Dissemination and implementation science activities across the Clinical Translational Science Award (CTSA) Consortium: Report from a survey of CTSA leaders

Advancing Translation of Clinical Research Into Practice and Population Health Impact Through Implementation Science

Translational and implementation sciences aim to prioritize and guide efforts to create greater efficiency and speed of scientific innovation across the translational science continuum to improve patient and population health. Key principles and practices rooted in translational and implementation science may be incorporated into clinical trials research, particularly pragmatic trials, to improve the relevance and impact of scientific innovation. This thematic review intends to raise awareness on the value of translational and implementation science in clinical research and to encourage its use in designing and implementing clinical trials across the translational research continuum. Herein, we describe the gap in translating research findings into clinical practice, introduce translational and implementation science, and describe the principles and practices from implementation science that can be used in clinical trial research across the translational continuum to inform clinical practice, to improve population health impact, and to address health care inequities.

Mixed methods evaluation of the inaugural year of the Cancer Prevention and Control Research Network's (CPCRN) scholars program

PURPOSE

A diverse workforce trained in dissemination & implementation (D&I) science is critical for improving cancer outcomes and reducing cancer-related health disparities. This study aims to describe and evaluate impact of the Cancer Prevention and Control Research Network (CPCRN) Scholars Program in preparing scholars for collaborative careers in cancer control and implementation research and practice, and offers evaluation-driven recommendations for program improvements.

METHODS

The CPCRN Scholars Workgroup conducted a sequential, mixed methods evaluation. We collected baseline and follow-up surveys and invited all 20 scholars and ten mentors to participate in an exit interview. We assessed the experience with the Scholar's program, ratings of D&I competences, progress on their project, feedback about the curriculum, and understanding of implementation science.

RESULTS

Over 86% partially or fully completed their project within 9 months; 78% of scholars engaged with a CPCRN workgroup. Scholars rated the following program components as valuable: the Putting Public Health Evidence in Action (PPHEIA) training (88.9%), D&I training modules (83.3%), and webinars (kickoff webinar-88.9% and selecting theories/models-88.9%). There was an increase in D&I competencies from baseline to posttest, with the greatest in community engagement topics. About 78% reported that they were satisfied with format of the activities and increased confidence in ability to discuss D&I concepts. From the qualitative interviews, the benefit of the program was becoming more knowledgeable about D&I research and networking.

CONCLUSION

The inaugural year of the program yielded positive results, particularly related to increasing knowledge about D&I science and cancer control. This program builds the capacity of students, researchers and practitioners in D&I science.

Un-Meetings as tools for translational idea generation: A semantic content analysis of an Opioid Crisis Un-Meeting

Background

Team development and idea generation are key intertwined steps in translational science that need a framework to accommodate unstructured, participatory interactions. To this end, we introduced Un-Meetings to the Clinical and Translational Science Awards (CTSA) Program, innovative events that facilitate cross-disciplinary idea generation and informal discussions between translational scientists, policy makers, community members, advocates, and public health professionals. Here we describe a mixed methods study to characterize the conceptual diversity and clusterization of ideas generated through an Opioid Crisis Un-Meeting.

Methods

An Un-Meeting targeting translation science approaches to the opioid crisis were hosted at the University of Rochester Center for Leading Innovation and Collaboration (CLIC). We used semantic analysis and conceptual mapping of keywords to analyze how attendee-led idea generation sessions identified topics for breakout discussions.

Results

One hundred and two individuals from 40 institutions proposed 150 unique ideas that were grouped into 23 breakout sessions. Network analysis showed that diverse pools of experts were bridged by topics addressing the complexities of the opioid crisis. Two clusters emerged: (1) systems, contexts, and community engagement, and (2) technologies, innovations, and treatment advancements.

Conclusions

The cross-disciplinary nature of topic areas that bridge across thematic communities provide opportunities for CTSA programs to engage and support development of diverse translational teams. Potential opportunities for team building include technological advancements of opioid prevention, treatment, surveillance, systems approaches, and studies focusing on special populations and health disparities. The analysis method here may be useful in identifying naturally emerging teams of experts and community gaps when addressing large problems.

Integrating community engagement with implementation science to advance the measurement of translational science

This special communication provides an approach for applying implementation science frameworks to a Clinical and Translational Science Institutes (CTSIs) community engagement (CE) program that measures the use of implementation strategies and outcomes that promote the uptake of CE in research. Using an iterative multi-disciplinary group process, we executed a four-phased approach to developing an evaluation plan: 1) creating an evaluation model adapted from Proctor's conceptual model of implementation research; 2) mapping implementation strategies to CTSI CE program interventions that support change in research practice; 3) identifying and operationalizing measures for each strategy; and 4) conducting an evaluation. Phase 2 employed 73 implementation strategies across 9 domains generated by the Expert Recommendations for Implementing Change project. The nine domains were used to classify each CE program implementation strategy. In Phase 3, the group used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to define measures for each individual strategy. Phase 4 demonstrates the application of this framework and measures Year 1 outcomes for the strategy providing interactive assistance, which we implemented using a centralized consultation model. This approach can support the CTSA program in operationalizing CE program measurement to demonstrate which activities and strategies may lead to benefits derived by the program, institution, and community.

Dissemination and implementation science resources, training, and scientific activities provided through CTSA programs nationally: Opportunities to advance D&I research and training capacity

Introduction

Clinical and Translational Science Award (CTSA) Program hubs are well-positioned to advance dissemination and implementation (D&I) research and training capacity nationally, though little is known about what D&I research support and services CTSAs provide. To address this gap, the CTSA Dissemination, Implementation, and Knowledge Transfer Working Group conducted an environmental scan of CTSAs (2017-2018).

Methods

Of 67 CTSA institutions, we contacted 43 that previously reported delivering D&I research services. D&I experts from these institutions were emailed a survey assessing D&I resources, services, training, and scientific projects. Responses were categorized and double-coded by study authors using a content analysis approach.

Results

Thirty-five of the 43 D&I experts (81.4%) responded. Challenges to CTSAs in developing and supporting D&I science activities were related to inadequate D&I science workforce (45.7%) and lack of understanding of D&I science (25.7%). Services provided included consultation/mentoring programs (68%), pilot funding/grants (50%), and workshops/seminars/conferences (46%). Training and workforce development in D&I were frequently identified as future priorities. Recommendations included increase training to meet demand (68.6%), accessible D&I tools/resources (34.3%), greater visibility/awareness of D&I methods (34.3%), consultation services (22.9%), and expand D&I science workforce (22.9%).

Conclusions

CTSAs have tremendous potential to support the advancement and impact of D&I science across the translational continuum. Despite the growing presence of D&I science in CTSAs, continued commitment and prioritization are needed from CTSA and institutional leadership to raise awareness of D&I science and its value, meet training demands, and develop necessary infrastructure for conducting D&I science.

A network analysis of dissemination and implementation research expertise across a university: Central actors and expertise clusters

Background:

Although dissemination and implementation (D&I) science is a growing field, many health researchers with relevant D&I expertise do not self-identify as D&I researchers. The goal of this work was to analyze the distribution, clustering, and recognition of D&I expertise in an academic institution.

Methods:

A snowball survey was administered to investigators at University of Rochester with experience and/or interest in D&I research. The respondents were asked to identify their level of D&I expertise and to nominate others who were experienced and/or active in D&I research. We used social network analysis to examine nomination networks.

Results:

Sixty-eight participants provided information about their D&I expertise. Thirty-eight percent of the survey respondents self-identified as D&I researchers, 24% as conducting D&I under different labels, and 38% were familiar with D&I concepts. D&I researchers were, on average, the most central actors in the network (nominated most by other survey participants) and had the highest within-group density, indicating wide recognition by colleagues and among themselves. Researchers who applied D&I under different labels had the highest within-group reciprocity (25%), and the highest between-group reciprocity (29%) with researchers familiar with D&I. Participants significantly tended to nominate peers within their departments and within their expertise categories.

Conclusions:

Identifying and engaging unrecognized clusters of expertise related to D&I research may provide opportunities for mutual learning and dialog and will be critical to bridging across departmental and topic area silos and building capacity for D&I in academic settings.

Getting To Implementation (GTI)-Teach: A seven-step approach for teaching the fundamentals of implementation science

Introduction:

Implementation Science (IS) is a complex and rapidly evolving discipline, posing challenges for educators. We developed, implemented, and evaluated a novel, pragmatic approach to teach IS.

Methods:

Getting To Implementation (GTI)-Teach was developed as a seven-step educational model to guide students through the process of developing, conducting, and sustaining an IS research project. During the four-week online course, students applied the steps to self-selected implementation problems. Students were invited to complete two online post-course surveys to assess course satisfaction and self-reported changes in IS knowledge and relevance of GTI-Teach Steps to their work. Results were summarized using descriptive statistics; self-reported post-course changes in IS knowledge were compared using paired t-tests.

Results:

GTI-Teach was developed to include seven Steps: 1. Define the implementation problem; 2. Conceptualize the problem; 3. Prioritize implementation barriers and facilitators; 4. Select and tailor implementation strategies; 5. Design an implementation study; 6. Evaluate implementation; 7. Sustain implementation. Thirteen students, ranging in experience from medical students to full professors, enrolled in and completed the first GTI-Teach course. Of the seven students (54%) completing an end-of course survey, six (86%) were very satisfied with the course. Ten students (77%) responded to the tailored, 6-month post-course follow-up survey. They retrospectively reported a significant increase in their knowledge across all steps of GTI-Teach (1.3–1.8 points on a 5-point Likert scale) and rated each of the Steps as highly relevant to their work.

Conclusions:

GTI-Teach is a seven-step model for teaching IS fundamentals that students reported increased their knowledge and was relevant to their work.

Moving beyond Aim Three: a need for a transdisciplinary approach to build capacity for economic evaluations in implementation science

BACKGROUND

Understanding the costs and economic benefits of implementation has been identified by policymakers and researchers as critical to increase the uptake and sustainment of evidence-based practices, but this topic remains relatively understudied. Conducting team science with health economists has been proposed as a solution to increase economic evaluation in implementation science; however, these recommendations ignore the differences in goals and perspectives in these two fields. Our recent qualitative research identified that implementation researchers predominantly approach health economists to examine costs, whereas the majority of health economists expressed limited interest in conducting economic evaluations and a desire to be more integrated within implementation science initiatives. These interviews pointed to challenges in establishing fruitful partnerships when health economists are relegated to the "Third Aim" (i.e., lowest-priority research objective) in implementation science projects by their research partners.

DISCUSSION

In this debate paper, we argue that implementation researchers and health economists need to focus on team science research principles to expand capacity to address pressing research questions that cut across the two fields. Specifically, we use the four-phase model of transdisciplinary research to outline the goals and processes needed to build capacity in this area (Hall et al., Transl Behav Med 2:415-30, 2012). The first phase focuses on the development of transdisciplinary research teams, including identifying appropriate partners (e.g., considering policy or public health researchers in addition to health economists) and building trust. The conceptual phase focuses on strategies to consider when developing joint research questions and methodology across fields. In the implementation phase, we outline the effective processes for conducting research projects, such as team learning. Finally, in the translation phase, we highlight how a transdisciplinary approach between health economists and implementation researchers can impact real-world practice and policy. The importance of investigating the economic impact of evidence-based practice implementation is widely recognized, but efforts have been limited due to the challenges in conducting team science across disciplines. Training in team science can help advance transdisciplinary efforts, which has the potential to increase the rigor and impact of economic evaluations in implementation science while expanding the roles taken by health economists.

Bootstrapping implementation research training: A successful approach for academic health centers

Demand for building competencies in implementation research (IR) outstrips supply of training programs, calling for a paradigm shift. We used a bootstrap approach to leverage external resources and create IR capacity through a novel 2-day training for faculty scientists across the four Texas Clinical & Translational Science Awards (CTSAs). The Workshop combined internal and external expertise, targeted nationally established IR competencies, incorporated new National Institutes of Health/National Cancer Institute OpenAccess online resources, employed well-known adult education principles, and measured impact. CTSA leader buy-in was reflected in financial support. Evaluation showed increased self-reported IR competency; statewide initiatives expanded. The project demonstrated that, even with limited onsite expertise, it was possible to bootstrap resources and build IR capacity de novo in the CTSA community.

Implementation Science to Improve Quality of Neurological Care

Neurological disorders are the leading cause of disability and the second leading cause of death globally. To challenge this enormous disease burden, scientists are pursuing innovative solutions to maintain and improve the quality of neurological care. Despite the availability of many effective evidence-based practices, many patients with neurological disorders cannot access these (or receive them inefficiently after a long delay) and may be exposed to unnecessary, expensive, and potentially harmful treatments. To promote the systematic uptake of evidence-based practices into the real world, a new scientific study of methods has been developed: implementation science. In implementation science research, transdisciplinary research teams systematically (using theory, model, and framework) assess local barriers to facilitate the adoption of evidence-based practices and examine potential solutions using implementation strategies (interventions that help adoption of intended practices) targeting multiple levels in the health care system, including patient, provider, clinic, facility, organization, or broader community and policy environment. The success of these strategies (implementation outcomes) is measured by the extent and quality of the implementation. Implementation studies can be either observational or interventional but are distinct from traditional efficacy or effectiveness studies. Traditional neuroscience research and clinical trials, conducted in controlled settings, focus on discovering new insights with little consideration of translating those insights into the everyday practice of a resource-constrained and dynamic health care system. Thus, neurologists should become familiar with implementation science to reduce the knowledge-practice gap, maximize health care value, and improve management of brain disorders affecting public health.

Integrating dissemination and implementation sciences within Clinical and Translational Science Award programs to advance translational research: Recommendations to national and local leaders

The National Center for Advancing Translational Sciences (NCATS) has defined translation as the process of turning observations into interventions that are adopted, sustained, and improve health. Translation must attend to research and community systems and context at multiple levels, and to key stakeholders. Dissemination and implementation (D&I) sciences are informed by an understanding of the critical role of people and systems in disseminating, adopting, and sustaining innovations within real-world settings. Thus, the D&I sciences provides a set of principles that can guide the translational work of Clinical and Translational Science Award (CTSA) programs from basic research to public health. In this special communication, our cross-domain working group of the CTSA consortium, comprised of experts in methods and processes, workforce development, evaluation, stakeholder engagement, and D&I sciences, share a vision of how CTSAs can enhance translation across the translational spectrum through the integration of D&I sciences into the critical areas of methods and processes, workforce development, and evaluation. We propose a set of recommendations for NCATS national and local leaders that are intended to move D&I sciences out of a position of unfamiliarity and ancillary value and into the core identity of who CTSAs are, how they think, and what they do, to advance translation and health.

Teaching for implementation: A framework for building implementation research and practice capacity within the translational science workforce

Implementation science offers a compelling value proposition to translational science. As such, many translational science stakeholders are seeking to recruit, teach, and train an implementation science workforce. The type of workforce that will make implementation happen consists of both implementation researchers and practitioners, yet little guidance exists on how to train such a workforce. We-members of the Advancing Dissemination and Implementation Sciences in CTSAs Working Group-present the Teaching For Implementation Framework to address this gap. We describe the differences between implementation researchers and practitioners and demonstrate what and how to teach them individually and in co-learning opportunities. We briefly comment on educational infrastructures and resources that will be helpful in furthering this type of approach.

Partnered innovation to implement timely and personalized care: A case study

Background:

Understanding how to translate research discoveries into solutions for healthcare improvement is a priority of NIH-funded Clinical and Translational Science Awards (CTSA). This study, supported by one CTSA, aims to capture one process of shaping and implementing innovations to advance the timeliness and patient-centeredness of cardiovascular care. Specifically, we sought to understand a partnership between a private digital health startup company, a university innovation lab, and an academic health system’s cardiology program pursuing this goal.

Findings:

The collaboration proceeded through clear phases to address the questions and challenges: problem definition, exploration and formalization of the partnership, innovation co-creation and pilot test, and scale-up planning. Phases were punctuated by key decisions, such as forming the partnership, negotiating terms of the partnership, iterating form and features of the innovation, and exploring sufficiency of its value-add for scale-up and sustainment. Key implementation concepts were apparent, including implementation strategies (e.g., champions and iterative trialing) and the implementation outcomes of acceptability, sustainment, and scale-up. Participants identified potential risks of collaboration, reflected on their co-creation process, and the value of engaging stakeholders in innovation design. Findings may inform subsequent collaborations between innovators and translational researchers.

Methods:

We conducted a case study to understand the partnership; characterize the questions they pursued, their decision points, information and data sources; and identify the challenges and risks. Data were collected through a series of four focus groups with members of each partnering organization. A transdisciplinary research team iteratively worked to condense and synthesize data from audio recorded transcripts into a case narrative.