression care changes. A comprehensive organizational assessment of implementation capability for depression care improvement may identify specific barriers or facilitators to readiness that require targeted attention from implementers.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0173-1) contains supplementary material, which is available to authorized users.

Tobacco cessation counseling training in US entry-level physical therapist education curricula: prevalence, content, and associated factors

BACKGROUND

The US Public Health Service (USPHS) recommends tobacco cessation counseling (TCC) training for all health care professionals. Within physical therapist practice, smoking can have adverse effects on treatment outcomes in all body systems. In addition, people with physical disabilities have a higher smoking prevalence than the general population, creating a strong need for tobacco cessation among physical therapy clientele. Therefore, TCC training is an important component of entry-level physical therapist education.

OBJECTIVE

The aims of this study were: (1) to determine need for TCC training within entry-level physical therapist education and (2) to identify potential barriers to implementation of USPHS guidelines in the academic environment.

DESIGN

A descriptive cross-sectional survey was conducted.

METHODS

Directors or academic coordinators of clinical education from entry-level physical therapist programs (N=204) were surveyed using an online instrument designed specifically for this study. Data regarding program and faculty characteristics, tobacco-related training content, and faculty opinions toward TCC in both physical therapist practice and education were analyzed descriptively.

RESULTS

The response rate was 71%. A majority (60%) of programs indicated inclusion of tobacco-related training, most commonly 1 to 2 hours in duration, and of these programs, 40% trained students in the implementation of USPHS clinical guidelines for TCC.

LIMITATIONS

Data analyses were constrained by limited or missing data in some areas. A single faculty member completed the survey for each program.

CONCLUSIONS

There is a need for TCC training in entry-level physical therapist education. Inclusion may be facilitated by addressing perceived barriers toward TCC as a component of physical therapist practice and promoting the relevance of TCC as it relates to intended outcomes of physical therapy interventions.

Statistical Power of Alternative Structural Models for Comparative Effectiveness Research: Advantages of Modeling Unreliability

The advantages of modeling the unreliability of outcomes when evaluating the comparative effectiveness of health interventions is illustrated. Adding an action-research intervention component to a regular summer job program for youth was expected to help in preventing risk behaviors. A series of simple two-group alternative structural equation models are compared to test the effect of the intervention on one key attitudinal outcome in terms of model fit and statistical power with Monte Carlo simulations. Some models presuming parameters equal across the intervention and comparison groups were underpowered to detect the intervention effect, yet modeling the unreliability of the outcome measure increased their statistical power and helped in the detection of the hypothesized effect. Comparative Effectiveness Research (CER) could benefit from flexible multi-group alternative structural models organized in decision trees, and modeling unreliability of measures can be of tremendous help for both the fit of statistical models to the data and their statistical power.

Roles of managers, frontline staff and local champions, in implementing quality improvement: stakeholders' perspectives

BACKGROUND

Translating promising research findings into routine clinical care has proven difficult to achieve; even highly efficacious programmes remain unadopted. Critical to changing care is an understanding of the context within which the improvement effort occurs, including the climate or culture. Health care systems are multicultural due to the wide variety of professionals, subgroups, divisions and teams within them. Yet, little work describes and compares different stakeholders' views on their and others' roles in promoting successful quality improvement implementation.

OBJECTIVE

To identify manager and frontline staff perspectives about which organizational stakeholders should play a role in implementation efforts as well as what implementation roles these stakeholders should perform.

METHODS

We conducted qualitative semi-structured interviews of a purposive sample of stakeholders at the clinic, medical centre and regional network levels. Participants included stakeholders across five clinics (n = 49), their four affiliated medical centres (n = 12) and three regional networks (n = 7). Working in coding teams, we conducted a content analysis utilizing Atlas.ti Version 5.

RESULTS

According to informants, individuals at each organizational level have unique and critical roles to play in implementing and sustaining quality improvement efforts. Informants advocated for participation of a wide range of organizational members, described distinct roles for each group, and articulated the need for and defined the characteristics of frontline programme champions.

CONCLUSIONS

Involvement of multiple types of stakeholders is likely to be costly for health care organizations. Yet, if such organizations are to achieve the highest quality care, it is also likely that such involvement is essential.

Quality improvement as a tool for translating evidence based interventions into practice: what the youth violence prevention community can learn from healthcare

Health care has been working for the past 2 decades to improve the translation of evidence based practice (EBPs) into care. The strategies used to facilitate this, and lessons learned, can provide useful models for similar work taking place in youth violence prevention. This article discusses the history of evidence translation in health care, reviews key strategies used to support translation of evidence based practice into care, and suggests lessons learned that may be useful to similar efforts in youth violence prevention and intervention services.

Using Implementation and Dissemination Concepts to Spread 21st-century Well-Child Care at a Health Maintenance Organization

We describe here the use of a conceptual framework for implementing and disseminating in a Health Maintenance Organization an evidence-based model of well-child care (WCC) that includes developmental and preventive services recommended by the American Academy of Pediatrics. Twenty-first Century WCC is a parent-centered, team-based, primary care model that combines online previsit assessments-completed by parents and caregivers regarding clinic-based weight, growth, and development assessments-with vaccinations and anticipatory guidance. Nurses, nurse practitioners, developmental specialists, and pediatricians all play roles in the WCC model. Patient and clinician interaction, health records, and resources are all facilitated through a Web-based diagnostic, management, tracking, and resource information tool. Implementation and dissemination concepts and their attendant practices and tools can reliably be used to augment strategic decisions about how to best disseminate and implement innovations in health care delivery. Unlike innovations that are embedded only in technical systems, validated models of team-based health care have multiple components that must be made compatible with complex sociotechnical systems. Interpersonal communication, work, coordination, and judgment are key processes that affect implementation quality. Implementation can involve tailoring to a particular site and customizing either the model or the organizational context to accommodate it.

Creating a quality-improvement dialogue: utilizing knowledge from frontline staff, managers, and experts to foster health care quality improvement

There is a growing consensus that a hybrid of two common approaches to quality improvement (QI), local participatory QI and expert QI, might be the best method for achieving quality care. Achieving such a hybrid requires that content experts establish an ongoing dialogue with both frontline staff members and managers. In this study we examined frontline staff members' and managers' preferences regarding how to conduct such a dialogue, and we provide practical suggestions for implementation. The two groups shared a number of preferences (e.g., verbal face-to-face exchanges, discussions focused on quality of care). There were also some differences. For example, although managers were interested in discussions of business aspects (e.g., costs), frontline staff members were concerned with workload issues. Finally, although informants acknowledged that engaging in a QI dialogue was time consuming, they also believed it was essential if health care organizations are to improve the quality of care they provide.

Evidence Locator: sources of evidence-based dentistry information

Multiple resources are available to help practitioners access the latest scientific evidence. Evidence-based dentistry (EBD) is an approach to clinical decision making that incorporates the most current and comprehensive scientific evidence with the practitioner's judgment and the patient's needs and preferences. One challenge in implementing this approach is access to evidence, and there are multiple online resources that can be used in this endeavor. This article presents the Evidence Locator, a list of Web sites that provide access to "secondary sources" of evidence. Such "secondary sources" are typically summaries of systematic reviews and evidence-based clinical recommendations or guidelines. Also presented is a list of other Web sites that may be useful to the practitioner in implementing EBD.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice

OBJECTIVE

To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.

DATA SOURCES/STUDY SETTING

We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.

STUDY DESIGN

In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.

DATA COLLECTION

To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.

PRINCIPAL FINDINGS

Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.

CONCLUSIONS

EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Applying Five Key Success Factors to Optimize the Quality of Care for Patients Hospitalized With Coronary Artery Disease

Quality improvement (QI) efforts aimed at optimizing adherence to coronary artery disease quality indicators are helping to bridge the serious gaps in the quality of care for this population. Motivation for these initiatives is prompted by a number of sources, including the public reporting of hospitals' adherence to these indicators found on the Center for Medicare and Medicaid Services Web site. Although complex barriers challenge QI efforts, results of recent studies demonstrate that the use of five key success factors reduces these barriers and accelerates improvement. Integral components of this model include administrative support that cultivates a blameless culture that strives for perfection; committed and respected champions; goals that are shared within the organization; the use of timely, credible data at the organizational and individual levels; and implementation of a QI initiative tailored to the complexity of the project. In this review article, the authors discuss how quality of care is measured, provide examples of successful QI programs, and describe how the use of a QI model composed of five key success factors can accelerate QI efforts and optimize the care of patients hospitalized with coronary artery disease.

Challenges to improving chronic disease care and training in residencies

PURPOSE

To improve quality of care for chronic disease, professional organizations and medical providers are adopting new care models. The transition to better delivery systems is not easy and there are many barriers under the best of circumstances. This study investigated residency-based experiences with changes in teaching and delivery of chronic disease care.

METHOD

In 2004-05 at the University of Southern California, the authors conducted qualitative cross-sectional in-depth interviews with directors of grant-funded residency-based chronic care projects. Open- and closed-ended questions explored the intent of and the challenges encountered by primary care residencies implementing improvements in chronic disease care and training.

RESULTS

Six out of 14 program director responded, reporting that rotation-based and longitudinal experiences were used to teach and deliver improved chronic disease care. Common challenges were identified across residency sites, as well as challenges unique to particular residency settings. Among these challenges were engaging faculty and residents who spend limited time in the practice center, as well as institutional barriers related to authority, competing priorities, process, and resources.

CONCLUSIONS

Successful innovations for chronic disease care and training are possible in residencies, but their implementation cannot be taken lightly. There are predictable barriers that can be dealt with locally, but also others that would benefit from coordinated national attention.

Transitional care: a critical dimension of the home healthcare quality agenda

Focusing on the critical transitions of patients and their caregivers across healthcare settings and among providers is a promising approach to enhancing care coordination and improving quality. This article describes the research base for the transitional care of older adults and offers recommendations to advance the science, translate best practices into home healthcare settings, and improve the transitions of high-risk older adults to and from home healthcare. Home healthcare is a component of the healthcare industry uniquely positioned to improve transitional care and outcomes for the growing population of older adults with continuous complex needs.

Primary care practice-based research networks: working at the interface between research and quality improvement

PURPOSE

We wanted to describe the emerging role of primary care practice-based in research, quality improvement (QI), and translation of research into practice (TRIP).

METHODS

We gathered information from the published literature, discussions with PBRN leaders, case examples, and our own personal experience to describe a role for PBRNs that comfortably bridges the gap between research and QI, discovery and application, academicians and practitioners--a role that may lead to the establishment of true learning communities. We provide specific recommendations for network directors, network clinicians, and other potential stakeholders.

RESULTS

PBRNs function at the interface between research and QI, an interface called TRIP by some members of the research community. In doing so, PBRNs are helping to clarify the difficulty of applying study findings to everyday care as an inappropriate disconnect between discovery and implementation, research and practice. Participatory models are emerging in which stakeholders agree on their goals; apply their collective knowledge, skills, and resources to accomplish these goals; and use research and QI methods when appropriate.

CONCLUSIONS

PBRNs appear to be evolving from clinical laboratories into learning communities, proving grounds for generalizable solutions to clinical problems, and engines for improvement of primary care delivery systems.

Strategies for increasing adherence to clinical guidelines and improving patient outcomes in small primary care practices

BACKGROUND

The best way to get research findings into practice needs to be determined, particularly in small practices. The Practice Partner Research Network (PPRNet) is a nationwide practice-based research network of small primary care practices that use the same electronic medical record (EMR). Between 2000-2003 the PPRNet Translating Research into Practice (TRIP) project tested a multimethod intervention to help practices improve primary and secondary prevention of cardiovascular disease and stroke. Intervention sites each hosted six to seven site visits and participated in two annual network meetings during the two-year intervention period. A model describing practice-based improvement strategies was validated using prospective data from 10 intervention and 9 control sites.

RESULTS

The model consisted of five categories of improvement strategies: Prioritize Performance, Involve All Staff, Redesign Delivery Systems, Activate Patients, and Use EMR Tools. PPRNet-TRIP intervention practices used more of the model items than did controls (69% versus 48%, p = .053), as did high-performing practices versus mid-range or low performers (81% versus 39% versus 46%, p = .001).

CONCLUSION

The PPRNet-TRIP Improvement Model might guide small practices in their efforts to translate research into practice and improve care outcomes.