Significant variation exists in health care practice patterns that creates concerns regarding the quality of care delivered. Clinical practice based on high-quality evidence provides a rationale for clinical decision making. Resources, such as evidence-based guidelines, provide that evidence to clinicians and improve patient outcomes by decreasing unwanted variation in clinical practice. Because knowledge dissemination alone is ineffective to translate scientific evidence into clinical practice, the field of implementation science has emerged to facilitate this translation of research into routine clinical practice. This article provides an introduction to implementation science, and its application in dentistry to promote adoption of evidence-based guidelines.
The Institutes of Medicine has documented quality gaps in medical care, including variation in practice patterns. Similar quality gaps and practice variation exist in dentistry.
Evidence-based health care was developed to address quality and practice variation, including evidence summary tools and dissemination tactics, such as evidence-based guidelines.
Because dissemination of evidence is not generally sufficient to instill change in clinical practice, the field of implementation science was developed to facilitate research regarding barriers and facilitators of provider behavior change and to develop and evaluate intervention strategies that lead to improved, evidence-based care.
The importance of translating evidence into practice
In 2001, the National Academies of Science’s Institute of Medicine (IOM) issued a report (“Crossing the Quality Chasm”) documenting some of the quality of care shortcomings of the US health care system and proposing reforms for the twenty-first century. The IOM identified significant gaps in the quality of care delivered throughout the United States, and characterized the gaps as overuse , underuse , and misuse . For example, an assessment of 3000 medical practices or treatments found that slightly more than a third were effective or likely to be effective, 15% to 25% were unneeded or potentially harmful, and 50% were of unknown effectiveness.
Overuse refers to the continued use of treatments that are known to be ineffective, or where the known harms exceed the known benefits. Systematic reviews on overuse identified several areas of consistent overuse in medicine, including the use of transesophageal echocardiography in patients with stroke, trends of increased use of computed tomography scans in the emergency department, and overuse of antidepressants in children. The proliferation of treatments in which harms exceed benefit include treatment for early-stage prostate cancer, oxygen for patients with moderate chronic obstructive pulmonary disease, nutritional interventions for inpatients with malnutrition, and antibiotic overuse. Overuse of screening and diagnostic testing is known to cause false-positive results and overdiagnosis, and overtreatment, with both medical therapies and procedural interventions, and places patients at risk of unnecessary adverse events. A common example of overuse in dentistry is the practice of prescribing prophylactic antibiotics for patients with prosthetic joints who are undergoing dental procedure. Recent guidelines based on the current best evidence recommend against this practice based on lack of association between dental procedures and prosthetic joint infection, and increased risk of harms, including antibiotic resistance, adverse drug reactions, and costs, associated with antibiotic use.
Underuse refers to the failure to provide treatments known to be effective and medically necessary. For example, in the United States there is an underuse of screening for serious diseases such as breast, colon, and lung cancer, with rates varying substantially by racial/ethnic, economic, and geographic status. These disparities in who receives screening leads to important disparities in health outcomes. When patients fail to consistently receive known effective care, patient and population health outcomes suffer. An important example of underuse in dentistry is the low rates of pit-and-fissure sealant use with patients at high risk of developing occlusal caries or with early noncavitated lesions that can be successfully managed with the need for operative intervention. This underuse occurs despite robust evidence of their effectiveness in primary and secondary caries prevention.
Misuse occurs when care is not provided correctly and safely and can be described as medical errors. One important example of misuse occurs when medications are prescribed for the wrong purpose, or not consistent with prescribing recommendations (dose and duration), leading to unnecessary adverse events. The current opioid epidemic in the United States is a prominent example of the harms incurred with the misuse of drugs resulting in large personal and societal costs.
Collectively, overuse, underuse, and misuse represent examples of what is termed the Know-Do Gap . The Know-Do Gap is simply the difference between what we know (the evidence) and what we do (current practice patterns). In an ideal situation, practice patterns should be consistent with evidence (Knowing = Doing), but unfortunately this is not consistently the case and leads to the Know-Do Gap.
What factors contribute to the development of a Know-Do Gap? Research suggests that the timeline from the creation of relevant evidence until it is adopted into routine practice can be surprisingly long. For example, one study estimated it took an average of 17 years for high-quality evidence to enter routine clinical practice. This may be due, in part, to the current model used for evidence transfer or dissemination. At many points, inefficiencies occur in the dissemination and adoption of information, contributing importantly to a failure of clinicians to willingly embrace new ideas. Glasziou and Haynes identified 7 stages at which the translation of evidence into routine clinical practice can break down, and failure at any of the following translational stages will impede the adoption into practice of new evidence ( Fig. 1 ): awareness of the evidence, acceptance of the evidence, determination if the evidence is applicable to the patient/population; ability to carry out the intervention; act on the evidence in use it in the decision-making process; agreed to by the patient, and patient/provider adherence . New knowledge is never completely translated through any of these steps. For example, if one imagines that 20% of the information at each step fails to transfer, the result will be that only approximately 21% of the knowledge generated would effectively be translated and ultimately adopted into routine clinical practice.
Adding to the Know-Do Gap is the rapid advancements ongoing in medical and dental science, which so often are accompanied by increasing complexity in the process of care delivery. Additionally, the number of individuals requiring such complex care, particularly for chronic diseases, continues to grow, placing a growing burden on the health care system and health care providers. As a result, the knowledge required among health care providers to stay “current” across the areas of diagnostics, prevention, and therapeutics also continues to grow.
One important challenge that needs to be addressed to lessen the Know-Do Gap is how to improve awareness and access to the ever-increasing evidence-base needed to inform appropriate clinical decision making. Keeping current on the scientific literature historically could be done using a somewhat unfocused reading of the clinical literature, drawing on high-quality information sources, “just in case” some kernel of wisdom could be gleaned for use with a future patient. However, over the past 2 decades, the rates at which new clinically relevant information is created and disseminated has reached a point where effectively reading the primary clinical literature in almost any health care field would be infeasible for most busy clinicians. Fortunately, translational researchers have addressed this issue of “information overload” using several strategies developed over the past 20 years.
Strategies to reduce information overload
Two major contributions from evidence-based health care methodologists for the management of information overload are the development of secondary data analysis methods (eg, systematic reviews) and a “just-in-time” approach to accessing high-quality evidence resources at the point of care. Systematic reviews summarize evidence on important topics and allow clinicians to rapidly understand what is known regarding a specific area of clinical care. Systematic reviews are developed through a rigorous and transparent scientific methodology to identify, appraise, and synthesize all relevant literature pertaining to a particular clinical question. Systematic reviews provide several advantages for the health care provider. The first is that they endeavor to identify all relevant scientific evidence on a particular clinical question, which in and of itself is a significant benefit, reducing the need for individuals to seek out and read what at times can be an extensive scientific literature. In addition, high-quality systematic reviews critically appraise all of the included studies, providing an assessment and transparency regarding the strengths and weaknesses of the evidence. Finally, systematic reviews provide an overall summary and conclusion about what is known regarding a specific area of clinical practice that is based on the best available scientific evidence. Systematic reviews thus provide a highly efficient approach to reading the clinical literature, while providing evidence that is minimally biased and thus likely validly describes the true benefits and harms of clinical interventions.
The other major advancement supporting an evidence-based approach to practice is the “just-in-time” attitude to information seeking. In this approach, clinicians with training in evidence-based practice address clinical questions that arise during routine patient care by using their ability to efficiently seek out high-quality evidence as an adjunct to clinical decision making. This was the original approach developed by Sackett and Guyatt at McMaster University in the 1990s, made possible by the development of online evidence databases (eg, PubMed) and associated search engines. Both of these concepts, evidence summarization via systematic reviews and rapid retrieval of relevant and high-quality evidence, when needed to inform clinical decisions, have the potential to contribute substantially to the quality of care delivered. However, the underlying concept of evidence-based practice that these ideas support are ad hoc in nature and depend on a willing and well-trained clinician to retrieve appropriate evidence. More recently, efforts to systematize the transfer of scientific information into clinical practice has been developing, with the aim of ensuring that all clinicians understand the current best evidence and appropriately apply it to all patients when indicated. This is the domain of translational research and represents a shift in focus from ad hoc, individual provider–driven application of clinical evidence to a system-level approach. The goal of scaling up the application of appropriate evidence to a system level and making it a routine part of clinical practice across an entire health care system has as its aim improvement in both patient and population health as well as increased efficiency in the delivery of care.
Five stages of translational research
In general terms, translational research refers to the study of ways of applying scientific research that lead to improved human health and well-being. This involves the entire process of transferring basic science information into knowledge that can be used clinically and is often referred to as the process of moving scientific discovery from “bench to bedside.” Translational research can be thought of as occurring in 5 stages, known as Translational Research Stages 0 to 4, or abbreviated as T0, T1, T2, T3, and T4 ( Fig. 2 ).
Along this continuum, T3 research focuses on the translation of evidence into routine clinical practice and is thus the domain of most relevance to evidence-based medicine (and dentistry). T3 research endeavors to improve the uptake of evidence into routine practice, through, among other things, the study of evidence dissemination and implementation. Clinical practice guidelines provide a good example of fruits of this area of study, and along with other similar tools aimed at synthesizing evidence, it has become clear that the process leading to adaptation of guidelines by practitioners and health care systems warrants study as its own area of research. This has led over the past 20 years to the birth of a new domain of research.
Clinical practice guidelines
One of the most important strategies developed to translate current scientific evidence into routine clinical practice has been the development of clinical practice guidelines (CPGs). CPGs are defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Guidelines are developed through a standardized and rigorous process ( Fig. 3 ), and leverage evidence available through systematic reviews to develop practical recommendations of how the science can be considered for usage in a practice setting. When implemented, guidelines can reduce inappropriate practice variation, promote use of effective interventions, reduce use of ineffective therapies, and improve patient and population health outcomes. Ultimately, they are a significant resource that helps to ensure that patients receive evidence-based care.
Nonetheless, publishing a clinical guideline does not ensure a change in clinical practice, and indeed, a review of 59 published evaluations of clinical guidelines concluded that guidelines could improve clinical practice, but the size of the improvements in performance varied considerably. Although guidelines can provide a reliable resource for providers in an attempt to bridge the quality chasm, they are not routinely adopted. Reasons for this include the following: overlapping and redundant guidelines developed by different organizations, the currency of guidelines that may quickly become outdated as new evidence arises, lack of awareness, complexity, and lack of personal or system-level ability to implement the guideline. The use of specific strategies overcomes barriers to adoption, and to implement research-based recommendations appears necessary to change practice, as more-intensive efforts are generally more successful.
Barriers to adopting CPG recommendations specific to dentistry include the changing current practice model, colleagues’ actions, trust in the validity or currency of the evidence, lack of clarity or contradictory information across various information sources, and personal experience that is perceived to contradict the recommendations. Financial barriers (eg, insurance reimbursement) are also created.
Importantly, social environment is a factor impacting behavior, and these results suggest that the peer influence was strongly associated with changing provider behavior, as was the perception of what was the prevailing standard of practice. Together, this information on barriers to adopting evidence-based recommendations provides insight into why proving information alone is often not sufficient to instill changes in practice patterns. Targeted and strategic efforts are required to translate science into practice.
As described in Fig. 2 , implementation science fits within the T3 phase of translational research. Implementation science comprises both dissemination and implementation. The terms dissemination and implementation are defined in Table 1 . As opposed to diffusion of knowledge, which occurs passively, dissemination uses specific tactics to increase awareness about scientific evidence. Implementation takes this to the next step by developing and evaluating specific strategies aimed at changing provider behavior in concordance with the evidence to the point at which the evidence-based treatment becomes routine and sustainable. Taken together, implementation science is targeted toward an increasing awareness and utilization of evidence to improve practice through individual, organizational, and policy-level change. The ultimate goal of implementation science is to develop permanent, sustained improvements in practice patterns through removing barriers to adoption and ultimately changing the culture around care delivery.
|Diffusion||Diffusion of knowledge and information that occurs without concerted promotion.||Word of mouth|
|Dissemination||Targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread knowledge and the associated evidence-based interventions (Implementation Science Journal).||
|Implementation||Methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice and hence improve the quality and effectiveness of health care (Implementation Science Journal).||