Diffusion, Dissemination and

Implementation: What is the

Difference?
Michael Parchman, MD, MPH
Director, MacColl Center for Health Care Innovation
Group Health Research Institute, Seattle
October 2015
 Objectives
• Definitions?”
• Where does it fit within the field of
“Translational Science?”
• Common Theories and Frameworks
• Who conducts IS research?
• Two examples
 What is Implementation Science?
• The scientific study of
methods to promote the
systematic uptake of
research findings and
other evidence-based
practice into routine
practice to improve the
quality and effectiveness
of health care and health
care services.
Other terms for “implementation”
• Knowledge translation
• Knowledge exchange
• Knowledge transfer
• Knowledge integration
• Research utilization
 A Continuum:
Diffusion-Dissemination-Implementation

Diffusion Dissemination Implementation

The passive, Active spread of The process of

untargeted and new practices to adoption, integration
unplanned the target and use of new
spread of new audience using practices within a
practices planned strategies setting
The Translational Research Spectrum

Westfall JM, et al. JAMA. 2007;4:405-6

 Why Do We Need It?
• It takes 17 years to turn • Two-thirds of
14 percent of original organizations' efforts to
research findings to the implement change fail
benefit of patient care – Damschroder LJ.
– Lenfant C. N Engl J Implement Science 2009
Med. 2003
• Patients receive 54.9% of
recommended evidence-
based care for prevention
and chronic illness care.
– McGlynn EA. NEJM 2003
 Theories, Models and Frameworks
(Oh My!)
• Theory
– principles or statements designed to structure our
observation, understanding and explanation of the world
• Model
– a deliberate simplification of a phenomenon
– model is descriptive, whereas a theory is explanatory as
well as descriptive
• Framework
– a structure, overview, outline, system or plan consisting of
various descriptive categories, e.g. concepts, constructs or
variables, and the relations between them that are
presumed to account for a phenomenon
Nilsen P. Making sense of implementation theories,
models and frameworks. Implement Sci 2015;10:53
 Approaches to building frameworks

Classical model Planned change model

• Passive & explanatory “…a set of logically interrelated
• Descriptive but not meant to concepts that
guide or cause change • Explain, in a systematic way, the
means by which planned
change occurs
• Predict how various forces in an
environment will react in
specified change situations
• Help planner or change agents
control variables that increase
or decrease the likelihood of
change.”

9
Examples of Theories and Frameworks
• Diffusion of Innovation • Consolidated
Theory – Framework for
– Rogers 1962 Implementation
• Dissemination and Research (CFIR)
Implementation of – Damschroeder 2009
Innovations in Health • Small Practice Change
Services Delivery Model
– Greenhalgh 2004 – Solberg 2007
Diffusion of Innovation Theory
Everett Rodgers-(1962)
 Chronic Care Model

Community Health System

Resources and Health Care Organization
Policies
Clinical
Self- Delivery
Decision Information
Management System
Support Systems
Support Design

Informed, Prepared,
Productive
Activated Proactive
Interactions Practice Team
Patient

Improved Outcomes
Greenhalgh: Determinants of Diffusion, Dissemination
and Implementation (2004)
 Consolidated Framework for
Implementation Research (CFIR)
 Framework for Practice Improvement

Leadership: Is it a -Change/QI strategy System level

burning -Change management changes, not
platform? skills asking people to
-Adequate resources just do better:
& time decision support,
-Mature information self-management
systems support, workflow
-Trust & Teamwork redesign, etc.
 Who Does IS Research?
• Clinicians • Health Informaticians
• Nurses • Health Administrators
• Psychologists • Biostatisticians
• Economists • Social Scientists
• Public Health • Health Care
• Organizational Scientists Management
• Epidemiologists • And many more
Examples of Implementation Research
Studies
• Diamond Initiative: Depression in Minnesota
• Practice Facilitation Improves Chronic Illness
Care: The ABC Intervention Study
 Diamond Study:
Conceptual Framework
 Change/Implementation Process
• Training: one physician, care manager
– Four face-to-face sessions
– Two conference calls/webinar
• Registry
• Tools/Resources: checklists, clinic workflow,
scripts for patient visits
• Monthly care manager support calls
Diamonds Study:
Practice Systems
 Diamond Study:
Methods & Results
METHODS • PHQ-9 Scores not
• 75 primary care clinics significantly different
• Stepped Wedge Design – Diamond: 13.2 to 8.0
– Control: 12.3 to 7.8
– 5 sequences of 10-40
clinics every 6 months – (p=.92)
• Depression remission
“This study shows the difficulty rates were not
of widespread implementation of significantly different
evidence-based practices that 36.4% Diamond Care vs
require major changes in roles 33.9% Control Clinics; (p
and extensive financial and
= .94)
leadership support.”
 Methods
• 38 small practices
• Stepped Wedge Design
– Initial Intervention (n=19)
– Delayed Intervention (n=19)
• 12 months of practice facilitation/coaching to
implement components of the CCM
• Tools/resources for improving diabetes
outcomes: A1c, BP, lipids (ABC)
 Outcomes
• Clinician Staff Surveys:
– Assessment of Chronic Illness Care
• Chart Abstractions (n=60 random per clinic)
– A1c
– BP
– Lipids
Care Consistent with the CCM?

Initial Intervention Delayed Intervention

 Trends in A1c Control
7.7

7.65

7.6

7.55

7.5

HbA1c 7.45
Delayed Intervention
7.4 Intervention
7.35

7.3

7.25

7.2

7.15
0 1 2 3 4 5 6 7 8

Quarters after Randomization

 Conclusions
“One of the most consistent findings from clinical and
health services research is the failure to translate
research into practice and policy. As a result of these
evidence-practice and policy gaps, patients fail to
benefit optimally from advances in healthcare and are
exposed to unnecessary risks of iatrogenic harms, and
healthcare systems are exposed to unnecessary
expenditure resulting in significant opportunity
costs…[and] our evidence on the likely effectiveness of
different strategies to overcome specific barriers remains
incomplete.”
-Jeremy Grimshaw 2012
 References
• The journal “Implementation Science” is open-source
and worth exploring back issues for interesting
articles:
– www.implementationscience.com
• Website: Consolidated Framework for Implementation
Science:
– www.cfirguide.org
• Greenhalgh T, et al. Diffusion of innovations in service
organizations: systematic review and recommendations.
Milbank Quarterly, 2004;82:581-629.
Questions?