International Journal for Quality in Health Care 14:233-249 (2002)
© 2002 International Society for Quality in Health Care
Translating research into practice: the future ahead
1Center for Practice Technology Assessment, Agency for Healthcare Research and Quality, Rockville, MD, USA
2Center for Effectiveness and Outcomes Research, Agency for Healthcare Research and Quality, Rockville, MD, USA
3National Guidelines Clearinghouse, Center for Practice Technology Assessment, Agency for Healthcare Research and Quality, Rockville, MD, USA
Address reprint requests to C. M. Farquhar, Department of Obstetrics and Gynaecology, National Women’s Hospital, Auckland, New Zealand. E-mail: c.farquhar{at}auckland.ac.nz
Objective. To summarize and analyze the focus and methodologies of the Translating Research into Practice (TRIP) projects funded 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 applications in 1999 and 2000 was produced from the data collected.
Data collection. The following items were abstracted from each of the successful applications: provider focus, patient population, vulnerable populations, methodologies, interventions for change, outcomes measured, and conceptual framework used.
Principal findings. AHRQ funded 27 TRIP grants in 1999 and 2000. A wide variety of health care providers, settings, and patients were the target of the grants. The most common study design was a randomized controlled trial. The most common TRIP interventions were educational and the most common frameworks were either adult learning theory or organizational theory. More than half of the projects planned to use information technology and half the projects had a focus on reducing errors.
Conclusions. The TRIP projects encompass a broad range of providers, environments, patients, and interventions. The field 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 evidence
Clinicians are increasingly challenged to provide quality health care in the midst of an environment of increasing health care choices, rising expectations, constrained resources, and increasing complexity of delivery systems. A definition of quality health care is often elusive, but the key components are health care that is effective, efficient, up to date, and timely [1,2]. Providing ‘the right care, at the right time, for the right person, in the right way’ is one way of describing quality health care [1]. In order to achieve at least some of these goals, it is necessary to use the findings of well designed research studies and translate them into everyday practice. Despite these best efforts to improve access to research information, the impact on clinician behavior or patient outcomes has been limited. For example, a recent review of published studies on the quality of care received by Americans found that only 60% of patients with chronic conditions received recommended care [3]. In most of these conditions, research evidence of effective strategies exists that could help improve health outcomes if it could be implemented successfully.
Although a number of strategies for implementing change have been proposed, research evidence to guide this phase of the process is lacking [4]. These strategies include continuing medical education, self-instructed learning, academic detailing, audit and feedback, provider reminder systems, incentives, local opinion leaders, outreach visits, continuous quality improvement initiatives, clinical information systems, and computer decision support systems. Despite a number of randomized controlled trials of quality improvement and implementation initiatives, considerable gaps in the research evidence remain [2,5–8].
Fortunately, some research has already demonstrated that implementation of available research evidence is worthwhile, as significant improvements in health outcomes will accrue [9–12]. Although no one successful strategy currently exists, a combination of different strategies may be effective in achieving behavior change. The impact of implementation strategies will depend on the context in which they are applied, and will be influenced by factors including incentives, health care settings, practitioner and patient perceptions, and the desired behavior change [13]. However, too little is known about which combinations of implementation strategies are effective in which clinical contexts and for which clinical conditions. These realities compound the problem of getting evidence into practice.
With these concerns in mind, the Agency for Health Care Policy and Research [known since December 1999 as the Agency for Healthcare Research and Quality (AHRQ)] announced its interest in grant applications focusing on translating research into practice (TRIP) in January 1999 [14]. These proposals were known as the TRIP I grants, and were awarded late in 1999 and in 2000. A further request for applications (RFA) for translating research into practice (TRIP II) was announced in December 1999 and these grants were awarded in September 2000 [15]. The overarching goal of the RFAs was to support the evaluation of interventions whose aim was to improve the outcomes, quality, effectiveness, efficiency, and/or cost-effectiveness of health care based on findings derived from sound research. The interventions would be evaluated for their effectiveness at changing processes and/or outcomes of care, as well as on whether they are sustainable, reproducible, and generalizable. A second goal was to demonstrate that the translation of research into practice leads to measurable and sustainable improvements in health care.
Broadly, these RFAs encouraged research related to innovative strategies for implementing evidence-based tools and information among practitioners caring for diverse populations in a variety of health care settings. A range of interventions was suggested, including: structural and organizational changes, comprehensive quality improvement systems, computerized drug information and dosage, clinician reminders, audit and feedback methods, interactive systems to facilitate shared decision making, computer systems to deliver educational materials at the point of care, and clinical practice guidelines and protocols. In addition, the RFAs encouraged applications from studies addressing how organizational research could be translated into practice, the impact of organizational variables on clinical translation, and the organizational and structural context of successful interventions needed to facilitate replication.
Applicants were encouraged to address conditions and settings where the most improvement was likely to occur, where wide variability in practice currently existed, where wide disparities in care existed for racial/ethnic minorities, and where a large burden of disease and poor quality of life were documented. The funding priority also focused on at least one of the six specified areas of the President’s Race and Disparities Initiative (infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection/AIDS, and child and adult immunizations), as well as mental health and pediatric asthma [16]. Of particular interest were interventions that used the strengths of information systems for implementing evidence-based strategies for health care improvement.
Methodologies that were sought included qualitative studies, quantitative research, and empirical work. In order to monitor and account for secular changes in practice patterns, studies employing control group designs were strongly encouraged. It was emphasized that to ensure internal and external validity, reliability and transferability, the evidence needs of organizations that might eventually implement similar interventions should be considered. Strategies to reduce bias such as use of randomization or concurrent comparisons were recommended. Applicants were further asked to consider the potential of evidence-based tools. They were also encouraged to consider the effect of local circumstances such as specific populations, diverse health settings, resources constraints, and political context on both the implementation process and the outcomes of care.
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The objective of this paper is to summarize and analyze the focus and methodologies of the TRIP projects funded in 1999–2000 by the AHRQ. The paper was compiled from the successful applications for the TRIP I and TRIP II funding rounds in 1999 and 2000. The following items were abstracted by one author (C.F.) from each of the successful applications: provider focus, patient population, vulnerable populations, methodologies, interventions for change, outcomes measured, and conceptual framework used. The applications were catergorized by C.F. in consultation with the co-authors. Categories for the conceptual frameworks included adult learning, social influence, marketing and social marketing, organizational theory, and behavioral theory [17].
Adult learning theory and health education theory focus on personal motivation to change and active participation of the learner [18,19]. Social influence theories focus on the role of social support, peer approval, and role models in promoting behavior change [20]. Marketing and social marketing theory together provide a framework for identifying factors that drive change and meet the needs of the target group [21]. Organizational theory focuses on the environmental context within which clinicians function as a key determinant of whether innovations are utilized, and the emphasis is on organizational and structural factors that may hinder or facilitate changes in practice [22]. Behavior theory, which focuses on environmental cues and reinforcement such as audit and feedback, is seen to be central in encouraging and maintaining behavioral change [19].
To learn more about the TRIP I and II research projects and to promote exchange of ideas among the TRIP researchers, the AHRQ designed a series of activities to take advantage of the similarities and differences among projects both in research design and execution of the studies. Previous experience had led the AHRQ to believe it was likely that recruitment problems, contamination issues, and problems concerning stability of delivery systems were challenging for implementation research. Since many of these obstacles can be difficult to overcome, it was thought that the investigators, the AHRQ, and eventually the research community could benefit by promoting formal venues for discussion among the investigators. In addition, all of the TRIP projects were limited to 3 years, so it was important that study problems be addressed early and effectively.
After the awarding of the TRIP I grants, AHRQ formed an internal coordinating committee to plan and support the TRIP II initiative, and convened a meeting of the TRIP I investigators. Grantees were asked to give a brief overview of their methods, problems anticipated or experienced, and the importance of their research. The discussion confirmed the AHRQ’s belief that some of the impediments to performing this type of research are not isolated or insignificant. The coordinating committee incorporated the findings from the TRIP I meeting into planning for the TRIP II initiative. After the TRIP II grants were awarded, the coordinating committee held a meeting of the principal investigator and partner from each TRIP II project. This meeting had the same purpose as the previous meeting of TRIP I investigators, in addition to the goal of establishing a TRIP II steering committee made up of representatives of TRIP II investigators and partners and the AHRQ. The major goals for the steering committee are to continue to develop the science base for implementation, provide leadership to the field, advance methods for the study of TRIP, lead the dissemination of TRIP II results, advise the AHRQ on future TRIP initiatives and on development of an agency toolbox of implementation tools and research aids, and conduct external evaluation. The steering committee is chaired by a TRIP II investigator and has established several working subcommittees. The steering committee meets at least twice a year with ongoing communication via conference call, Email, and ad hoc meetings of subcommittees.
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A total of 27 grants were awarded, 14 TRIP I grants in 1999 and 2000, and 13 TRIP II grants in 2000. A description of each of the grants is given in Table 1.
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The key dimensions of the projects are presented in Table 2. The grants focused on a wide variety of health care providers and patients. Primary care providers (10) and multidisciplinary teams (10) were the most frequent health care providers. Collaborators were most often provider or university networks (21) and only six were managed care organizations. Children were the most common patient population (eight) followed by nursing home residents (four) and Medicaid beneficiaries (four). Nearly half of the studies included substantial numbers of patients from different ethnic and racial groups. Prevention services were a common focus (eight), as was cardiovascular disease (five). Eighteen of the studies were community-based and the remainder hospital- (five) or nursing home-based (four).
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The study methodologies are presented in Table 3. The most common study design was a randomized controlled trial (22), and the unit of randomization was most often a practice or clinic (eight), hospital or nursing home (five), or provider (five). However, the unit of analysis was the patient in 15 of the studies. There was a strong guideline focus in 25 of the studies. The framework for change was most often organizational theory (16) or adult learning (16). The categories of the health care processes are presented in Table 4. The most common TRIP interventions were multifaceted educational strategies, with academic detailing, opinion leaders, and feedback on practice all being commonly employed. More than half of the projects planned to use information technology (17) and half the projects had a focus on reducing medical errors (13).
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The goals of the AHRQ were to focus on a number of areas, including research into implementation, disparities and vulnerable populations, and certain disease areas. Many of these are being addressed by the proposed studies, although interestingly none included topics in mental health. The interventions that are being tested are broad and will provide information on a number of strategies applied in a diversity of health care settings. A particular interest was the use of information technology, and many of the grants will focus specifically on different aspects of computer-assisted decision support systems and reduction in medical errors.
One of the anticipated products of these projects will be a set of ‘tools for an evidence-based toolbox’ that would reduce the need for researchers and those involved in quality improvement efforts to have to ‘re-invent the wheel’. Some examples of these tools are patient and practitioner surveys, methodologies for capturing data from electronic medical records, electronic medical record templates for specific diseases or prevention, standardized protocols and algorithms, patient and provider education programs, analytical methods to account for randomization at the group level, pocket cards for evidence decisions, other decision support aids, and evidence-based calculators.
A challenge for the TRIP project was to find the balance between rigor of design and generalizability. In the past, studies have tended towards one or the other [23]. It is inevitable that there will be a trade-off between optimal study design for internal validity and relevance. Interestingly, in spite of the problems of randomization of practices and clinicians, the majority of the TRIP projects were randomized controlled trials. A number of challenges exist for these studies. For example, many health care systems undergo rapid changes in patient populations, providers, administrative support, and administrative policies during a study. A further challenge will be obtaining adequate numbers of participating patients and providers without risking contamination of the comparison group by the intervention. In addition, bioethical issues surrounding enhanced implementation of evidence-based information has become a topic of concern in controlled studies.
The ability of these interventions to be sustained, to be generalized, and to be transferable will depend, in part, on the relationships between health care systems and organizations, and researchers. Previous research in total quality management has suggested that these organizational relationships need further assessment [24]. With this end in mind, most of the grants provided evidence of collaborations between networks of health care providers and hospitals and the researchers. Such relationships will determine whether research translation efforts are truly effective when applied in health care settings, and will potentially increase the impact of studies by addressing and incorporating decision makers’ needs and ideas on practice improvement. The involvement of the health care providers includes some financial commitment, and indicates a level of interest in implementation research, suggesting that successful implementation strategies identified by the TRIP projects should be sustainable following the study’s completion. Finally, because decision makers in different organizations often face similar challenges and communicate with each other, it is hoped that the collaborative activities of the funded projects will together address how this program’s findings can spread rapidly across health care organizations and systems.
As health care delivery has migrated to new settings, researchers and funding agencies have found that settings for applied research have also changed. Creating productive and positive associations between delivery systems and researchers will not only enhance the quality of research but, the AHRQ hopes, will promote dissemination of the findings. If the aim of increasing sustainability, generalizability and transferability is achieved by encouraging collaborative arrangements then is hoped that this information will be useful and applicable across a range of health care settings, with varied health care providers and patient populations.
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The views expressed do not necessarily reflect those of the staff of the Commonwealth Fund or the AHRQ.
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C.M.F. was supported by the Commonwealth Fund of New York.
Accepted for publication February 7, 2001.
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