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  • 1. International Journal for Quality in Health Care 2002; Volume 14, Number 3: pp. 233–249Translating research into practice:the future aheadCYNTHIA M. FARQUHAR1, DANIEL STRYER2 AND JEAN SLUTSKY31Center for Practice Technology Assessment, Agency for Healthcare Research and Quality, 2Center for Effectiveness and OutcomesResearch, Agency for Healthcare Research and Quality and 3National Guidelines Clearinghouse, Center for Practice TechnologyAssessment, Agency for Healthcare Research and Quality, Rockville, MD, USAAbstractObjective. To summarize and analyze the focus and methodologies of the Translating Research into Practice (TRIP) projectsfunded in 1999–2000 by the US Agency for Healthcare Research and Quality (AHRQ).Data sources and study design. An analysis of the successful applications for the TRIP I and II requests for applicationsin 1999 and 2000 was produced from the data collected.Data collection. The following items were abstracted from each of the successful applications: provider focus, patientpopulation, vulnerable populations, methodologies, interventions for change, outcomes measured, and conceptual frameworkused.Principal findings. AHRQ funded 27 TRIP grants in 1999 and 2000. A wide variety of health care providers, settings, andpatients were the target of the grants. The most common study design was a randomized controlled trial. The most commonTRIP interventions were educational and the most common frameworks were either adult learning theory or organizationaltheory. More than half of the projects planned to use information technology and half the projects had a focus on reducingerrors.Conclusions. The TRIP projects encompass a broad range of providers, environments, patients, and interventions. Thefield of applied research and quality improvements should be considerably enhanced by these research projects.Keywords: applied research, decision aids, evidence-based medicine, guidelines, implementation, quality improvements,research evidenceClinicians are increasingly challenged to provide quality health help improve health outcomes if it could be implementedcare in the midst of an environment of increasing health successfully.care choices, rising expectations, constrained resources, and Although a number of strategies for implementing changeincreasing complexity of delivery systems. A definition of have been proposed, research evidence to guide this phase ofquality health care is often elusive, but the key components the process is lacking [4]. These strategies include continuingare health care that is effective, efficient, up to date, and medical education, self-instructed learning, academic detailing,timely [1,2]. Providing ‘the right care, at the right time, for audit and feedback, provider reminder systems, incentives,the right person, in the right way’ is one way of describing local opinion leaders, outreach visits, continuous qualityquality health care [1]. In order to achieve at least some of improvement initiatives, clinical information systems, andthese goals, it is necessary to use the findings of well designed computer decision support systems. Despite a number ofresearch studies and translate them into everyday practice. randomized controlled trials of quality improvement andDespite these best efforts to improve access to research implementation initiatives, considerable gaps in the researchinformation, the impact on clinician behavior or patient evidence remain [2,5–8].outcomes has been limited. For example, a recent review of Fortunately, some research has already demonstrated thatpublished studies on the quality of care received by Americans implementation of available research evidence is worthwhile,found that only 60% of patients with chronic conditions as significant improvements in health outcomes will accruereceived recommended care [3]. In most of these conditions, [9–12]. Although no one successful strategy currently exists,research evidence of effective strategies exists that could a combination of different strategies may be effective inAddress reprint requests to C. M. Farquhar, Department of Obstetrics and Gynaecology, National Women’s Hospital,Auckland, New Zealand. E-mail: c.farquhar@auckland.ac.nzPublished by Oxford University Press 233
  • 2. C. M. Farquhar et al.achieving behavior change. The impact of implementation Methodologies that were sought included qualitative stud-strategies will depend on the context in which they are ies, quantitative research, and empirical work. In order toapplied, and will be influenced by factors including incentives, monitor and account for secular changes in practice patterns,health care settings, practitioner and patient perceptions, and studies employing control group designs were strongly en-the desired behavior change [13]. However, too little is known couraged. It was emphasized that to ensure internal andabout which combinations of implementation strategies are external validity, reliability, and transferability, the evidenceeffective in which clinical contexts and for which clinical needs of organizations that might eventually implement sim-conditions. These realities compound the problem of getting ilar interventions should be considered. Strategies to reduceevidence into practice. bias such as use of randomization or concurrent comparisons With these concerns in mind, the Agency for Health Care were recommended. Applicants were further asked to con-Policy and Research [known since December 1999 as the sider the potential of evidence-based tools. They were alsoAgency for Healthcare Research and Quality (AHRQ)] an- encouraged to consider the effect of local circumstances suchnounced its interest in grant applications focusing on trans- as specific populations, diverse health settings, resourceslating research into practice (TRIP) in January 1999 [14]. constraints, and political context on both the implementationThese proposals were known as the TRIP I grants, and were process and the outcomes of care.awarded late in 1999 and in 2000. A further request forapplications (RFA) for translating research into practice (TRIPII) was announced in December 1999 and these grants were Methodsawarded in September 2000 [15]. The overarching goal ofthe RFAs was to support the evaluation of interventions The objective of this paper is to summarize and analyze thewhose aim was to improve the outcomes, quality, effect- focus and methodologies of the TRIP projects funded iniveness, efficiency, and/or cost-effectiveness of health care 1999–2000 by the AHRQ. The paper was compiled frombased on findings derived from sound research. The in- the successful applications for the TRIP I and TRIP IIterventions would be evaluated for their effectiveness at funding rounds in 1999 and 2000. The following items werechanging processes and/or outcomes of care, as well as onwhether they are sustainable, reproducible, and generalizable. abstracted by one author (CMF) from each of the successfulA second goal was to demonstrate that the translation of applications: provider focus, patient population, vulnerableresearch into practice leads to measurable and sustainable populations, methodologies, interventions for change, out-improvements in health care. comes measured, and conceptual framework used. The ap- Broadly, these RFAs encouraged research related to in- plications were categorized by this author in consultationnovative strategies for implementing evidence-based tools with the co-authors. Categories for the conceptual frameworksand information among practitioners caring for diverse popu- included adult learning, social influence, marketing and sociallations in a variety of health care settings. A range of marketing, organizational theory, and behavioral theory [17].interventions was suggested, including: structural and or- Adult learning theory and health education theory focusganizational changes, comprehensive quality improvement on personal motivation to change and active participation ofsystems, computerized drug information and dosage, clinician the learner [18,19]. Social influence theories focus on the rolereminders, audit and feedback methods, interactive systems of social support, peer approval, and role models in promotingto facilitate shared decision making, computer systems to behavior change [20]. Marketing and social marketing theorydeliver educational materials at the point of care, and clinical together provide a framework for identifying factors thatpractice guidelines and protocols. In addition, the RFAs drive change and meet the needs of the target group [21].encouraged applications from studies addressing how or- Organizational theory focuses on the environmental contextganizational research could be translated into practice, the within which clinicians function as a key determinant ofimpact of organizational variables on clinical translation, whether innovations are utilized, and the emphasis is onand the organizational and structural context of successful organizational and structural factors that may hinder orinterventions needed to facilitate replication. facilitate changes in practice [22]. Behavior theory, which Applicants were encouraged to address conditions and focuses on environmental cues and reinforcement such assettings where the most improvement was likely to occur, audit and feedback, is seen to be central in encouraging andwhere wide variability in practice currently existed, where maintaining behavioral change [19].wide disparities in care existed for racial/ethnic minorities, To learn more about the TRIP I and II research projectsand where a large burden of disease and poor quality of life and to promote exchange of ideas among the TRIP re-were documented. The funding priority also focused on at searchers, the AHRQ designed a series of activities to takeleast one of the six specified areas of the President’s Race advantage of the similarities and differences among projectsand Disparities Initiative (infant mortality, cancer screening both in research design and execution of the studies. Previousand management, cardiovascular disease, diabetes, HIV in- experience had led the AHRQ to believe it was likely thatfection/AIDS, and child and adult immunizations), as well recruitment problems, contamination issues, and problemsas mental health and pediatric asthma [16]. Of particular concerning stability of delivery systems were challenging forinterest were interventions that used the strengths of in- implementation research. Since many of these obstacles canformation systems for implementing evidence-based strategies be difficult to overcome, it was thought that the investigators,for health care improvement. the AHRQ, and eventually the research community could234
  • 3. Table 1 Summary of the TRIP I and II grants TRIP I .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 1. Balas Point of care Family Patients of family physicians Adult learning Computer decision support % of patients (who are) University of Missouri, delivery of physicians (diabetes, acute myocardial theory system with interactive treated in accordance Columbia University, research infarction, heart failure, Organizational electronic guidelines with with evidence and Duke University evidence pneumonia, stroke/transient theory feedback, including resources guidelines Randomized controlled trial ischemic attack/atrial and education fibrillation, breast cancer) 2. Chin Improving Health care Indigent vulnerable patients Adult learning Breakthrough series of Quality of care University of Chicago, diabetes care providers at with diabetes who attend Organizational communication/behavior standards Bayer Institute collaboratively community community health centers theory interventions: extended training Randomized controlled trial in the health in quality management and community centers chronic disease model, brainstorming and problem solving, patient–provider communication 3. Davis Pediatric Pediatricians Children with otitis media, Organizational Evidenced-based decision Changes in provider University of Washington evidence- and family acute sinusitis, allergic theory support system behavior Randomized controlled trial based phyisicians rhinitis, bronchiolitis Marketing theory medicine 4. Feldman Evidence- Home Patients with cardiac heart Behavioral theory Electronic ‘just in time’ Process measures Visiting nurse service of based visiting failure and cancer Organizational reminders, follow-up with Patient health status New York/Johns Hopkins reminders in nurses Two-thirds of the patients theory experts, clinical practice Use and cost of health University home health are female Medicare guidelines, and patient care services Randomized controlled trial care recipients education continued235 Translating research into practice
  • 4. 236 Table 1 continued C. M. Farquhar et al. TRIP I .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 5. Gurwitz Reducing Health care Long-term care residents Organizational Computer-based clinical Reduction in adverse Universty of Massachusetts adverse drug providers at theory decision support systems drug events Randomized controlled trial events in long stay nursing resident care homes units 6. Holmes-Rovner Patient Mixed: Patients following a Social influence Decision support and coaching Physician prescribing, Michigan State University decision physicians, myocardial infarction theory health behaviors, Comparative study support and nurses Adult learning functional status, counselling theory cholesterol measurements, utility, patients perception 7. Horbar Evidence- Pediatricians Neonates at risk of Social influence Multifaceted approach to Patient outcomes of University of Vermont/ based respiratory disease syndrome theory education by training mortality, treatment University of Alabama/ surfactant Adult learning workshops, reviewing evidence, given, time to first Vermont Oxford Network treatment for theory feedback and audit, and peer dose, chronic lung Randomized controlled trial pre-term comparisons disease, infection infants 8. Katz Improving the Emergency Patients with unstable Cognitive Linking adherence to guidelines Patient outcomes University of Wisconsin evidence for department angina feedback/ to patient outcome related to unstable Randomized controlled trial unstable physicians knowledge angina angina guidelines continued
  • 5. Table 1 continued TRIP I .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 9. Manfredi Smoking Health care Women in maternal and Organizational Academic detailing for Provider compliance University of Illinois control in providers in child health clinics theory providers, train the trainer with AHRQ guidelines Randomized controlled trial maternal and maternal and (pregnant, post-partum, Adult learning workshop Reduction in patients’ child health child health well-child, family planning theory Patients’ access to centralized smoking clinics clinics services) telephone counseling 10. Morrison Interventions Inpatient Surgical and medical Adult learning Education of nurses and Change in pain intensity Mt Sinai School of Medicine to improve units inpatients theory physicians Pain relief Comparative study pain outcomes Behavioral theory Patient education Analgesic prescribing Marketing theory Audit and feedback practices Computer decision support system 11. Shafer Do urine tests Nurses in Sexually active teens Adult learning Educational: targeting and % urine testing for University of California San increase outpatient theory training clinic nurses, 5 hour Chlamydia testing in Francisco/Kaiser Chlamydia pediatric workshop sexually active Randomized controlled trial screening in clinics adolescents (part of teens? (HMO) HEDIS reporting) 12. Swartz Practice Physicians Cigarette smokers Adult learning Personalized data feedback and % of patients with Maine Medical Assessment profiling to theory educational office visits tobacco status Foundation increase (profiling) ascertained by providers Randomized controlled trial tobacco and practice cessation Patients and provider survey continued237 Translating research into practice
  • 6. 238 C. M. Farquhar et al. Table 1 continued TRIP I .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 13. Thompson Translating Primary care Adolescents aged 14–20 Adult learning Opinion leaders, measurement Adherence to guidelines Group Health Puget Sound Chlamydia physicians of years theory and feedback, prompts, and for chlamydia measured Randomized controlled trial guidelines into an HMO Behavioral theory chart prompts by the % of females practice Social influence tested for Chlamydia theory 14. Titler Evidence- Nurses and Elderly patients with hip Organizational Guideline development Rate and extent of University of Iowa, based practice: physicians in fracture theory: Rogers’ Acute pain management in the innovation adoption by partnership with 12 acute pain hospitals (1995) model for elderly nurses and physicians hospitals in the Midwest management diffusion of Quick reference guides Nurse and physician Randomized controlled trial in the elderly innovation Incorporation into existing perceived barriers to policies and procedures use of evidence-based Focus groups guidelines Education and use of nurse Cost of delivering an and physician leaders intervention that Web-based, video, and written promotes adoption of resources evidence-based Use of change champions and guidelines core group approach continued
  • 7. Table 1 continued TRIP II .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 15. Allison An internet Primary care Women at risk of Chlamydia Adult learning Internet-based learning % of women at risk University of Alabama/US intervention providers trachomatis aged between Audit and feedback screened for Chlamydia Quality Algorithms to increase 16 and 26 years old Case-based medical education trachomatis (HEDIS) Randomized controlled trial Chlamydia screening 16. Bates Improving Primary care Patients (not specified) Organizational Electronic reminders, electronic Guideline compliance, Partners Health Care System quality with physicians theory links to evidence-based utilization, quality of Randomized controlled trial outpatient Behavioral theory information care decision support continued239 Translating research into practice
  • 8. 240 Table 1 continued C. M. Farquhar et al. TRIP II .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 17. Borbas Improved Hospitals Ischemic stroke patients Social marketing Use of formal hospital Guideline adherence: Minneapolis Medical utilization of Behavior theory leadership teamed with the appropriate use of Research Foundation, ischemic informal medical opinion thrombolytic and aspirin Hospital consortium stroke research leaders and the feedback of therapy, avoidance of Randomized controlled trial organizational data as well as excessive blood pressure clinical data at the intervention reduction, early sites mobilization, anti- embolism efforts, patient and family education, therapy assessment within 48 hours, long-term anti- thrombotic therapy and planning for anti- hypertensive management at discharge 18. Cloutier Use of a Primary care Children with asthma Organizational Asthma management program Guideline adherence, University of Connecticut/ pediatric providers theory (Easy Breathing) utility rates, prescription ConnectiCare (IPA, MCO) asthma Marketing/social rates, hospital and Randomized controlled trial management marketing emergency room rates, program by patient, family, and providers provider satisfaction, through a quality of life, cost MCO continued
  • 9. Table 1 continued TRIP II .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 19. Fifield Better Primary care Children with asthma Organizational Guideline prompts at point of Process data: asthma University of Connecticut pediatric providers theory care action plans Health Center/Community outcomes Adult learning Family education Patient data: symptom Health Network of through control Connecticut, Inc, Medicaid chronic care Health-related quality of MCO life Comparative study Pharmaceutical use Emergency room visits and hospitalization Cost 20. Gerber Multimedia Primary care Patients with diabetics Adult learning Computer-based education for Patient knowledge, self- University of Illinois, Cook diabetes providers patients with diabetes efficacy and self-care, County Hospital education glycosylated Ambulatory Network hemoglobin, patient and Randomized controlled trial staff satisfaction 21. Irwin Implementing Primary care Adolescents Organizational Training and use of evidence- Rates of delivery of University of California, San adolescent providers theory based medicine tools preventive services and Francisco/Kaiser preventive adolescents Permanente guidelines Randomized controlled trial continued241 Translating research into practice
  • 10. 242 Table 1 continued C. M. Farquhar et al. TRIP II .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 22. Jones Improving Nursing Nursing home residents Organizational Translation of multiple clinical Process measures: University of Colorado, pain home staff theory—diffusion practice guidelines for pain into Identification of Area Health Education management of innovations training residents in pain Centers in nursing Videos for staff and Medication Comparative study homes educational videos for residents appropriateness and their families Staff survey of Also use of chart review and knowledge and attitudes feedback to physicians Outcomes measures: Creation of an internal pain Assessment of pain team Improved staff knowledge and attitudes about pain management Improved organizational policies related to pain Cost 23. Levine Translating Nurses and Low income patients who Organizational Nurse-mediated prevention Proportion of Meharry Medical College/ prevention physicians require preventive services theory reminders preventive services Meharry Medical Practice research into delivered for infant Plan practice mortality, cardiovascular Randomized controlled trial disease, cancer screening, HIV/AIDs, and adult and child immunization continued
  • 11. Table 1 continued TRIP II .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. 24. Loeb Optimizing Nursing staff Residents of nursing homes Organizational Implement evidence-based Reduction of antibiotic McMaster University, antibiotic use in nursing theory clinical algorithm by use Hospital Network in long-term homes Marketing theory teleconferencing, site visits, Randomized controlled trial care distribution of printed material, workshops 25. Ornstein Prevention of Primary care Patients who receive Adult learning Academic detailing and Guideline Medical University of South coronary heart physicians preventive services Social influence electronic medical record adherence—15 process Carolina/Practice Partners disease and theory through practice site visits, measures Research Network cerebrovascular Organizational sharing of quality improvement Randomized controlled trial disease theory techniques by investigator Marketing theory meetings, ongoing support by project investigators 26. Vargas Developing Head Start Pre-school children with Organizational Multifaceted asthma case Process outcomes: Arkansas Children’s Hosp an asthma personnel asthma theory management model Attendance Research Institution/Head management Marketing theory Start sites model for Head Start children continued243 Translating research into practice
  • 12. 244 C. M. Farquhar et al. Table 1 continued TRIP II .............................................................................................................................................................................................................................................................................................................. Principal investigator/ Health care Conceptual/ organization/collaborators/ providers Patient population/ theoretical study design Project title involved condition framework TRIP intervention Outcomes .............................................................................................................................................................................................................................................................................................................. Randomized controlled trial Adult learning Patient outcomes: Asthma-related school absences Asthma symptoms Quality of life for parents and children Medication use Cost 27. Watson A model of Nursing staff Residents of nursing homes Organizational Identify, evaluate and follow up Guideline adherence University of Rochester/ use of urinary in nursing theory cases of urinary incontinence (eight parameters) Nursing home network incontinence homes Adult learning Comparative study guidelines in nursing homes MCO, managed care organization.
  • 13. Translating research into practiceTable 2 Key dimensions of translating research into practice projects Focus on disparities/Health care Grantee Patient vulnerableprovider institution Collaborators1 population1 populations1 Condition focus Setting Location.............................................................................................................................................................................................................................Primary care University University Nursing Ethnic/ Asthma (3) [18, Home/ Urban (7)providers (10) (22) [1–3, networks (10) home racial (13) 19,26] community [7,8,10,11,[1–3,12,16,19,20, 5–11,14–16, [1–3,5,10,12,16, residents (4) [2,4,9,14,16, (18) [1–4,6, 16,18,21]21,23,25] 18–25,27] 17,23,24] [5,22,24,27] 19–23,25,26] 9,11–13,15, 16,18–21, 23,25,26]Hospital staff Research MCO (6) Children/ Children/ Pain Inpatient Rural (only)(4) [7,8,14,17] Foundation/ [11–13,18,19, adolescents adolescents management (4) (5) [7,8,10, (0) institute (3) 21] (8) [3,7,11, (7) [3,7,11, [4,10,14,22] 14,17] [12,17,26] 13,18,19,21, 13,19,21,26] 26]Nursing staff (5) MCO (1) Commercial (1) Elderly (3) Elderly (9) Urinary Nursing Mixed (20)[3,4,11,22,27] [13] [15] [4,14,17] [4–6,10,14, incontinence (1) home (4) [1–5,9, 17,22,24,25, [27] [5,22,24,27] 12–15,17, 27] 19,20, 22–27]Multidisciplinary Nursing Provider Medicaid/ Medicaid/ Infections/group (10) [5,6, service (1) network (5) indigent (4) indigent (4) antibiotic use9–11,13,15,18, [4] [2,9,17,20,25] [2,9,12,23] [2,9,12,23] (2) [3,24]24,26] Nursing home Population Diabetes (2) networks (2) based (4) [2,20] [5,27] [1,10,15,16] Hospital Disease Cardiovascular networks (4) specific (5) disease (5) [4,6, [6–8,14] [6,8,17,20, 8,17,25] 25] Other (2) [22, Prevention 26] services (8) [7,9, 11–13,15,21,23]MCO, managed care organization.1 More than one category possible.Total number of projects in the named category is given in parentheses, and reference number of project is in square brackets, listedbelow by principal investigator (see Table 1).1. Balas; 2. Chin; 3. Davis; 4. Feldman; 5. Gurwitz; 6. Holmes-Rovner; 7. Horbar; 8. Katz; 9. Manfredi; 10. Morrison; 11. Shafer; 12.Shwartz; 13. Thompson; 14. Titler; 15. Allison; 16. Bates; 17. Borbas; 18. Cloutier; 19. Fifield; 20. Gerber; 21. Irwin; 22. Jones; 23. Levine;24. Loeb; 25. Ornstein; 26. Vargas; 27. Watson.benefit by promoting formal venues for discussion among The coordinating committee incorporated the findings fromthe investigators. In addition, all of the TRIP projects were the TRIP I meeting into planning for the TRIP II initiative.limited to 3 years, so it was important that study problems After the TRIP II grants were awarded, the coordinatingbe addressed early and effectively. committee held a meeting of the principal investigator and After the awarding of the TRIP I grants, AHRQ formed partner from each TRIP II project. This meeting had thean internal coordinating committee to plan and support the same purpose as the previous meeting of TRIP I investigators,TRIP II initiative, and convened a meeting of the TRIP I in addition to the goal of establishing a TRIP II steeringinvestigators. Grantees were asked to give a brief overview committee made up of representatives of TRIP II in-of their methods, problems anticipated or experienced, and vestigators and partners and the AHRQ. The major goalsthe importance of their research. The discussion confirmed for the steering committee are to continue to develop thethe AHRQ’s belief that some of the impediments to per- science base for implementation, provide leadership to theforming this type of research are not isolated or insignificant. field, advance methods for the study of TRIP, lead the 245
  • 14. C. M. Farquhar et al.Table 3 Features of study methodology Focus on guidelines or performance Unit of Framework forStudy design measures randomization Unit of analysis1 change1 Project evaluation1 .............................................................................................................................................................................................................................Randomized National (14) Hospitals (3) Hospital (3) Adult learning/ Process outcomescontrolled trial [4,8–10,12,14,15, [7,14,17] [7,14,17] health education (5) [10,21,22,25](22) [1–5,7–9, 19–23,25–27] theory (16) [1–3,6,7,11–18,20,21, 9–13,15,19,20,25–27]23–26]Comparative (5) Professional Provider (5) Provider (5) Social influence Provider outcomes[6,10,19,22,27] organization (5) [1,3,4,16,21,23] [3,12,13,18,21] theory (4) [6,7,13,25] (6) [3,6,12,18,20,22] [2,3,7,17,18] Local/adapted (4) Practices/clinics Practice/clinic Marketing/Social Hospital/nursing [1,6,16,24] (6) [11–13,15,18, (2) [18,25] marketing theories home/practice 25] (7) [3,10,17,18, outcomes (13) [5,6, 24–26] 7,11,13,14,17,18,21, 23–25,27] HMO/HEDIS Community Community Organizational Patient outcomes measure (2) [13,15] health centers/ health centers/ theory (17) [1,2,4,5,9, (17) [1,2,4,6,8,9,10, maternal and maternal and 11,14,15,18–27] 12,14–16,18–22,26] child health child health clinics (3) [2,26] clinics (1) [11] Nursing homes Nursing homes Behavioral theory/ Cost (12) [2–4,6,10, (2) [5,24] (4) [5,22,24,27] cognitive feedback 13,14,16,18,20,22, (6) [4,5,8,13,15,17] 25] Patient (3) [8,20] Patients (15) Preceed/proceed Qualitative (4) [1,2,4,6,8–10,12, model (10) [4,7,10, [2,22,24,25] 14–16,19,20,25, 11,13,15,16,21,22] 26] Not randomized Roger’s diffusion of controlled trials innovation model (1) (5) [6,10,19,22,27] [14]MCO, managed care organization.1 More than one category possible.Total number of projects in the named category is given in parentheses, and reference number of project is in square brackets, listedbelow by principal investigator (see Table 1).1. Balas; 2. Chin; 3. Davis; 4. Feldman; 5. Gurwitz; 6. Holmes-Rovner; 7. Horbar; 8. Katz; 9. Manfredi; 10. Morrison; 11. Shafer; 12.Shwartz; 13. Thompson; 14. Titler; 15. Allison; 16. Bates; 17. Borbas; 18. Cloutier; 19. Fifield; 20. Gerber; 21. Irwin; 22. Jones; 23. Levine;24. Loeb; 25. Ornstein; 26. Vargas; 27. Watson.dissemination of TRIP II results, advise the AHRQ on future The key dimensions of the projects are presented in TableTRIP initiatives and on development of an agency toolbox 2. The grants focused on a wide variety of health careof implementation tools and research aids, and conduct providers and patients. Primary care providers (10) andexternal evaluation. The steering committee is chaired by a multidisciplinary teams (10) were the most frequent healthTRIP II investigator and has established several working care providers. Collaborators were most often provider orsubcommittees. The steering committee meets at least twice university networks (21) and only six were managed carea year with ongoing communication via conference call, organizations. Children were the most common patient popu-E-mail, and ad hoc meetings of subcommittees. lation (eight) followed by nursing home residents (four) and Medicaid beneficiaries (four). Nearly half of the studies included substantial numbers of patients from different ethnicResults and racial groups. Prevention services were a common focus (eight), as was cardiovascular disease (five). Eighteen of theA total of 27 grants were awarded, 14 TRIP I grants in 1999 studies were community-based and the remainder hospital-and 2000, and 13 TRIP II grants in 2000. A description of (five) or nursing home-based (four).each of the grants is given in Table 1. The study methodologies are presented in Table 3. The246
  • 15. Translating research into practiceTable 4 Categories of targeted health care processes Medium of contact with Focus onClinical health care Types or components of information Focus onprocess providers1 TRIP interventions1 Service function1 technology1 reducing errors1.............................................................................................................................................................................................................................Screening/ Face-to face Education Patient encounter Computer- Point of carepreventive meetings (14) services: assisted decision reminders (7)services (10) [2,4,6,7,9,11–13, support systems [1,2,4,11,14,15,[6,7,9,11,12, 17,21,22,24,25,27] (11) [1,3,5,6,10, 25]13,15,21,23, 14–16,19,22,25]25]Diagnostic: Standard mail (1) Educational outreach visits/ Telephone contacts Electronic Prescribing [24] academic detailing (12) [4,6,9, (3) [2,6,9] reminders (3) reminders (4) 10–14,17,21,22,25,27] [1,13,16] [3,5,6,24]Treatment Telephone, fax, Opinion leaders (11) [4,6,7,9, Ambulatory Electronic Tracking(7) [3,4,5,10, and computer- 11–14,17,24,25] contacts (15) [1–3, medical record systems for14,22,24] based 9,11,13,15,16, (4) [1,16,25,26] abnormal results communication 18–21,24–26] (1) [16] (12) [1,3–6,10,11, 15,16,19,24,26]All aspects Other broadcast Other educational activities Emergency Educational Other (1) [8]of care (12) media (1) [22] (7) [2,4,7,9,15,18,21] contacts (2) [8,17] programs:[1–3,8,12,16–20,26,27] Not applicable (2) Feedback on practice (13) Inpatient/nursing Patients (3) [1,3,7,10–15,17,18,22,25] home contacts (8) [9,20,22] [5–7,10,14,22,24,27] Written, graphic or computer- Transfers (1) Providers (3) based materials (10) [1–3,5,7, [3,7,11] 11,15–18,22,24] Patient/family-directed Home (1) [4] educational program (9) [4,6, 9,10,15,18–20,26] Administrative changes Health information management Systems (11) [3–5,11,13,14,16, Medical records (2) 21–23,27] [25,26] Prompts and decision support Provider case review and management communications (7) [6,8,17,19,22,25,26] management (3) [1,4,19] Policy, regulatory changes, and standards/protocols (2) [11,23] Financial incentives based on quality of performance Covered services Bonus or withhold programs Incentives to patients (2) [26]MCO, managed care organization.1 More than one category possible.Total number of projects in the named category and given in parentheses, and reference number of project is in square brackets, listedbelow by principal investigator (see Table 1).1. Balas; 2. Chin; 3. Davis; 4. Feldman; 5. Gurwitz; 6. Holmes-Rovner; 7. Horbar; 8. Katz; 9. Manfredi; 10. Morrison; 11. Shafer; 12.Shwartz; 13. Thompson; 14. Titler; 15. Allison; 16. Bates; 17. Borbas; 18. Cloutier; 19. Fifield; 20. Gerber; 21. Irwin; 22. Jones; 23. Levine;24. Loeb; 25. Ornstein; 26. Vargas; 27. Watson. 247
  • 16. C. M. Farquhar et al.most common study design was a randomized controlled The ability of these interventions to be sustained, to betrial (22), and the unit of randomization was most often a generalized, and to be transferable will depend, in part, onpractice or clinic (eight), hospital or nursing home (five), or the relationships between health care systems and or-provider (five). However, the unit of analysis was the patient ganizations, and researchers. Previous research in total qualityin 15 of the studies. There was a strong guideline focus in management has suggested that these organizational re-25 of the studies. The framework for change was most lationships need further assessment [24]. With this end inoften organizational theory (16) or adult learning (16). The mind, most of the grants provided evidence of collaborationscategories of the health care processes are presented in Table between networks of health care providers and hospitals and4. The most common TRIP interventions were multifaceted the researchers. Such relationships will determine whethereducational strategies, with academic detailing, opinion research translation efforts are truly effective when appliedleaders, and feedback on practice all being commonly in health care settings, and will potentially increase the impactemployed. More than half of the projects planned to use of studies by addressing and incorporating decision makers’information technology (17) and half the projects had a focus needs and ideas on practice improvement. The involvement ofon reducing medical errors (13). the health care providers includes some financial commitment, and indicates a level of interest in implementation research, suggesting that successful implementation strategies identifiedDiscussion by the TRIP projects should be sustainable following the study’s completion. Finally, because decision makers in dif-The goals of the AHRQ were to focus on a number of ferent organizations often face similar challenges and com-areas, including research into implementation, disparities and municate with each other, it is hoped that the collaborativevulnerable populations, and certain disease areas. Many of activities of the funded projects will together address howthese are being addressed by the proposed studies, although this program’s findings can spread rapidly across health careinterestingly none included topics in mental health. The organizations and systems.interventions that are being tested are broad and will provide As health care delivery has migrated to new settings,information on a number of strategies applied in a diversity researchers and funding agencies have found that settingsof health care settings. A particular interest was the use of for applied research have also changed. Creating productiveinformation technology, and many of the grants will focus and positive associations between delivery systems and re-specifically on different aspects of computer-assisted decision searchers will not only enhance the quality of research but,support systems and reduction in medical errors. the AHRQ hopes, will promote dissemination of the findings. One of the anticipated products of these projects will be If the aim of increasing sustainability, generalizability anda set of ‘tools for an evidence-based toolbox’ that would transferability is achieved by encouraging collaborative ar-reduce the need for researchers and those involved in quality rangements then is hoped that this information will be usefulimprovement efforts to have to ‘re-invent the wheel’. Some and applicable across a range of health care settings, withexamples of these tools are patient and practitioner surveys, varied health care providers and patient populations.methodologies for capturing data from electronic medicalrecords, electronic medical record templates for specificdiseases or prevention, standardized protocols and algorithms, Disclaimerpatient and provider education programs, analytical methodsto account for randomization at the group level, pocket cards The views expressed do not necessarily reflect those of thefor evidence decisions, other decision support aids, and staff of the Commonwealth Fund or the AHRQ.evidence-based calculators. A challenge for the TRIP project was to find the balancebetween rigor of design and generalizability. In the past, Acknowledgementsstudies have tended towards one or the other [23]. It isinevitable that there will be a trade-off between optimal study C.M.F. was supported by the Commonwealth Fund of Newdesign for internal validity and relevance. Interestingly, in York.spite of the problems of randomization of practices andclinicians, the majority of the TRIP projects were randomizedcontrolled trials. A number of challenges exist for thesestudies. For example, many health care systems undergo Referencesrapid changes in patient populations, providers, administrative 1. Eisenberg E, Power E. Transforming insurance coverage intosupport, and administrative policies during a study. A further quality health care: voltage drops from potential to deliveredchallenge will be obtaining adequate numbers of participating quality. J Am Med Assoc 2000; 284: 2100–2107.patients and providers without risking contamination of thecomparison group by the intervention. In addition, bioethical 2. Effective Health Care Bulletin. Getting Evidence into Practice. York: University of York, 1999.issues surrounding enhanced implementation of evidence-based information has become a topic of concern in controlled 3. Schuster MA, McGlynn E, Brook RH. How good is the qualitystudies. of health care in the United States? Milbank Q 1998; 76: 517–563.248
  • 17. Translating research into practice 4. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic 15. Translating Research into Practice Request for Research Ap- bullets: a systematic review of 102 trials of interventions to plications I. http://grants.nih.gov/grants/guide/rfa-files/RFA- improve professional practice. Can Med Assoc J 1995; 153: HS-00-008.html 1423–1431. 16. United States Advisory Commission on Consumer Protection 5. Magnan S, Solberg LI, Kottke TE et al. IMPROVE: bridge over and Quality in the Health Care Industry. Quality First: Better troubled waters. Jt Comm J Qual Improv 1998; 24: 566–578. Health Care for All Americans: Final Report to the President of the United States, The President’s Advisory Commission on Consumer Protection and 6. Goldberg HI, Wagner EH, Fihn SD et al. A randomized Quality in the Health Care Industry. Washington, DC: Government controlled trial of CQI teams and academic detailing: can they Printing Office, 1998. alter compliance with guidelines? Jt Comm J Qual Improv 1998; 24: 130–142. 17. Lomas J. Teaching old (and not so old) docs new tricks: effective ways to implement research findings. In Dunn EV, Norton PG, 7. Curley C, McEachern JE, Speroff T. A firm trial of in- Stewart M et al. (eds): Dissemination of Research and Changing terdisciplinary rounds on the inpatient medical wards: an inter- Practice. Research Methods for Primary Care. Vol. 6. London: Sage vention designed using continuous quality improvement. Med Publications, 1994. Care 1998; 36 (8 suppl.): AS4–AS12. 18. Moulding N, Silagy C, Weller D. A framework for effective 8. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, change in clinical practice: dissemination and implementation Thompson MA. Closing the gap between research and practice: of clinical practice guidelines. Qual Health Care 1999; 3: 177–183. an overview of systematic reviews of interventions to promote the implementation of research findings. Br Med J 1998; 317: 19. Conner M, Norman P. The role of social cognition in health 465–468. behaviors. In Conner M, Norman P. (eds): Predicting Health Behaviors. Buckingham: Open University Press, 1996. 9. Center for Health Economics. NHS Center for Reviews and Dissemination. Implementing clinical practice guidelines: can 20. Kotler P. Social marketing of health behavior. In Fredericksen guidelines be used to improve clinical practice? Eff Health Care LW, Soloman LJ, Brehony KA (eds): Marketing Health Behavior: 1994: 8: 1–12. Principles, Techniques and Applications. New York: Plenum Press, 1984.10. Thompson O’Brien MA, Oxman AD, Davis DA, Haynes BH, Freemantle N, Harvey EL. Audit and feedback versus alternative 21. Garside P. Organizational context for quality: lessons from the strategies: effects on professional practice and health outcomes. fields of organizational development and change management. The Cochrane Library 2000. Issue 4. Qual Health Care 1998: 7: S8–S15.11. Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, 22. National Health and Medical Research Council. How To Put Brown GD. The clinical value of computerized information Evidence Into Practice: Implementation and Dissemination Strategies. services. A review of 98 randomized clinical trials. Arch Fam Canberra: Biotext, 2000. Med 1996; 5: 271–278. 23. Stryer DB, Clancy C. A view of the bridge: The effectiveness12. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer- of interventions to improve cardiovascular care (abstract). J Am based clinical decision support systems on physician per- Coll Cardiol 1999; 33 (2 suppl. A): 228A. formance and patient outcomes. A systematic review. J Am Med 24. Shortell SM, Jones RH, Rademaker AW et al. Assessing the Assoc 1998; 280: 1339–1346. impact of total quality management and organizational culture13. Greco PJ, Eisenberg JM. Changing physicians’ practice. N Engl on multiple outcomes of care for coronary artery bypass graft J Med 1993; 329: 1271–1273. surgery patients. Med Care 2000; 38: 207–217.14. Translating Research into Practice Request for Research Ap- plications I. http://grants.nih.gov/grants/guide/rfa-files/RFA- HS-99-003.html Accepted for publication 7 February 2001 249

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