Laura Damschroder, MS, MPH, Implementation Scientist, ESCALATES
It sometimes seems like there are two separate worlds when it comes to figuring out how to deliver the very best medical care to all patients equally well everywhere. Researchers, in their world, are saying, “We’ve tested hundreds of interventions that improve care in clinical trials, why aren’t patients receiving this care?” While clinicians, in their world, are saying, “Why aren’t you producing interventions and best practice recommendations we can use and that we need to solve our problems?”
The disconnect between these two worlds contributes to the long time it takes to get the best care to patients; researchers mostly work in a protected world of laboratories and tightly controlled clinical trials, while clinicians work in a world of constantly changing complexity and challenges. Through implementation science, EvidenceNOW and ESCALATES are working to bridge these two worlds together so researchers can apply scientific approaches to solve real challenges faced by clinicians who serve diverse populations of patients. This approach is needed to bridge both worlds so researchers can learn from clinicians and clinicians can learn and implement meaningful new evidence generated by researchers to continuously improve the lives of the patients they serve.
This approach is needed to bridge both worlds so researchers can learn from clinicians and clinicians can learn and implement meaningful new evidence generated by researchers to continuously improve the lives of the patients they serve.
The world of medical science is focused on the discovery of new knowledge that can lead to new or life-improving treatments and devices. For example, there may be a new treatment for reducing blood pressure that reduces the risk of heart attack. The vast majority of all research funding goes toward this type of discovery and the scientists who work in this world must work in very exacting conditions: in labs that are free of outside (contextual) influences (regarded as contaminants). When a new substance or intervention has been identified, and can be packaged into a treatment that can be delivered reliably (for example, in a pill or a structured program), trials in humans are funded. Like lab conditions, these trials require human study participants who meet exacting criteria such as people within a specific age range with diabetes and no other complicating conditions. When there is enough evidence that a treatment under these conditions helps people (e.g., reduces heart attacks), scientists may then agree that a new clinical practice guideline is needed that includes that treatment. The guideline is based on expert opinion and evidence from controlled trials, and provides recommendations for clinicians and clinical teams for their patients. This is the “typical” research pathway by which evidence-based practices develop.
Evidence-based practice information is relatively abundant, but its implementation occurs at a snail’s pace because too often the bridge to connect this world to the world of clinicians is missing. The bridge is important because the reality is that every primary care clinician is embedded in a complex practice setting, which itself, is embedded in a milieu of multiple layers of influences that may change week by week and that may enable or block use of a new treatment. Clinicians treat complex patients who, for example, have not only diabetes but also hypertension, hypocholesteremia and chronic pain. This is a complex world of practice where clinicians feel like their challenges are unique and each clinician too often feels isolated and overwhelmed with the flood of evidence-based practices being generated without a bridge to translate that information into action. This is the world in which practice-based evidence is developed; where methods, techniques, and evidence are created to determine how to take those guidelines and implement them to improve the health of patients within a setting of uncontrolled patient complexity. One challenge is that only pennies are spent for each dollar that is spent on generating evidence-based practices, so it’s hard to keep up! Unfortunately, more often than not, the bridge between the two worlds of evidence-based practice and practice-based evidence fails to connect.
Implementation scientists are attempting to build a bridge between the two worlds by taking guidelines and exploring how to use them in highly uncontrolled contexts.
Fortunately, there are positive signs of change. Implementation scientists are attempting to build a bridge between the two worlds by taking guidelines and exploring how to use them in highly uncontrolled contexts. Implementation scientists in this practice-based world embrace complexity rather than attempt to control or ignore it. Networks of practices and communities are banding together to weave webs of knowledge with the vision of enabling every patient of every practice across highly diverse settings to equally share in the benefits of new treatments.
The ESCALATES national evaluation team, as part of the EvidenceNOW initiative, is leveraging implementation science approaches to focus on generating practice-based evidence about which implementation strategies (which bridges) are ideal in which practice settings. The ESCALATES evaluation will provide compelling insights into the impact of primary care extensions on primary care practices’ abilities to integrate the evidence-based ABCS guidelines to benefit their patients. The power of knowledge gained through the experiences and accomplishments of these entities will be amplified by this unprecedented opportunity to learn from seven outstanding extension services reaching out to 1500 practices in 12 different states. Then, ultimately, scaling that knowledge more broadly to build the two-way bridge between the evidence-based practice world and practice-based evidence world needed to improve patient care – because neither world is complete on its own.