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Overview of the State of Dissemination of Evidence-based Interventions: Art, Science or both?

Overview of the State of Dissemination of Evidence-based Interventions: Art, Science or both?. Jon F. Kerner Ph.D. Deputy Director, DCCPS Emerging Issues in Dissemination Research: Implications for Cancer Prevention and Control University of North Carolina Chapel Hill, NC -June 2, 2005.

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Overview of the State of Dissemination of Evidence-based Interventions: Art, Science or both?

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  1. Overview of the State of Dissemination of Evidence-based Interventions: Art, Science or both? Jon F. Kerner Ph.D. Deputy Director, DCCPS Emerging Issues in Dissemination Research: Implications for Cancer Prevention and Control University of North Carolina Chapel Hill, NC -June 2, 2005

  2. Metast. Clinical Malignant Normal Cancer Disease Tumor Cell Cancer Control as a Multi-Stage Process Terminal Diagnosis Prevention Early Detection Care & Treatment Support Risk Factor Surveillance Support Health Follow-up & Follow-up Behaviors Carcinogenesis as a Multi-stage Process* Progression Conversion Initiation Promotion Initiated Preneoplastic Cell Lesion

  3. Dissemination as a Multi-stage Process* Conversion Initiation Promotion Progression Metast. Implement/ Research and/ Adoption/ Clinical Malignant Review & Initiated Normal Regular or Evaluation Adaptation Cancer Maintain Disease Synthesis Tumor Change Cell Services Carcinogenesis as a Multi-stage Process* Progression Conversion Initiation Promotion Initiated Preneoplastic Cell Lesion

  4. How do we model partnership across the continuum? How do we increase investment in the development to delivery process? THE DISCOVERY-DELIVERY CONTINUUM Development Delivery Discovery

  5. THE DISCOVERY-DELIVERY CONTINUUM Development Delivery Discovery Policy Knowledge Synthesis Dissem. Implement Research ReplicationResearch Diffusion Implementation Dissemination CBPR D&I Research Evaluation Replication Research

  6. Policy Ideology, Interests, Institutional Norms & Practices, Prior Info.* Counts? Context Data • Kinds of Evidence* • Description • Analytic Information • Evaluation • Policy Analysis Public Health Practice Primary Care Practice Oncology Specialty Practice *Weiss CH. What kind of evidence in Evidence-Based policy? Third International, Interdisciplinary Evidence- Based Policies and Indicator Systems Conference, July 2001 THE DISCOVERY-DELIVERY CONTINUUM Discovery Delivery Development

  7. TERMS AND DEFINITIONS • Diffusion - the passive process by which a program is absorbed into more widespread use • Replication - moving a tested prototype program to new settings or target populations • Dissemination - the active promotion or support of a program to encourage its widespread adoption within larger populations or additional settings in which the program was originally tested. Adapted from Glasgow, et al. (2004) Cancer 101 (Suppl 5):1239-1250 NCI (2002) Designing for Dissemination Conference, Summary Report

  8. TERMS AND DEFINITIONS (cont.) • EfficacyResearch - research conducted under tightly controlled conditions to establish causality under optimal conditions • EffectivenessResearch - research conducted under generalizable or “real-world” conditions to determine results under typical conditions Flay, et al (1986) Efficacy and effectiveness trials…Preventive Medicine 15:451-474 Glasgow, R SBM (2005) 26th Annual SBM Meeting, Symposium #22: Disseminating Behavioral Medicine Research: Making the Translational Leap.

  9. Levels of Research Efficacy Effectiveness Dissemination Psychologists Physicians Managed Care/Health Agency Adapted from Ken Resnicow, PhD, University of Michigan, School of Public Health SBM 26th Annual SBM Meeting, Symposium #22: Disseminating Behavioral Medicine Research: Making the Translational Leap.

  10. Dissemination “Fast Food” Model Efficacy Effectiveness Dissemination First Restaurant 2nd-3rd Restaurant Franchising Recipe Design Recipe Standardized Minimizing Human Input Creativity Common Prep Automation Best Ingredients Common Ingredients Frozen & Prepared Frequent Menu Change Occasional Menu Change Rare Menu Change Master Chef Line Cook Short Order Cook Adapted from Ken Resnicow, PhD, University of Michigan, School of Public Health SBM 26th Annual SBM Meeting, Symposium #22: Disseminating Behavioral Medicine Research: Making the Translational Leap.

  11. TERMS AND DEFINITIONS (cont.) • Dissemination Research – research to evaluate the targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to evaluate the spread of knowledge and the associated evidence-based interventions. • ImplementationResearch - research conducted to evaluate the use of strategies to introduce or change evidence-based health interventions within specific settings.

  12. The “Evidence-Based” Dilemma • Can we (should we) wait until strategies are proven effective by RCT standards? • Efficacy • Effectiveness • Dissemination • Cost benefit • Generalizable • SES, Ethnicity, Region • Practitioner Adapted from Ken Resnicow, PhD, University of Michigan, School of Public Health SBM 26th Annual SBM Meeting, Symposium #22: Disseminating Behavioral Medicine Research: Making the Translational Leap.

  13. PAR-04-041 PBRNs and Translation of Research Into Practice David Lanier, M.D. AHRQ Jon Kerner, PhD; Stephen Taplin, MD; Cynthia Vinson, MA NCI

  14. 17:14 It takes 17 years to turn 14 per cent of original research to the benefit of patient care Original research 18% variable Negative results Dickersin, 1987 Submission 46% 0.5 year Kumar, 1992 Koren, 1989 Acceptance Negative results 0.6 year Kumar, 1992 Publication Expert opinion 35% 0.3 year Poyer, 1982 Balas, 1995 Lack of numbers Bibliographic databases 50% 6. 0 - 13.0 years Antman, 1992 Poynard, 1985 Reviews, guidelines, textbook 9.3 years Inconsistent indexing Implementation E.A. Balas, 2000

  15. PBRNs and Translation of ResearchInto Practice (AHRQ/NCI PAR-04-041):Review Issues Raised in Round 1 • Most applications focused on efficacy rather than dissemination • Little process data with which to evaluate dissemination • Efficacy & effectiveness of USPSTF recommendations questioned by committee within study context • Human subjects concerns (who is being studied?) • RCT’s preferred design for all studies Explicit vs. Tacit Knowledge

  16. Dissemination Supplements for R01-funded projects with established efficacy • DCCPS invited NCI-funded intervention investigators to submit competitive one-year supplement applications ($125,000 direct costs) for dissemination planning and implementation. • A peer review mechanism set up to identify which applications have sufficient efficacy data and a viable plan for evaluating dissemination potential. • Successful applicants provided resources to support market research and cost-effectiveness research, product promotion, and actual dissemination and diffusion of the intervention products with appropriate evaluation

  17. Efficacy data strongly supports value of dissemination Applicant demonstrated thorough understanding of dissemination principles and theories Proposed dissemination approaches had potential for broad reach Investigative team strong both on intervention and dissemination expertise Findings from study had potential to contribute to dissemination knowledge base Efficacy data limited, missing or does not justify dissemination Limited understanding of dissemination theory or how to apply it to design and evaluation Overly ambitious with respect to one-year time frame Evaluation methods did not focus on dissemination Replication is not dissemination Intervention modified to be too different from original intervention Lacked documentation of practice partner organizations Investigative team lacked dissemination research expertise Content Analysis of First Three Rounds of D&D Supplement Reviews* Outside Fundable Range Fundable Range * Conducted by Cynthia Vinson, Dissemination Research Coordinator, DCCPS, NCI

  18. Increase the number of systems providing evidence based cancer control Increase the number of practitioners providing evidence based cancer control Increase the number of individuals receiving evidence based cancer control Bridging the Gap: A Synergistic Model Getting Evidence - Based Cancer Control Interventions Into Practice GOAL: To increase the adoption, reach and impact of evidence - based cancer control Delivery Capacity Science Push Market Pull/ Building the capacity Documenting, Demand of relevant systems to improving, Building a market deliver the and communicating and demand for the intervention the intervention for intervention wide population use - - - ULTIMATE GOAL: Improve population health and well being “We believe that any statewide or national prevention initiative must include ample time and money for local capacity building….” Elliot DS, Mihalic S. Issues in disseminating and replicating effective prevention prorgrams. Prevention Science 2004; 5(1): 51.

  19. Evidence-based Knowledge Clinical Practice TRANSLATION “The transfer of evidenced-based knowledge into routine or representative practice” Glasgow, R SBM (2005) 26th Annual SBM Meeting, Symposium #22: Disseminating Behavioral Medicine Research: Making the Translational Leap.

  20. Explicit Evidence- Based Knowledge Informed Application Tacit Clinical and Contextual Knowledge INTEGRATION “The informedcombination of evidence-based knowledge and local contextual knowledge into community applications.” Adapted from Glasgow, R SBM (2005) 26th Annual SBM Meeting, Symposium #22: Disseminating Behavioral Medicine Research: Making the Translational Leap.

  21. TranslatingResearchintoImproved Outcomes (TRIO) • Use and communicate cancer and behavioral surveillance data to identify needs, track progress and motivate action. • Collaboratively develop tools for accessing, and promoting adoption of, evidence-based cancer control interventions. • Support regional and local partnerships to develop models for identifying infrastructure barriers, expanding capacity and integrating science into comprehensive cancer control planning and implementation.

  22. http://cancercontrol.cancer.gov/d4d/

  23. Can Names Pictures/testimonials Wording (reading level) Location Incentives Timeline Cannot Health topic Removal of strategies Insertion of strategies Theoretical foundation RTIPs Adaptation Summary: What can I modify?

  24. New Funding Opportunities • New CCSG Guidelines include Dissemination Research Shared Resource (see pages 24-25 of 9/04 Guidelines revision http://www3.nci.nih.gov/cancercenters/download.html) • NCI R25E PAR http://grants1.nih.gov/grants/guide/pa-files/PAR-05-065.html • Trans-NIH Dissemination Research PAR (look for in September 2005) • NCI Dissemination Research Supplements refocusing on the dissemination of surveillance data (FY06)

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