Onil Bhattacharyya

What Is Implementation Research? Rationale, Concepts, and Practices.

Despite the growing knowledge base on evidence-based practices in social work and medicine, there is a large gap between what is known and what is consistently done. Implementation research is the study of methods to promote the uptake of research findings into routine practice. In this article, we describe the rationale for implementation research and outline the concepts and effectiveness of its practices. Despite a large number of systematic reviews of implementation interventions, many of the fundamental questions regarding what approaches should be used in which settings for which problems remain unanswered. We go on to argue that future implementation studies should assess the context of practice and key features of interventions to better inform service quality improvement efforts.

Evolution of primary care in China 1997–2009

Primary health care, once the cornerstone of Chinas health system, has been neglected in the countrys market-oriented system. Recent primary care reform was designed to improve access, quality and efficiency of health service use, but the results are unclear. The government is dramatically increasing funding for community health services, but there is concern about maximizing the impact of this investment. This paper draws on policy analysis, literature review, and a secondary analysis of two case studies and two surveys to review the structure of community health services and public reaction to them. Our results suggest that despite several years of primary care reform, current performance remains poor. The capacity of providers is low, services are not felt to be affordable, and patients report concerns about safety, all contributing to low utilization of community health facilities. We argue that the minimum skill set for community health service providers should be clearly defined to focus training efforts as should the role of community health facilities within the health system. Moreover, a quality and accountability framework for community health service is needed so that increased funding can produce a strong foundation for Chinas health system.

Innovative health service delivery models in low and middle income countries - what can we learn from the private sector?

BackgroundThe poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease. They frequently use the private health sector, due to perceived or actual gaps in public services. A subset of private health organizations, some called social enterprises, have developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models. This study aims to characterize these models and identify areas of innovation that have led to effective provision of care for the poor.MethodsAn environmental scan of peer-reviewed and grey literature was conducted to select exemplars of innovation. A case series of organizations was then purposively sampled to maximize variation. These cases were examined using content analysis and constant comparison to characterize their strategies, focusing on business processes.ResultsAfter an initial sample of 46 studies, 10 case studies of exemplars were developed spanning different geography, disease areas and health service delivery models. These ten organizations had innovations in their marketing, financing, and operating strategies. These included approaches such a social marketing, cross-subsidy, high-volume, low cost models, and process reengineering. They tended to have a narrow clinical focus, which facilitates standardizing processes of care, and experimentation with novel delivery models. Despite being well-known, information on the social impact of these organizations was variable, with more data on availability and affordability and less on quality of care.ConclusionsThese private sector organizations demonstrate a range of innovations in health service delivery that have the potential to better serve the poors health needs and be replicated. There is a growing interest in investing in social enterprises, like the ones profiled here. However, more rigorous evaluations are needed to investigate the impact and quality of the health services provided and determine the effectiveness of particular strategies.

Monitoring use of knowledge and evaluating outcomes.

In the knowledge-to-action cycle, after the intervention related to knowledge translation has been implemented, uptake of knowledge should be monitored. [1][1] This step is necessary to determine how and to what extent the knowledge is used by the decision-makers. [1][1] How we measure uptake of

Improving the clarity of the interprofessional field: Implications for research and continuing interprofessional education

Significant investments are being made around the world to improve interprofessional collaboration, yet limits in our knowledge of this field restrict the ability of decision makers to base their decisions upon evidence. Clarity of the interprofessional field is blurred by a conceptual and semantic confusion that affects our understanding of key elements of education and practice activities, their interlinked relationship, and their effects on health or system outcomes. Systematic reviews of interprofessional education (IPE) and interprofessional collaboration (IPC) have provided some insight into the nature and effectiveness of this field, but a lack of clarity remains. In this article we report on a scoping review currently being undertaken to analyze the interprofessional field, improve its conceptual clarity, and identify elements needed to enhance its development. Emerging review findings regarding participants and settings, interventions, and outcomes are reported. The article provides implications from this review and discusses them in relation to continuing IPE and future research.

Harmonization of guidelines for the prevention and treatment of cardiovascular disease: the C-CHANGE Initiative

Cardiovascular disease is the most prevalent chronic medical condition in Canada, and evidence-based management of risk factors for cardiovascular disease can reduce morbidity and mortality.[1][1] However, there are more than 400 individual recommendations for risk management of cardiovascular

Management of cardiovascular disease in patients with diabetes: the 2008 Canadian Diabetes Association guidelines

Diabetes mellitus is a chronic condition that requires complex management; however, the time of health care providers is limited and patient motivation varies. How can health care providers design realistic treatment plans and establish priorities that maximize health benefits for patients? The 2008

Universal Drug Coverage and Socioeconomic Disparities in Major Diabetes Outcomes

OBJECTIVE Due in large part to effective pharmacotherapy, mortality rates have fallen substantially among those with diabetes; however, trends have been less favorable among those of lower socioeconomic status (SES), leading to a widening gap in mortality between rich and poor. We examined whether income disparities in diabetes-related morbidity or mortality decline after age 65 in a setting where much of health care is publicly funded yet universal drug coverage starts only at age 65. RESEARCH DESIGN AND METHODS We conducted a population-based retrospective cohort study using administrative health claims from Ontario, Canada. Adults with diabetes (N = 606,051) were followed from 1 April 2002 to 31 March 2008 for a composite outcome of death, nonfatal acute myocardial infarction (AMI), and nonfatal stroke. SES was based on neighborhood median household income levels from the 2001 Canadian Census. RESULTS SES was a strong predictor of death, nonfatal AMI, or nonfatal stroke among those <65 years of age (adjusted hazard ratio [HR] 1.51 [95% CI 1.45–1.56]) and exerted a lesser effect among those ≥65 years of age (1.12 [1.09–1.14]; P < 0.0001 for interaction), after adjusting for age, sex, baseline cardiovascular disease (CVD), diabetes duration, comorbidity, and health care utilization. SES gradients were consistent for all groups <65 years of age. Similar findings were noted for 1-year post-AMI mortality (<65 years of age, 1.33 [1.09–1.63]; ≥65 years of age, 1.09 [1.01–1.18]). CONCLUSIONS Observed SES differences in CVD burden diminish substantially after age 65 in our population with diabetes, which may be related to universal access to prescription drugs among seniors.

Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: a realist review

OBJECTIVES To identify factors associated with the implementability of clinical practice guidelines (CPGs) and to determine what characteristics improve their uptake. STUDY DESIGN AND SETTING We conducted a realist review, which involved searching multiple sources (eg, databases, experts) to determine what about guideline implementability works, for whom, and under what circumstances. Two sets of reviewers independently screened abstracts and extracted data from 278 included studies. Analysis involved the development of a codebook of definitions, validation of data, and development of hierarchical narratives to explain guideline implementability. RESULTS We found that guideline implementability is associated with two broad goals in guideline development: (1) creation of guideline content, which involves addressing the domains of stakeholder involvement in CPGs, evidence synthesis, considered judgment (eg, clinical applicability), and implementation feasibility and (2) the effective communication of this content, which involves domains related to fine-tuning the CPGs message (using simple, clear, and persuasive language) and format. CONCLUSION Our work represents a comprehensive and interdisciplinary effort toward better understanding, which attributes of guidelines have the potential to improve uptake in clinical practice. We also created codebooks and narratives of key concepts, which can be used to create tools for developing better guidelines to promote better care.

Methodologies to evaluate the effectiveness of knowledge translation interventions: a primer for researchers and health care managers

OBJECTIVE The evidence base for interventions to change clinical practice is modest but growing. Given the large variation in impact and costs, this review aims to highlight the importance of evaluating knowledge translation (KT) interventions by managers and researchers. STUDY DESIGN AND SETTING To meet its objectives, this review article discusses how the need for local or generalizable information and the resources available guide the evaluations. Furthermore, we discuss how study designs can focus on establishing internal validity or applicability and how the choice of focus affects the study design. RESULTS This review argues that managers should routinely incorporate simple evaluation designs into program implementation to assess and increase the impact of their services, whereas researchers should focus on creating cumulative knowledge through rigorous designs and rich descriptions of context and implementation to explore reasons for success and failure. CONCLUSION We suggest that the combined effort of managers and researchers will provide a richer knowledge base to move the field of KT forward and increase the use of evidence-based implementation strategies to improve the quality of health care provided.