Integrating Science Into Clinical Practice to Improve Patient Outcomes in Oncology
Orlando, FL—Integrating research findings and clinical trial evidence into healthcare policy and clinical practice is not always simple, according to David Chambers, DPhil, MSc, Deputy Director for Implementation Science, Division of Cancer Control and Population Sciences, National Cancer Institute, at the 2017 Quality Care Symposium.
Implementation science concentrates on getting valuable evidence-based interventions into practice within a reasonable time frame. In clinical trials, the focus is largely on methods and health outcomes, without a substantial focus on dissemination of the evidence. Implementation science, conversely, is not about drug development or discovery, but is centered on the delivery of healthcare interventions at different stages (eg, those outlined in the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework).
Assumptions are often made, however, in the development of new interventions that can hinder this process. “We assume that if we build it, they will come,” said Dr Chambers. “But too often, they don’t come.”
For example, effective colorectal cancer screening is widely available, but only approximately 65% of adults aged 50 to 75 years are up to date on colorectal cancer testing. Human papillomavirus vaccinations can prevent the vast majority of cervical cancer cases in young women, but the vaccine series is underutilized. Often, high-risk populations are simply not found, and therefore cannot benefit from early identification and enhanced monitoring, such as in Lynch syndrome.
“We might have all of these wonderful tools, but we need to focus on taking that next step and moving them along [into practice],” he said.
Implementing Evidence-Based Cancer Interventions Is Key
According to Dr Chambers, an evidence-based cancer intervention is only as good as how and whether it is adopted into clinical practice—if providers are trained to deliver it, and then actually choose to deliver the intervention, and eligible patients are able to receive it.
“If we assume a 50% threshold for each of those steps, even if we have no problems with access, adherence, dosage, or maintenance, we’re already down to about 6% of the potential value of this ‘magic bullet,’” Dr Chambers suggested.
Dr Chambers pointed out certain areas that are ripe for exploration. Attention should be paid, he said, to the sustainability of a set of interventions in a changing context and to the impact of dissemination strategies on practice.
“We need to scale up practices across health plans, systems, networks, and nations,” Dr Chambers noted. “And…not just bringing more and more in, but how do we potentially do less? How do we learn more about de-implementation?”
When designing interventions, Dr Chambers stressed the need to focus on implementation. “We need to think more about delivering these interventions, fitting with the patient population, and building in training, support, adherence, mediators, and moderators for high-quality delivery,” he said. “Moving forward is about changing the way that we, as an overall field, think about discovery and delivery.”
Evidence-based practices shift over time. Implementation is a process, and choosing not to implement can be rational. “Patients are not homogenous, but often we assume that evidence-based interventions are one size fits all,” Dr Chambers pointed out.
“But a one hundred percent implementation target isn’t necessarily helpful, given the variety of needs and fits that we need to be thinking about.” More attention should be placed on capturing practice-based evidence and using technology to gather data seamlessly into a broader ecosystem, he added.
Dr Chambers encourages thinking with complexity about the sustainability of interventions and factoring evolution into the concept of evidence-based practices.
“If medicine continues to evolve, should existing interventions be sustained in the same form that we’ve created them? How does the system cope with a dynamic field that is constantly changing?” he asked.
Evidence-based practices are often constrained to fidelity, but according to Dr Chambers, it is time to think about adaptation.