Yale Psychiatry Grand Rounds: October 7, 2022

Transcript

• 00:00Thank you so much, Doctor.
• 00:03Thank you so much Doctor O'Malley.
• 00:04I really appreciate you inviting me to
• 00:08this and to seeing all of you here,
• 00:10and really excited to start spreading
• 00:12the word even more about the
• 00:15importance of implementation science.
• 00:21So we all know this quote that on average
• 00:25it takes 17 years for just 14% of original
• 00:29research to make its way into practice.
• 00:32And so this really shows that we
• 00:34really don't have an evidence
• 00:35problem when it comes to research,
• 00:37but we have an implementation problem.
• 00:39And this is where the field of implementation
• 00:42science really comes into play,
• 00:44that we really need to be
• 00:46thinking and and training.
• 00:48People to think about the relevance of their
• 00:51research and the impulse impactful Ness
• 00:53that they can have from a very early stage.
• 00:56We really need to be working
• 00:58with a range of stakeholders,
• 01:00healthcare leaders, staff,
• 01:01people in the Community,
• 01:03patients and families in order
• 01:05to break down this research to
• 01:07practice gap and increase the public
• 01:10health impact of our work.
• 01:11And we also need to be thinking about
• 01:14the different study designs that we
• 01:16use in order to speed that development,
• 01:18as doctor Melley mentioned,
• 01:20so that we don't have to wait 17 years
• 01:23and that we can have more than 14% of
• 01:26the research make its way into routine care.
• 01:30People have been spending a lot of
• 01:32time thinking about why we waste
• 01:34so much of our research funding
• 01:36and they don't necessarily focus on
• 01:38implementation science when they do this.
• 01:40But some of the things that they
• 01:43really highlight that we need to
• 01:45be doing more of are very relevant
• 01:47implementation science.
• 01:48So in,
• 01:49you know,
• 01:50work that's been happening since 2009,
• 01:53Chalmers and colleagues have been
• 01:55focusing on this,
• 01:56this number of 85% of waste in reporting.
• 01:59The use of research evidence,
• 02:01which I'm sure you've also heard about,
• 02:03and it's just staggering because if you
• 02:06look at numbers from 2010 where there
• 02:09was $200 billion of research funding,
• 02:11that means that about $170
• 02:13billion never of research,
• 02:16never really made it into publication,
• 02:19into practice, into dissemination.
• 02:21And so lots of people spend time thinking,
• 02:24why is that?
• 02:25And so they these are some of the questions
• 02:28that they're saying that we need to.
• 02:30To focus on more in our research,
• 02:32you know,
• 02:32are our research decisions that
• 02:34we're making based on questions
• 02:36that are relevant to users?
• 02:38Are we using appropriate research designs,
• 02:40methods and analysis?
• 02:42If not,
• 02:43really going to get into research
• 02:45regulation and management here,
• 02:46but that is certainly an issue.
• 02:49Do we make our research findings
• 02:52accessible and our our reports unbiased?
• 02:55And importantly,
• 02:56are they usable to the people who need them?
• 02:59So I'm going to be thinking about.
• 03:00These questions,
• 03:01along with other things that are
• 03:04related to implementation science
• 03:05throughout this talk to really think
• 03:08about how we can reduce this gap
• 03:11from evidence into implementation.
• 03:13I love this screenshot because it's
• 03:15the editorial from the very first
• 03:18issue of the journal implementation
• 03:21Science back in 2006 by Martin Eccles
• 03:24in the UK and Brian Mittman in the US.
• 03:27I've been very fortunate to have
• 03:29Brian as a mentor and implementation
• 03:31science for the last 15 years.
• 03:33And what I love about this is that
• 03:35even though implementation science
• 03:37had been around prior to 2006,
• 03:39we didn't really have a
• 03:40specific journal for it.
• 03:41And so now, I mean you will
• 03:43find implementation science
• 03:44articles in many journals,
• 03:45but this is considered our flagship.
• 03:47And in this they defined what
• 03:49implementation research is,
• 03:50which is the scientific study of methods
• 03:53to promote the systematic uptake of
• 03:55research findings and other evidence
• 03:57based practices into routine practice,
• 03:59routine care and hence to improve the
• 04:01quality and effectiveness of health services.
• 04:04And care.
• 04:04And so this is really where I'm
• 04:07coming from when I talk to you
• 04:09today about implementation science
• 04:11and implementation research.
• 04:13No one has ever told me these
• 04:14are the three unique aspects
• 04:16of implementation science,
• 04:17but they are what I think are
• 04:19the three unique aspects.
• 04:20We have implementation strategies that
• 04:22we've developed and I'll say more about
• 04:25each of these throughout this talk.
• 04:27We have these implementation strategies
• 04:28that we need to use and test to make
• 04:31sure that our evidence gets into practice.
• 04:33We've developed our own type of study design,
• 04:36which is this hybrid effectiveness
• 04:38implementation trial design,
• 04:40and we also really need to focus on
• 04:42the pragmatic aspects of our research.
• 04:45So first, the strategies.
• 04:46This paper was a seminal paper from 2015
• 04:50by Byron Powell and colleagues really.
• 04:52And they used a modified
• 04:54Delphi consensus approach.
• 04:55I was one of many,
• 04:57many people who participated in this
• 04:59work to really think about what are
• 05:02the strategies that we need to use
• 05:04to get our research into practice,
• 05:06and they define implementation
• 05:08strategies as methods or techniques
• 05:11used to enhance the adoption,
• 05:13implementation and sustainability.
• 05:14Of a clinical programmer practice,
• 05:17they list 73 strategies in this
• 05:19paper and that's very overwhelming.
• 05:22And I would say that you know
• 05:24this papers from 2015,
• 05:25there are many more identified
• 05:27and developed since then.
• 05:29So I think it's really more helpful
• 05:30to think about the buckets or
• 05:32the categories of implementation
• 05:33strategies that we can use.
• 05:35And this is actually from an
• 05:36earlier paper by the same group.
• 05:38And so here are these nine buckets
• 05:41of implementation strategies.
• 05:42I would say that the ones I
• 05:43use the most are bucket.
• 05:453 adapting and tailoring to the context.
• 05:48Bucket 4 developing
• 05:50stakeholder relationships.
• 05:52Bucket 5 training and educating stakeholders,
• 05:56and six supporting clinicians.
• 05:57We've also tried to do a little
• 06:00bit around changing infrastructure.
• 06:02That's a little bit harder,
• 06:03but all of these are things that you can
• 06:05think about when you're thinking about,
• 06:07well, how?
• 06:08What are the methods, techniques,
• 06:09and tools I need to use,
• 06:11identify, use, develop, and test?
• 06:15To get evidence into practice.
• 06:19And then our hybrid designs,
• 06:20which are really just the
• 06:22most important part,
• 06:24I was one of the most important
• 06:26parts of implementation science
• 06:27that I would say and this is really
• 06:29trying to help speed that that
• 06:32evidence to implementation process.
• 06:33So there are three types,
• 06:35hybrid type one, Type 2 and Type 3.
• 06:38And I'm going to make the argument
• 06:40that any randomized control trial
• 06:42needs to be a hybrid type one.
• 06:44And I'll be saying that more and more,
• 06:46but this is what we would
• 06:47consider a traditional.
• 06:48Randomized controlled trial of effectiveness.
• 06:51But more and more people are
• 06:52using this in efficacy too.
• 06:53And I'll say more about that too.
• 06:54But this is where we have our
• 06:56primary goals of effectiveness.
• 06:58And then we usually have our aim.
• 06:59Three, to understand more about
• 07:01the implementation context.
• 07:03You know,
• 07:03what is it that we are learning
• 07:05about from this particular trial
• 07:07that can help us move evidence
• 07:10into practice sooner and apply that
• 07:13information into the next study.
• 07:15Hybrid Type 2 is when we have dual aims
• 07:17of effectiveness and implementation.
• 07:19Trying to understand it what not only
• 07:21is our intervention effective but our
• 07:24our implementation strategies effective.
• 07:26And hybrid Type 3 is when we
• 07:27flip things on their head.
• 07:29And our primary aim is we know
• 07:31that our intervention works.
• 07:33We've tested this,
• 07:34we know this,
• 07:35we've tested it in multiple settings.
• 07:36Now we need to know what are the
• 07:38most effective strategies and so we
• 07:40randomize on strategies and that's
• 07:41really exciting and I'll I'll talk
• 07:43about some work that we're doing there too.
• 07:46And then the pragmatic aspect of our work,
• 07:49you may already know about the
• 07:52pragmatic explanatory continuum
• 07:53indicator summary or the precise.
• 07:54And this is the second version of it.
• 07:56And these are the types of
• 07:58things that we can think about.
• 07:59All randomized controlled trials are on a
• 08:03spectrum from explanatory to pragmatic.
• 08:06the Super tight controlled efficacy trials,
• 08:09especially things like drug trials,
• 08:10they're going to be at the one
• 08:13level here really controlled highly.
• 08:15Restricted, very rigid and you know,
• 08:18especially in the world of drug trials,
• 08:20that's important.
• 08:21But we're really talking about
• 08:23behavioral interventions here.
• 08:24And so these can be much more
• 08:26pragmatic moving up the scale from
• 08:28one to five in terms of what are
• 08:30the outcomes that we're assessing.
• 08:32We need to make sure that these are
• 08:34relevant to the people involved.
• 08:35You know,
• 08:36if you are talking to your
• 08:38stakeholders early,
• 08:39you'll find out that maybe one
• 08:40of the things that patients and
• 08:41families want to know about is
• 08:43like how can my loved one get back
• 08:45to work or how can my loved one.
• 08:46Have enough energy to play with their
• 08:48grandchildren or something like that.
• 08:50And so those aren't necessarily the things
• 08:52that we assess in a in an efficacy trial,
• 08:54but these are the things that
• 08:55matter to the people who are
• 08:57going to be using our research.
• 08:58Eligibility is a big thing in our.
• 09:03Try.
• 09:06And. Controlled trial,
• 09:09the expanded exclusive and often
• 09:11we exclude the people who are going
• 09:13to benefit most from our work
• 09:15and that is really true in mental
• 09:17health and substance use research.
• 09:19And a pragmatic trial would say be more
• 09:22inclusive, open it up to more people.
• 09:24Those are the people that we're really
• 09:25going to be able to affect in the
• 09:27future and we need to know if our work,
• 09:29if our research works for them now.
• 09:31And that's part of the problem of
• 09:33the research to of the evidence to
• 09:35implementation gap is that we didn't
• 09:37involve these people in the beginning.
• 09:39We excluded them and then when we
• 09:41move into Community settings we
• 09:43find that it's not working for them.
• 09:45And this gets to the setting piece,
• 09:46where is the trial being done?
• 09:48Often our work is being done
• 09:49in hospital settings,
• 09:50what we call the ivory tower,
• 09:52and we're not reaching the people
• 09:53for whom that is not the place
• 09:55where they're getting their care.
• 09:57And so again,
• 09:58another push for talking to stakeholders,
• 10:00moving our research out into
• 10:02the Community faster,
• 10:03doing more hybrid trials so that we
• 10:05can understand how our intervention
• 10:06is going to work in the place that
• 10:09we want to eventually see it in.
• 10:11And then the delivery and you know
• 10:12and this is really hard when with
• 10:15very highly protocolized renal
• 10:16randomized controlled trials,
• 10:17I understand.
• 10:18But there are things that we can do to
• 10:20think more about the flexible delivery
• 10:21and I'm going to give you an example
• 10:23of what we've done in one of those.
• 10:26So recently people have been trying to
• 10:29think about with what are the really
• 10:31key things we need to be doing to
• 10:33move evidence into implementation.
• 10:35And this is a paper that I did with
• 10:38colleagues Sarah Becker and Kelly Scott,
• 10:40who were Brown and now at
• 10:43Northwestern University,
• 10:43where we really thought about what
• 10:46are the guiding principles that
• 10:48anyone should use in terms of moving
• 10:51their research into implementation.
• 10:53And so there we came up with
• 10:55five guiding principles.
• 10:56For that,
• 10:56this paper just actually came
• 10:58out a few days ago in print.
• 11:00And then another paper that actually
• 11:03Doctor O'Malley shared with me came
• 11:05out in August in in Jamaica psychiatry
• 11:08by Beth McGinty and Matthew Eisenberg.
• 11:10Really thinking about exactly what
• 11:12we're talking about here that we have.
• 11:15We don't have an evidence problem.
• 11:16We have an implementation problem.
• 11:18And in this paper they talked about
• 11:20four different strategies that
• 11:22any researcher should use to to
• 11:24address that implementation problem.
• 11:26And that's so I've been thinking
• 11:27about this for a while and I spend a
• 11:30lot of time trying to build capacity
• 11:32for implementation science among,
• 11:34you know everyone from PhD students,
• 11:36postdocs, early career,
• 11:38up to full professors.
• 11:39And even though I've been part of this work,
• 11:42I really think when I compare like
• 11:45what Doctor Becker's got and I
• 11:47did and what Doctor McGinty and
• 11:48Doctor Eisenberg did,
• 11:49I really think that you can combine
• 11:51them into 4 strategies to increase the
• 11:54uptake of behavioral interventions and.
• 11:56I would say that first of all when
• 11:57I use the word strategies here,
• 11:59I'm not talking about an implementation
• 12:01strategy as we just mentioned,
• 12:02but just what are the ways that we can
• 12:05reduce the 17 year gap and what are
• 12:08the ways that we can make research
• 12:10less wasteful, more impactful.
• 12:12And so I would say these strategies
• 12:14are we need to conduct more hybrid
• 12:17effectiveness implementation trials
• 12:18and that was mentioned in our
• 12:20paper and also the McKinsey paper
• 12:23let's theory be your guide,
• 12:25I always say to people.
• 12:26Here is your friend Siri tells you exactly
• 12:29what it is that you need to be addressing,
• 12:31that you need to be measuring,
• 12:33and can help you plan your work.
• 12:34And we also talked about this in our paper.
• 12:37You need to get to know your stakeholders
• 12:39and that is just essential you.
• 12:41I'm not an intervention developer,
• 12:44treatment developer,
• 12:44but I talked to people who are all
• 12:47the time and I feel it at that stage.
• 12:49We need to be talking to stakeholders.
• 12:51Why develop something that
• 12:52isn't going to work?
• 12:53You can find that out from the beginning.
• 12:55Even if you conducted a really strong,
• 12:58highly controlled,
• 12:58randomized controlled trial
• 13:00and you did find effective or
• 13:02efficacy for your intervention,
• 13:03if it's not acceptable to people,
• 13:05it's not going to make it into the.
• 13:07Community based settings in which we
• 13:09want it to and so involve stakeholders
• 13:11right from the beginning and something
• 13:13that is unique and wasn't mentioned
• 13:15in those two previous papers that I
• 13:17just talked to you about is I think
• 13:19we really need to tell your tailor
• 13:20our dissemination efforts more.
• 13:22This is a big,
• 13:24there are a lot of people who focus on this,
• 13:25Ross Brownson at Washington
• 13:27University in Saint Louis.
• 13:28But I've been involved now in a quarry
• 13:32project where we really are needing
• 13:35to move our work out into wider.
• 13:38Widespread use and this tailoring
• 13:40is just really hit me over the
• 13:44head with how essential this is.
• 13:46And then of course I said 4
• 13:48strategies in a month term and
• 13:49you're going what is the mantra?
• 13:50And so mantra is fun for me to think about.
• 13:53I'm actually somebody who
• 13:55studies mantram meditation.
• 13:56And mantram in that context is
• 13:59usually a spiritual word or phrase
• 14:01that has a spiritual meaning or a
• 14:04higher level meaning and can help
• 14:07us bring focused attention to what
• 14:09it is that we need to be working on.
• 14:11It can help us also block out the noise.
• 14:14It can bring awareness to the issue and.
• 14:17A slow down and process and and so
• 14:19you'll see why I've been interested
• 14:20in this in the in the mental
• 14:22health space in a minute.
• 14:24But here I think the mantra now is
• 14:27that we really need to integrate
• 14:30HealthEquity with implementation science.
• 14:33This is not a new thing.
• 14:35It's quite a long you know a call
• 14:38to action that is long overdue.
• 14:40But you know we are now seeing
• 14:42more and more implementation
• 14:44scientists and more and more funding.
• 14:47Opportunities really focusing
• 14:48on how not only are we going to
• 14:51bring our evidence into practice,
• 14:53but how are we going to do
• 14:54this in an equitable way.
• 14:55And so just to make sure
• 14:56we're on the same page,
• 14:57I like to use this definition that
• 14:59was in a blog post in the journal
• 15:02Health Affairs that HealthEquity
• 15:03refers to providing a fair and
• 15:05just opportunity to be healthy by
• 15:07reducing and ultimately eliminating
• 15:09disparities in health and its
• 15:11determinants that adversely affect
• 15:13excluded or marginalized groups.
• 15:15So or seeing.
• 15:16All of the work here today is that we
• 15:19need to be integrating HealthEquity
• 15:22with implementation science.
• 15:23So let's go back to this first
• 15:26strategy of using hybrid trials.
• 15:28When I've talked to Jeff Kern
• 15:30and Brian Mittman,
• 15:30authors of the Seminole Paper
• 15:33on hybrid designs from 2012,
• 15:35they wish they would have emphasized
• 15:36more in that paper that every
• 15:38randomized control trial should
• 15:39be a hybrid type one trial.
• 15:41As I mentioned, you can do a really rigorous,
• 15:45unbiased trial of effectiveness,
• 15:47and some people are now doing
• 15:49it in efficacy work while also
• 15:52collecting implementation context.
• 15:53Along the way,
• 15:54and this is the information that's
• 15:56going to help you understand
• 15:57what it is that you still need
• 15:59to do to increase this uptake of
• 16:01evidence into practice.
• 16:02If we do hybrid trials that have
• 16:04a focus on effectiveness we need,
• 16:07we can then also hopefully not need to do
• 16:12as much adaptation of our intervention
• 16:15or our strategies in the future.
• 16:17So we always talk about interventions have
• 16:19core components and those are essential.
• 16:21We can't change those.
• 16:23There are essential things about,
• 16:25you know,
• 16:26cognitive behavioral therapy
• 16:27that have to happen.
• 16:29But we can talk about cultural adaptations,
• 16:31we can talk about setting adaptations.
• 16:34Targeted audience adaptations,
• 16:35the people who deliver them.
• 16:37Adaptations that will not change the core
• 16:40components of cognitive behavioral therapy,
• 16:43but will increase the uptake
• 16:44of its use in practice.
• 16:46And if we start there,
• 16:48as opposed to a really highly
• 16:50controlled efficacy trial,
• 16:51we might actually be able to build
• 16:53those things in and not need to do so
• 16:55much adaptation work in the future.
• 16:57We also need to be as Chalmers
• 16:59and colleague mentioned earlier
• 17:00that really need to think about
• 17:02what are the research questions
• 17:03that are relevant to the end users
• 17:05that could be the providers who
• 17:07are going to be delivering them,
• 17:08the patients,
• 17:08families who are going to be receiving them,
• 17:11participating in them.
• 17:11So think about that early on and we
• 17:14can do that in a hybrid trial and also
• 17:16then focus on that pragmatic issues,
• 17:18you know,
• 17:18making sure that the outcomes that
• 17:20we're measuring are relevant to
• 17:22participants that that we're not
• 17:23as rigid in who can participate
• 17:25in our trials and that helps
• 17:27with. Increasing HealthEquity and then also
• 17:30expanding our recruitment efforts as well.
• 17:34So my colleagues Megan landfall,
• 17:36Jeff Kern and Renat Badas created
• 17:38this what I love this really cool
• 17:41subway map of implementation research.
• 17:43And so you can really identify
• 17:45yourself along this line.
• 17:46So where are you in terms of
• 17:48your practice of interest?
• 17:50You know, what is it that you want to
• 17:52see implemented in real world settings?
• 17:54And then you can follow along,
• 17:55where are you?
• 17:56And so if you feel that you really
• 17:59still need more efficacy research, done.
• 18:02And you can still design for implementation
• 18:05and that's why a hybrid designs are
• 18:08now moving into the efficacy space.
• 18:10You can still do the,
• 18:12you can still do efficacy research,
• 18:14really rigorous control things
• 18:16and obviously of course in drug
• 18:18medication trials this is essential.
• 18:21But you can still be collecting information
• 18:23on what are the perceived benefits of this,
• 18:26what are the challenges to doing
• 18:27this so that you are prepared for
• 18:29moving this forward and in fact
• 18:31if you are aware of the VA's.
• 18:33Cooperative studies program where
• 18:35trials are funded at like $35 million.
• 18:38They now have a policy that everyone
• 18:42of those very large 5 to 7 year
• 18:45trials must be a hybrid type 1.
• 18:48So you even if you're doing efficacy
• 18:50research think about a hybrid type
• 18:52one or maybe you feel that you
• 18:54still need to do effectiveness.
• 18:55You you have efficacy you can move
• 18:59into effectiveness but you know this
• 19:01is where the comment from current and
• 19:03mitman come in that even an effectiveness
• 19:05research trial should be a hybrid one.
• 19:07Think you should be thinking about how
• 19:09you can get yourself onto that green line.
• 19:12I don't know if you you know in
• 19:13Boston we just call our subway lines
• 19:15by colors red line, yellow line,
• 19:17green line, the red line right now.
• 19:19It's not so great in the subway
• 19:21world in Boston.
• 19:22The Orange Line,
• 19:23which we don't have here is horrific.
• 19:25The green line is OK.
• 19:27Hopefully the green line here
• 19:28for implementation research is
• 19:29a little bit better.
• 19:31But I feel like,
• 19:32you know,
• 19:33you can do a hybrid trial at any
• 19:35point and you can also be doing
• 19:37these mixed method studies,
• 19:38designing and testing your
• 19:41implementation strategies.
• 19:42So in this trial which I will tell
• 19:44you started out as more of a clinical
• 19:46trial and I am not a clinical trialist.
• 19:48I partnered with my colleague Jill
• 19:50Bornman at VA San Diego to do a
• 19:53trial testing mantram repetition or
• 19:54mantra meditation as a treatment for
• 19:57post traumatic stress disorder among
• 19:59veterans who had been in combat.
• 20:02And our our funder which was VA
• 20:04clinical services research and
• 20:06development really wanted more
• 20:07efficacy trials but we did some
• 20:10pre work talked to a lot of.
• 20:12Stakeholders,
• 20:12because of our implementation
• 20:14science background and found that
• 20:16what we intended to do in this
• 20:18trial was not going to work.
• 20:20Maybe it could have worked
• 20:21in the trial itself,
• 20:22but it wasn't going to work long term.
• 20:23So for example, one of the
• 20:25things that we wanted to do was
• 20:26do this as a group treatment.
• 20:27We wanted to do group based monitoring,
• 20:29repetition. Jill had done lots of
• 20:32work already with mantram repetition.
• 20:34In this case, she had been looking to
• 20:37see how it could increase adherence
• 20:39to HIV treatment and she wanted
• 20:40to now move it into this PTSD.
• 20:42Space and we talked to veterans of
• 20:44all genders and found that they had
• 20:47absolutely no intention of doing
• 20:48this in a group based setting,
• 20:50but they were very happy to participate
• 20:53this in individual treatment.
• 20:54So we had to request a modification
• 20:56and move into individual treatment
• 20:57and that was our first step in
• 20:59that pragmatic space of thinking
• 21:01about that flexible delivery.
• 21:03We cannot do how this had initially
• 21:05been planned because we knew
• 21:06even if it worked in this trial,
• 21:08it wasn't going to work in the real world.
• 21:10The other thing we did is we
• 21:11really thought about who would
• 21:12be delivering these services and
• 21:14that's another pragmatic issue.
• 21:15We didn't want to hire PhD level
• 21:17people who were going to disappear
• 21:19after the study and we're only
• 21:21going to be interventionist.
• 21:23And so we talked to the clinicians.
• 21:26Masters degree level clinicians at each
• 21:28of our sites to see who would want
• 21:30to become involved in this project
• 21:32and so we really didn't involve the people,
• 21:35a lot of social workers for example,
• 21:37who would be involved in delivering
• 21:39mantra repetition in the future.
• 21:41So that was a great,
• 21:42great first step towards becoming
• 21:44more of a pragmatic design.
• 21:46Mantram repetition Mantra Meditation
• 21:48was developed by Eknath Ishwaran,
• 21:51who developed the Blue Mountain
• 21:53Retreat Center Meditation Retreat
• 21:55Center in San Diego.
• 21:57And you know,
• 21:58Mantram is just it's it's so simple,
• 22:02which is actually essential
• 22:04for implementation.
• 22:05It's not complex at all,
• 22:06and these are a couple of the books
• 22:08available at that website there.
• 22:10But really, mantram is a way of slowing down,
• 22:15having focused attention.
• 22:16Trying to make sure that you can
• 22:19block out a lot of the challenges,
• 22:21especially the kinds of things that
• 22:23happen in post traumatic stress disorder,
• 22:25nightmares incurring.
• 22:26So you the person starts,
• 22:28the first thing that you have to
• 22:30do is actually pick a montrem
• 22:31if you're in this group.
• 22:32And so the mantram has to be
• 22:34a spiritual word or phrase.
• 22:36It doesn't.
• 22:36You don't have to be a religious person,
• 22:38but you need to have a sense of
• 22:41higher order and can come from
• 22:43any religion and if any of these
• 22:46religious or spiritual words.
• 22:48Don't seem to fit for someone.
• 22:49They can pick something else.
• 22:52And so we would say if none of these work,
• 22:54you can just use the word one.
• 22:56You could not use anything vulgar,
• 22:58you couldn't use a swear word,
• 22:59etcetera, had to have a higher order.
• 23:01And we often say to people that
• 23:03your mantra will pick you.
• 23:05So for example, I went through the
• 23:07training myself because I thought, well,
• 23:08if I'm going to be trying to do this trial,
• 23:09I need to practice mantra meditation
• 23:11and see what this is like.
• 23:13And I really wanted the word.
• 23:15I really wanted the phrase Om Namah shivaya.
• 23:18It sounds so beautiful, you know,
• 23:20and a lot of these words come from
• 23:23Sanskrit or are, you know, maybe Hindi.
• 23:26Some of these words are from Buddhism,
• 23:29others are from Judaism,
• 23:32Christianity, etcetera.
• 23:33I really wanted Onama shivaya
• 23:35invocation to beauty and fearlessness.
• 23:38But as I went through the training and
• 23:40you need to learn how to invoke the mantra
• 23:42when you need it, like on the spot,
• 23:44I couldn't remember my mantra and
• 23:46so then I understood why the mantra.
• 23:48Makes you the one word that I
• 23:50could remember always was Rama,
• 23:51Eternal joy within.
• 23:52So that became my mantra.
• 23:54So I would silently say it to myself.
• 23:57I would write it down.
• 23:58Those are the kinds of things that we
• 24:01ask people to do when they need it.
• 24:03First you learn how to use the
• 24:04mantra when you don't need it,
• 24:05and then you move to using
• 24:07it when you need it.
• 24:09And we compared this to a very active
• 24:11treatment arm of present centered therapy,
• 24:14which through Polish,
• 24:16schnurr and others has really
• 24:19established very strong.
• 24:21Effectiveness and efficacy work.
• 24:23It's really helping people to
• 24:25alter their present maladaptive
• 24:27reactions and patterns and providing
• 24:30some sorry cycle education.
• 24:32And importantly,
• 24:33there's no meditation at all
• 24:34and no mantra meditation.
• 24:36And so it was a really good
• 24:38comparison arm and again,
• 24:38we had masters level people
• 24:41who were using this.
• 24:42And importantly,
• 24:43in both of our mental health settings,
• 24:46neither one of these treatments
• 24:48was available as routine and so
• 24:50it was considered something new.
• 24:51Any veteran participating?
• 24:52And so we use the caps,
• 24:55which is I will admit is not
• 24:56exactly the outcome that matters
• 24:58to the people who are using.
• 25:00It is very difficult to both
• 25:02administer and participate in.
• 25:04But you know,
• 25:05we had 89 people in our monitoring
• 25:07group and 84 in our present centered
• 25:10group and the Montreal Group improved
• 25:13tremendously on that measure over time.
• 25:15And so the present centered
• 25:17group also improved,
• 25:18but not as much as the mantra in
• 25:20terms of the Caps scoring and
• 25:22we also wanted to know.
• 25:23What was driving PTSD and so we
• 25:25thought that we could maybe find out
• 25:28if insomnia had anything to do with this.
• 25:30And so we asked about the using
• 25:33the Insomnia Severity Index and
• 25:35found that the present centered
• 25:37therapy group really didn't change
• 25:38in terms of insomnia over time.
• 25:40But the sorry the the mantra group
• 25:43did that their insomnia improved a
• 25:46little bit and kept going down but
• 25:48didn't get to the point where it
• 25:51it wasn't clinically meaningful.
• 25:52Both things both groups still
• 25:53had clinically meaningful.
• 25:55Some symptoms.
• 25:57And so this is where we were like we need
• 25:59to know about how,
• 26:00how is this actually going to work?
• 26:01We saw that it works in this group of
• 26:04veterans with post Traumatic stress
• 26:07disorder resulting from combat.
• 26:09But what was it going to take
• 26:11to make this work in real life?
• 26:13And so this is where a
• 26:14process evaluation comes in.
• 26:15After the recruitment was done,
• 26:18after providers were no longer
• 26:20referring patients to us and providers
• 26:22were such an essential part of this.
• 26:25So they really needed to have.
• 26:27Buy in, they needed to believe
• 26:28that we were doing something unique
• 26:30and helpful for the veterans
• 26:32that they were serving.
• 26:33We wanted to find out from them what
• 26:35were are some potential barriers
• 26:37and facilitators to implementation
• 26:38that we can think about now so
• 26:40that we can address in the future.
• 26:42And so this gets into strategy #2 already,
• 26:45which is the that we were guided by
• 26:47theory with this and we chose the
• 26:49theory of diffusion of innovation
• 26:51which actually was not developed
• 26:53in healthcare at all,
• 26:54really developed in the agricultural space.
• 26:57And really says that there are
• 26:59key features of any innovation,
• 27:02any adoption of innovation.
• 27:03And that is that a user will see it
• 27:06as a perceived relative advantage
• 27:07compared to anything else that they're doing,
• 27:10that it's compatible with their
• 27:12perceived needs, values, norms,
• 27:14low complexity,
• 27:15sure.
• 27:16Yet that's essential and have the
• 27:18best intervention in the world.
• 27:19But if it's seen as too complex,
• 27:21it won't be adopted.
• 27:22And so these are the kinds of things
• 27:24that we needed to assess in our
• 27:26process evaluation with our providers.
• 27:28Did they see this as a relative advantage
• 27:30for themselves and their veterans?
• 27:31Did they see it compatible
• 27:32with their perceived needs,
• 27:33values and norms and their veterans?
• 27:36And was it low in complexity to
• 27:38them and also to their veterans?
• 27:41And what the theory of diffusion
• 27:43of innovation says is when we
• 27:44start to have conversations,
• 27:46peer-to-peer conversations with others
• 27:47that we work with who are in our networks,
• 27:50in our communities,
• 27:51and we hear what they think
• 27:54about that innovation,
• 27:55then we start to consider change
• 27:57and we start to consider adoption.
• 27:59And we do this because we have
• 28:01a sense of trust.
• 28:02We believe in the person
• 28:03that we're talking to.
• 28:04And although we may not have seen
• 28:07this benefit yet of this innovation,
• 28:09we start to trust them.
• 28:11Because they are already somebody
• 28:13who we consider credible,
• 28:15and if they're telling us that it works,
• 28:17we're going to try it out too.
• 28:20And so we did a survey with 69 of
• 28:22the providers who participated in
• 28:24this trial in terms of referring
• 28:26patients to us and then we did a 12
• 28:30interviews with a subset of those just
• 28:32to get a little bit more deeper dive.
• 28:34And from the survey and the interviews
• 28:36we really had three main themes
• 28:38that came out that were can really
• 28:40inform implementation of this
• 28:42mantra meditation in the future.
• 28:44We the first two are things
• 28:45that have been talked
• 28:46about in the literature already that you know
• 28:48believing in one's own clinical judgment.
• 28:49Often Trump's the actual evidence based
• 28:52treatment because we just don't see
• 28:54that as being relevant for our patient.
• 28:57And then there are some other factors.
• 28:59But what was new in our work
• 29:01was that people, clinicians,
• 29:03providers were doing just extraordinary
• 29:06things to deliberately manufacture time,
• 29:09to have conversations with
• 29:10trusted others in their clinic,
• 29:12to learn more about Mantra meditation,
• 29:15to learn more about other evidence based
• 29:18treatments for PTSD and so for example.
• 29:21Things that they told us was that,
• 29:22you know, they wanted to have
• 29:24lunch to talk about these things,
• 29:26and they knew that having lunch
• 29:28would mean that they'll have to stay
• 29:30late to write their clinical notes.
• 29:31But doing this once a month or so
• 29:33is worth it because it was at this
• 29:36lunchtime conversation that they
• 29:37learned important aspects of treatment.
• 29:39That they really went to great effort
• 29:41to talk to colleagues outside of work
• 29:43and even walking to a colleague's car
• 29:45after work in order to have 10 minutes
• 29:48outside of the car was how they snuck
• 29:50time they were sneaking time to have
• 29:52these conversations with just really
• 29:54resonated as just like a way of trying
• 29:57to learn whatever they could and really
• 30:00emphasize to us how conversations
• 30:02about evidence based practices,
• 30:04mantra,
• 30:04meditation,
• 30:05anything are really not interwoven
• 30:07into the system yet and.
• 30:10In a way that is helpful for change.
• 30:12So here we're not talking about
• 30:14anything really related to the
• 30:16meditation trial in terms of the
• 30:18meditation as an intervention.
• 30:20We're talking about all of the organizational
• 30:22and cultural things that are happening
• 30:24in settings that we need to address.
• 30:26And we took this information and said
• 30:28this is the implementation strategy
• 30:30that we need to use in future work.
• 30:33We need to think about how do
• 30:35you promote network weaving and
• 30:36that is identifying and building
• 30:38out existing high quality working
• 30:40relationships within an organization.
• 30:42To promote information sharing,
• 30:44collaborative problem solving,
• 30:45shared goals related to an implementation.
• 30:48This is one of those 73 implementation
• 30:50strategies that's listed in
• 30:52Byron Powell's 2015 paper.
• 30:53But this really showed us that
• 30:55what we were learning from our
• 30:57providers was what we needed to do.
• 30:58And so we have since developed a social
• 31:01network survey of three questions asking
• 31:03people who do they talk to at work?
• 31:05Who do they seek advice from,
• 31:07who do they go to when there's a difficult
• 31:10clinical problem that they have,
• 31:11and answers to these questions.
• 31:13Help us identify who those champions are
• 31:15at each other's sites and who we can
• 31:18involve in our implementation efforts
• 31:20and how we can promote network weaving.
• 31:22How can we get that champion,
• 31:24that trusted person,
• 31:25to start talking to other people
• 31:27about the implementation effort.
• 31:29And that's really essential.
• 31:30And so without having done a hybrid type
• 31:33one and adding this process evaluation,
• 31:35we would never have known this.
• 31:38And so this moves us into Strategy 2,
• 31:40which is let theory be your guide.
• 31:41And I know you know that.
• 31:43You've all seen this quote from Kurt Lewin.
• 31:44Nothing is more practical than a good theory.
• 31:47And one of the things that this
• 31:49addresses in the Chalmers that all
• 31:51research waste issue is that theory
• 31:53can help us develop appropriate
• 31:55research design methods and analysis.
• 31:57And hopefully that will help us speed
• 32:00that public health impact translation.
• 32:02I always tell people that
• 32:03theory is your friend.
• 32:04It tells you what you need to measure.
• 32:06It tells you how frequently.
• 32:09Perhaps you need to do this.
• 32:10What are the kinds of concerns that that
• 32:12might occur that you haven't thought about?
• 32:14And also, we won't waste research
• 32:16dollars if we're collecting data
• 32:18that we're not intending to use.
• 32:20Theory helps us figure that out,
• 32:22and this is a wonderful website
• 32:24that is a collaboration between
• 32:25the University of Colorado and
• 32:27Washington University in Saint Louis.
• 32:29You can go to the website here.
• 32:30It's free to use.
• 32:31There are lots and lots of
• 32:33different theories, models,
• 32:34and frameworks to look at that are used
• 32:37in the implementation science space.
• 32:39In a paper in 2018 by Sharon
• 32:42Strauss and colleagues in Toronto,
• 32:44they identified at least 159 theories,
• 32:47models and frameworks.
• 32:48So we don't need any more
• 32:50development of these theories,
• 32:51models and frameworks.
• 32:52We just need to figure out
• 32:54which ones work for us.
• 32:56So in my work that I'm doing
• 32:58in the VA with my colleagues,
• 33:00Umm Keith McGuinness,
• 33:01Amanda Midboe, David Snelson,
• 33:03we have something called the bridge.
• 33:05Prairie Bridge is a short name
• 33:07for bridging the care continuum
• 33:09for vulnerable veterans in VA
• 33:11and community care settings.
• 33:13And we're really focusing on how to
• 33:15increase the uptake of three different
• 33:18evidence based practices related
• 33:19to mental health and substance use.
• 33:22We're in each of these projects.
• 33:24Each one is a hybrid Type 3 design.
• 33:25Being implemented in at least
• 33:27six sites around the country.
• 33:29Some of these are VA sites,
• 33:30some of these are community based sites.
• 33:32So for example,
• 33:33the top one veterans with opioid
• 33:35use disorder,
• 33:36this is the homeless overdose
• 33:39prevention expansion program
• 33:41that's being led by Amanda Midvale.
• 33:43And the one on the bottom right is on
• 33:46veterans released from incarceration.
• 33:49This is the pie program.
• 33:51This is called the post Incarceration
• 33:53engagement program and the.
• 33:55Now on the bottom left is the
• 33:59mission CJ program,
• 34:00and this is the maintaining independence
• 34:03and sobriety through systems integration,
• 34:05outreach and networking.
• 34:07Criminal justice,
• 34:08which is why I had to look at my notes
• 34:09because I can never remember that.
• 34:11But in each of these there are there's
• 34:13lots of evidence for this treatment.
• 34:16We are trying to, in some cases,
• 34:19use peers.
• 34:19So having a flexible delivery
• 34:21model and also thinking about who
• 34:23can deliver these interventions,
• 34:24we're using peer specialists.
• 34:26And we're trying to do this in what
• 34:28we're doing this in a hybrid Type 3,
• 34:31which means that our focus is on
• 34:33the implementation strategies.
• 34:34So I'll say more about that.
• 34:36And so here are the projects and
• 34:38I lead the implementation core,
• 34:40which is responsible for overseeing
• 34:43the tracking of the implementation
• 34:45strategies that we're using,
• 34:47focusing on how we can increase
• 34:49the spread and sustainability and
• 34:51making sure that each of the projects
• 34:53is collecting the same outcomes,
• 34:54implementation outcomes and
• 34:56effectiveness outcomes.
• 34:57So that we can make some comparisons
• 34:59across these 18 sites that are involved.
• 35:02Even though there are three different
• 35:04evidence based practices happening,
• 35:06a hybrid Type 3 focus is really on.
• 35:09That's the last hybrid step before
• 35:12truly trying to sustain something
• 35:15in in routine care.
• 35:17And so as a result of that,
• 35:18we decided to use the dynamic
• 35:21sustainability framework as our way
• 35:23of focusing on not just implementation
• 35:26of sustainability and the DSF,
• 35:28which was developed by David Chambers,
• 35:30Russ Glasgow Heart stage Dangy is
• 35:33that we need to constantly assess
• 35:35not just one time,
• 35:37but over time how the intervention
• 35:40fits with the practice setting and
• 35:42fits within the ecological system.
• 35:44So oftentimes we only assess
• 35:46these things once.
• 35:47But we really need to do this overtime.
• 35:49And so we have developed a system
• 35:51of looking at pre implementation,
• 35:52implementation and sustainability
• 35:54across these three hybrid type threes.
• 35:56So we're always learning about what's
• 35:58happening with the intervention,
• 36:00what needed to be adapted,
• 36:02how are things working in that
• 36:03particular practice setting,
• 36:04because sometimes we are in jail
• 36:06settings that are outside the VA,
• 36:08sometimes we are in outpatient settings.
• 36:10So we need to figure out you know what
• 36:12the organizational climate is like,
• 36:14what's the staffing,
• 36:14what kind of training and supervision
• 36:16is needing and then.
• 36:17Certainly the ecological system which
• 36:19is our real world factors like what's
• 36:22happening in the world of policy
• 36:24and regulation and market forces.
• 36:25So a perfect example is that we
• 36:28intended to have these sites,
• 36:30the 12 of the sites that are using peers,
• 36:33higher peers at certain times.
• 36:35So that we could use a cluster
• 36:38randomized stepped wedge design
• 36:40to roll out our evidence based
• 36:42practices to sites at a time.
• 36:44And then COVID hit this actually this
• 36:46grant got funded on October 2020,
• 36:49so we were in the midst of COVID and then
• 36:52the American Rescue Plan Act got funded.
• 36:55The ARPA in VA got lots of
• 36:58money to hire peers.
• 36:59And so even though we had staggered our
• 37:02hiring at peers at these sites to meet
• 37:05with our cluster stepped wedge design,
• 37:08we could no longer have a
• 37:10stepped wedge design because our
• 37:12sites got peers immediately so.
• 37:14In terms of flexible adaptation,
• 37:17we had to switch from a stepped wedge
• 37:20design to more of an adaptive design,
• 37:23and that was a really hard switch
• 37:25in the middle of our planning,
• 37:27but was essential because of
• 37:29the ecological system changes.
• 37:32And one of the things that I'm overseeing
• 37:34is that we are randomizing sites in
• 37:36now are now adaptive designs to either
• 37:39receive high intensity strategies
• 37:41which we're calling implementation
• 37:43facilitation or low intensity
• 37:45strategies of education,
• 37:47outreach and academic detailing.
• 37:48And both of these have very clear
• 37:51definitions of what they are and we
• 37:53are tracking and in a hybrid type 3,
• 37:56the research groups do not do
• 37:58the implementation strategy work,
• 38:00we train people on the sites.
• 38:02Appears that we've hired or in the
• 38:04case of the Hope project we train a
• 38:06lot of the social workers who are
• 38:08involved to actually do the training
• 38:10of the intervention at that site.
• 38:12And so they we are using our
• 38:14implementation strategies with those
• 38:16those people and then they in turn
• 38:19are delivering the intervention.
• 38:20And so I you know often talk about
• 38:23implementation science being
• 38:24just gigantic tracking effort.
• 38:26We track a lot of things.
• 38:28We have calls often with the
• 38:29sites to learn what they're doing
• 38:30and talk to the point of.
• 38:32Contact to learn more about what's happening.
• 38:35We've created dashboard to look at the
• 38:37different outcomes that we are assessing.
• 38:39This is just a fake version just
• 38:41for presentation to show that we're
• 38:43trying to learn about acceptability,
• 38:45appropriateness, feasibility and
• 38:47trying to see if organizational change,
• 38:50readiness for implementing change
• 38:53changes increases, gets worse etcetera.
• 38:56Over the time of the of the project,
• 38:58people will be hired,
• 39:00people will leave at cultural changes
• 39:02will happen.
• 39:03So we're just trying to track all of that
• 39:05and see how that impacts sustainability.
• 39:07We are actually presenting this
• 39:09work as part of a symposium at
• 39:12the DI Conference in in December
• 39:14if people attend that conference.
• 39:17And the other thing that we're
• 39:18doing is we're also keeping track
• 39:20of the qualitative work that we're
• 39:22collecting according to the Dynamic
• 39:24sustainability framework pieces
• 39:25and to see what we can learn from
• 39:27that in order to adapt any of
• 39:29our strategies if needed.
• 39:30And we're also presenting
• 39:32that work at the conference.
• 39:33So the third strategy is that we need to
• 39:35get to know your stakeholders and this is.
• 39:37To go back to the Chalmers piece,
• 39:39we need to be have research that's
• 39:40relevant to the users of the
• 39:42research and we need to provide fully
• 39:44accessible research information.
• 39:45And we can do this if we build these
• 39:47partnerships and these relationships
• 39:49with our stakeholders from the beginning.
• 39:51And so a project that I've done with
• 39:53colleagues and Pittsburgh funded by pecori,
• 39:55this is the heel study.
• 39:57Heel was developed long before the
• 39:59night of heel and in this case
• 40:01heel stands for healing encounters
• 40:03and attitudes list.
• 40:04It's a set of 6 self report questionnaires
• 40:07built on the promise methodology.
• 40:10Really generalizable to any treatment,
• 40:11but we're trying to use them
• 40:13to see what we can,
• 40:14how these measures might be used to reduce
• 40:17opioid use in community based pain clinics.
• 40:21And so these are our measures of treatment,
• 40:23expectancy,
• 40:23patient provider connection,
• 40:25healthcare environment,
• 40:27positive outlook,
• 40:28spirituality added towards
• 40:29towards complementing restorative
• 40:31medicine through spirit.
• 40:33Through our formative evaluation work.
• 40:35We actually decided not to focus
• 40:37on spirituality and attitudes
• 40:38and only use healthcare
• 40:40environment a little bit.
• 40:41So most of the project focuses on treatment,
• 40:43expectancy, patient provider,
• 40:45connection and positive outlook and we
• 40:48partnered every Pecori project has to
• 40:50have stakeholders involved anyway and so.
• 40:51We partnered with the UPMC Pain
• 40:54Medicine Chair, Vice Chair,
• 40:55and even though UPMC is
• 40:57central in Pittsburgh,
• 40:58a lot of their satellite clinics are
• 41:00suburban and some are even considered
• 41:02rural because they read they're
• 41:04like 2 hours away from Pittsburgh.
• 41:06And so it was a really great place to
• 41:08try to do a true implementation project.
• 41:11Carol Greco,
• 41:12who led the project with Ajay Wassan,
• 41:14had already done so much work to show
• 41:16that there was a strong relationship
• 41:18between responses to treatment expectancy,
• 41:20positive outlook.
• 41:21Patient provider relationship and
• 41:23promise measures of pain severity,
• 41:25promise measures of global
• 41:27functioning etcetera.
• 41:28We just wanted now to see can we put
• 41:30these measures into what was already
• 41:32happening in the clinic and the clinic
• 41:35was already using the choir platform,
• 41:37the collaborative Health Outcomes
• 41:39Information Registry and open source
• 41:41web-based patient reported outcome
• 41:43application where patients are sent
• 41:45an e-mail link and or they can
• 41:47complete the survey questions on
• 41:48a clinic pad and the survey is of.
• 41:52The promised measures had started
• 41:53in 2016 and we wanted to roll into
• 41:56this the treatment expectancy,
• 41:58patient provider out,
• 41:59patient provider relationship
• 42:01and positive outlook questions.
• 42:03So this is the kind of report on
• 42:05the promise measures that clinicians
• 42:06in the pain clinics would get
• 42:08before they saw their patients.
• 42:10And so we would be adding in these
• 42:12treatment expectancy questions for example,
• 42:14so that they could look at them.
• 42:15And the whole goal was to try to
• 42:18increase greater conversation about
• 42:20pain treatment between the provider
• 42:22and the patient and reduce opioids
• 42:25hopefully and then refer to other
• 42:27non pharmacological treatments.
• 42:28And so we had a lot of,
• 42:31we did formative evaluation work,
• 42:33we did process evaluation and
• 42:35summative evaluation.
• 42:35But really the intervention here
• 42:37was putting these heel measures
• 42:39into the choir platform,
• 42:40so involved the IT group and then
• 42:43trying to use our strategies to get.
• 42:46Clinic staff to talk to this
• 42:47about with their with their people
• 42:49who check in for the clinic,
• 42:51trying to talk to the providers about it,
• 42:53reminding them that these aren't.
• 42:56Measuring.
• 42:57A.
• 43:01There's evaluation work,
• 43:02and the other work is forthcoming.
• 43:05And here are some examples
• 43:07of treatment expectancy.
• 43:09So Umm, you know,
• 43:10not surprising to any of you,
• 43:13but I'm confident in this treatment,
• 43:15this treatment will be successful.
• 43:16I feel good about this treatment, etcetera.
• 43:18And so our formative work was really to
• 43:20talk to patients and providers and staff
• 43:22to find out what they thought about it.
• 43:24And again, we drew on the theory
• 43:26of diffusion of innovation.
• 43:27So we wanted to know what
• 43:29did they think about it.
• 43:30And we were able to figure out what was the
• 43:32relative advantage of this considered higher,
• 43:34low and so some patients.
• 43:36Said that it was high that, you know,
• 43:38when they go to the pain center,
• 43:39they don't expect to leave pain free.
• 43:41They want their pain just to
• 43:43be manageable or tolerable.
• 43:45They think that their doctor feels that
• 43:47the opioid problem is people not wanting
• 43:48to have pain and but really what they
• 43:50want is just to be able to manage it.
• 43:52And so they felt it would be great
• 43:54to answer these treatment expectancy
• 43:56questions and then to have a conversation
• 43:58with their provider about it.
• 44:00Some providers thought it would be
• 44:02a great idea because they are very
• 44:04interested in treatment expectancy.
• 44:05They know how it affects.
• 44:06Pain perception.
• 44:07And then some patients
• 44:09and providers thought oh,
• 44:10these,
• 44:10you know,
• 44:11these questions are really repetitive
• 44:13and people aren't going to want to
• 44:15listen to this or people aren't going
• 44:17to want to complete these items.
• 44:19And so they were really doubtful about it.
• 44:20And then this gave us some information
• 44:24to develop implementation strategies.
• 44:26And so for patients,
• 44:28we did these FAQ sheets where we
• 44:31look specifically at, you know,
• 44:34these questions seem repetitive.
• 44:35Do I really need to answer these,
• 44:36you know, will my doctor talk to me about?
• 44:38These will these affect my treatment.
• 44:39Those are the kinds of things that
• 44:41we were hearing from patients and
• 44:43our interviews and so we created some
• 44:45educational strategies to address that.
• 44:47For providers,
• 44:47we went a little bit more actively
• 44:50and we created these six videos
• 44:52with our stakeholder champion,
• 44:55the clinic lead about the different
• 44:57types of measures that we were
• 45:00using and really sharing with
• 45:02providers what was important.
• 45:04So they were short,
• 45:06you know two-minute videos
• 45:07that we sent to clinics.
• 45:09The clinics would then do a little red
• 45:11CAP survey to to say that they'd watched
• 45:12it and then you know the Clinton,
• 45:14we had a little competition going,
• 45:16clinics who watched more of the survey,
• 45:20more of the videos,
• 45:22got coffee and Donuts for that week.
• 45:24So just trying to get the word out in
• 45:27an educational strategy and sort of
• 45:29engaging way about why it's important
• 45:31to do this because this project was
• 45:34a true implementation project.
• 45:36It was not a hybrid type three.
• 45:37We did not have any research.
• 45:39Staff in the clinics,
• 45:40we were just trying to remotely
• 45:42convince people at these clinics
• 45:43that this is what they needed to do,
• 45:46and so a real true test of behavior change.
• 45:50And so we're still working on the results.
• 45:52The project has ended in April,
• 45:55but you know over we have these
• 45:56different nine month periods that
• 45:58we looked at and there were a lot of
• 46:00unique patients at these clinics,
• 46:01a lot of patient appointments and
• 46:04we looked at initially did patients
• 46:06complete the surveys and did staff
• 46:08complete looking at those reports
• 46:10because we really didn't have any
• 46:12other way of seeing how engaged
• 46:14they were with these results.
• 46:16So pre implementation of
• 46:18these measures which was 2018.
• 46:21These were sort of our baseline when it
• 46:23was just the patient reported outcomes,
• 46:25just the promise measures in the
• 46:26system surveys were being completed,
• 46:28about 72% of the patients,
• 46:30about 79% of the staff were looking at these.
• 46:32These are pretty high numbers and
• 46:34we didn't know if we'd be able
• 46:36to improve upon that post heal,
• 46:38but still pre COVID around 2019,
• 46:41so post heal implementation,
• 46:43so now the heel measures of treatment
• 46:46expectancy etcetera are in the system
• 46:48are more people completing the surveys.
• 46:51Not really.
• 46:52Our more staff reviewing their reports.
• 46:54No, it's totally the same.
• 46:56And so we had to like up our
• 46:59implementation strategies.
• 46:59We did further educational efforts,
• 47:02we did a retreat.
• 47:03We did started doing journal clubs,
• 47:04we did lunch and learns,
• 47:06then COVID hits and everything
• 47:09went remote and interestingly.
• 47:11As a result of telemedicine,
• 47:13when people could not see their patients
• 47:15and patients could not see their
• 47:17doctors in real life everything was virtual.
• 47:19We had a higher survey completion rates.
• 47:22And we had a higher rate of clinicians
• 47:24and staff looking at those reports and
• 47:27so really indicated that there was
• 47:30a real need for understanding more
• 47:32about how people were feeling about
• 47:34their treatments in this telemedicine space.
• 47:37And when we looked at changes over time
• 47:40in terms of what was happening with,
• 47:43you know, and we and it's not
• 47:45a controlled trial at all,
• 47:460 control on this.
• 47:47We're making a lot of assumptions and of
• 47:49course there are a lot of limitations here.
• 47:51But we can see that from 2018 until now,
• 47:55there's been a big increase in
• 47:57referrals to integrative medicine,
• 47:5950%.
• 48:00And there's been an increase of 19%
• 48:03in referrals to psychiatric and
• 48:05psychological services and maybe.
• 48:08This is a result of having a decrease
• 48:10in prescriptions for opioids,
• 48:11which are down 8 to 14%.
• 48:13Orders for injections are down
• 48:15a little bit and interestingly,
• 48:17orders for physical therapy
• 48:18and occupational also down,
• 48:19and we think it might be because they're
• 48:21referring more to integrative medicine.
• 48:23We also saw a decrease in the
• 48:25number of ER visits and urgent care
• 48:28visits per pain patient.
• 48:30That doesn't mean these visits were
• 48:32not necessarily related to a pain
• 48:34issue that they were experiencing.
• 48:36And so it's just an observation.
• 48:38That we've made.
• 48:39But this is a true implementation project.
• 48:42This is, there's nothing controlled here,
• 48:44there's no research staff.
• 48:45This is just the use of strategies to try
• 48:49to increase the uptake of something that
• 48:51we think will work to change practice
• 48:54behavior and change prescribing behavior.
• 48:56And all built on the formative evaluations
• 48:59and process evaluations that we're
• 49:01doing to learn what's working and
• 49:04what's not working in the clinics.
• 49:06And so the final strategy is that we need
• 49:10to tailor our dissemination efforts more.
• 49:11And this will really help address the
• 49:14Chalmers comment of having unbiased
• 49:16and usable research reports like
• 49:17what can we create for the different
• 49:20audiences and the different groups who
• 49:23need to know more about our efforts
• 49:25to decide that they also want to
• 49:28adopt it and invest in this.
• 49:30And I just will say that Yale
• 49:33has a terrific dissemination.
• 49:34I don't know what you call it,
• 49:37a report, a report on strategies,
• 49:41but I use this all the time.
• 49:43I share it with lots of people.
• 49:45If you aren't familiar with this,
• 49:46it's it's the link is there
• 49:48and I will share these slides.
• 49:49But really talking about these key
• 49:51characteristics of an effective
• 49:52dissemination plan and that number one,
• 49:54is super important to orienting towards the
• 49:56needs of the audience using appropriate
• 49:59language and information levels.
• 50:00And when we are thinking about this,
• 50:02a quarry project that we just completed
• 50:04and how can we start to convince people
• 50:07that they can add these questions,
• 50:09these treatment expectancy, excuse me,
• 50:11expectancy, positive outlook,
• 50:14patient provider relationship
• 50:16questions in a way that may inform
• 50:19the conversations that providers and
• 50:22patients are having and may inform future
• 50:25treatments moving away from opioid use,
• 50:27moving into non pharmacological
• 50:28treatments we think well what is it?
• 50:30That a clinic needs to know what is
• 50:32it that leadership needs to know
• 50:34and we're talking to, you know,
• 50:36small, you know,
• 50:37small clinics around the country.
• 50:38We're talking to larger hospital based.
• 50:41What do they need to know?
• 50:43And honestly what they need to know is
• 50:46what are the costs of implementing this.
• 50:49And luckily,
• 50:50Lisa Saldana,
• 50:50who's at the Oregon Social Learning Center,
• 50:53has worked done a lot of work on
• 50:55something called the stages of
• 50:57implementation completion checklist,
• 50:59which she has also shown can be
• 51:01a way of tracking the costs of
• 51:04implementing these strategies.
• 51:05And these are the eight steps in an
• 51:08implementation pipeline if you will.
• 51:10First,
• 51:10there's a pre implementation phase of
• 51:13engagement understanding, feasibility,
• 51:15readiness planning with a site.
• 51:18So those are considered.
• 51:19The first three steps are pre
• 51:21implementation work and then so besides
• 51:23done all that and they're ready to implement,
• 51:26you can move to the implementation
• 51:27phase which is we hire staff and train
• 51:29them or we don't need to hire staff
• 51:31but we move staff into certain roles,
• 51:33we do some fidelity monitoring we.
• 51:36Maybe the research team provides some
• 51:37consultation to get started up and
• 51:39maybe at that point then someone at
• 51:40the site takes over that consultation,
• 51:42working with the different groups of the
• 51:44clinic on that implementation effort.
• 51:46There's going to be some ongoing
• 51:47monitoring of what's going on.
• 51:49That's the implementation phase.
• 51:50And then obviously we need to
• 51:52understand has true competency been
• 51:54achieved which can lead to sustainment.
• 51:56Each of these eight steps requires the
• 51:59research team to do a lot of tracking
• 52:02of the different efforts involved in
• 52:04every implementation to understand
• 52:06what does engagement mean for me?
• 52:08What does feasibility mean for me?
• 52:10Who's involved with that?
• 52:11But through this meticulous tracking,
• 52:13and especially if you're working
• 52:15with a champion like we were with
• 52:17the head of the Pain Medicine Group,
• 52:19we could start to identify what does
• 52:20that mean in terms of minutes and what
• 52:23does that mean in terms of costs for
• 52:25the people who are working on this.
• 52:27And so through a lot of work we did a cost,
• 52:30we got an extension for Macquarie to do
• 52:31a cost of implementation enhancement.
• 52:33We tracked costs from March 1st
• 52:35to November 30th of 2021.
• 52:37We found that at this point
• 52:39there were 24,000 patients.
• 52:41This involved 74 clinic personnel.
• 52:43We could figure out when people
• 52:45moved from a pre implementation to
• 52:47an implementation to a sustainment
• 52:49phase in each of these clinics.
• 52:51And then we also could figure out
• 52:53who at each of the clinics was
• 52:55working on this and so in general.
• 52:57We collected costs that are going
• 52:59to help a future clinic decide
• 53:01do they want to invest in this,
• 53:03what is this going to mean for
• 53:05us at what's the bottom line.
• 53:07And so looking at attending physicians,
• 53:09mid level providers, nurse managers,
• 53:11nurses etcetera,
• 53:12including front desk staff
• 53:14because they're very important.
• 53:15We found that one hour of heal
• 53:19implementation of tracking,
• 53:21you know the input,
• 53:22you know for everything from encouraging
• 53:25people to complete the surveys sending out.
• 53:28Survey links reminding them
• 53:30downloading reports, looking at them,
• 53:33having conversations, etcetera.
• 53:34But that was about $572 per hour.
• 53:39Per clinic and a 10 minute increment for
• 53:42all clinic staff is about $95 because
• 53:44not everything happens in an hour time,
• 53:46sometimes just little bits and pieces,
• 53:48which means that a total implementation
• 53:51cost for heal is about $28,000.
• 53:53And so this is now something that we
• 53:56can disseminate to clinics to think
• 53:59about is this worth your investment
• 54:02and if people think about what having?
• 54:05Patients use opioids has led to and
• 54:08what that crisis is like and what
• 54:10they might be saving elsewhere.
• 54:12This is the kind of decision making
• 54:14that can happen in terms of deciding
• 54:16whether or not to adopt or not
• 54:17adopt an innovation or in this
• 54:19case an evidence based practice.
• 54:21So in summary,
• 54:22we've talked about a lot of things that
• 54:24can address the implementation gap and
• 54:26reduce waste and research by increasing
• 54:28uptake of evidence into the community.
• 54:30We talked about using hybrid study designs,
• 54:33be guided by theory,
• 54:34get to know your stakeholders and
• 54:36tailor your dissemination efforts.
• 54:38And throughout it all,
• 54:40we hope that HealthEquity can be achieved
• 54:42through using pragmatic real-world research.
• 54:45Few, if any exclusions, we take all comers.
• 54:49Research is meaningful to the end users.
• 54:51Adaptation needs are considered
• 54:53at the beginning so that we're
• 54:55not implementing something that
• 54:56isn't going to work in real world.
• 54:59And we also can start to
• 55:00incorporate new ways of thinking,
• 55:01and I didn't really talk about this yet,
• 55:02but this is what is going on right now
• 55:04in the HealthEquity space is how can
• 55:06we take the existing theories that
• 55:07we have and just and just incorporate
• 55:09new ways of thinking into them.
• 55:11So if we're thinking about did we reach
• 55:13people we can think about or who's adopting,
• 55:16we can answer ask questions that have
• 55:19a HealthEquity perspective to them.
• 55:21So did all settings equitably
• 55:22adopt the intervention?
• 55:24Are the health impacts that we
• 55:25see equitable across all groups?
• 55:27Are all populations?
• 55:28Equitably reached by this intervention.
• 55:31So just taking our theory but thinking
• 55:33about them in new ways in which we
• 55:35can achieve HealthEquity and that's
• 55:37definitely something a goal for me.
• 55:39I'm not yet there trying to do that
• 55:41with like current projects and hope it
• 55:44becomes something that we do all the time.
• 55:47And with that, I'll stop.
• 55:48Thank you very much.
• 55:50Thank you so much.
• 55:52Really enjoyed your presentation.