Evidence-based practices (EBPs) take an average of 17 years to be incorporated into routine medical practice and a number of neurosurgical care recommendations in the fields of degenerative disc disease, trauma, stroke and other common diagnoses are not universally applied, creating an “evidence-practice mismatch”. Implementation science (“ImpSci”) seeks to study and promote the uptake of EBPs to more successfully translate medical knowledge into healthcare improvements. ImpSci is a burgeoning research field with an increasing footprint of federal funding, particularly in the areas of cancer care and addiction medicine, and resulting theoretical frameworks and research rigor are increasingly impactful in a variety of health settings. This field can provide helpful guidance for neurosurgeons looking to improve uptake of evidence-based practices in their own practice, referral bases and health systems.
ImpSci seeks to define and study qualities of intervention success in terms of its implementation in real world healthcare settings. These qualities often include the acceptability of the intervention to stakeholders, the feasibility of the intervention in a given setting, the cost of the intervention, the sustainability of the intervention over time, the “penetration” of the intervention (integration within a system), the “fidelity” of the intervention (how closely the intervention in the real world mimics the originally studied protocols), and the appropriateness or perceived fit of the intervention to a particular setting.
In order to aid in the conceptualization and monitoring of the numerous qualities involved in intervention implementation, several theoretical frameworks have been devised and are heavily utilized in both practice and research. The Consolidated Framework for Implementation Research (CFIR ) and Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM ) frameworks two of the most popular frameworks, both with extensive online resources cfirguide.org (re-aim.org) to assist in their utilization. The CFIR is particularly helpful in articulating barriers to implementation and has its own gamified version for implementation teams (https://implementationsciencecomms.biomedcentral.com/articles/10.1186/s43058-020-00099-1). In addition, the Veterans Affairs system has created their own process model for implementation, which intersects with quality improvement (QI), called the QUERI Roadmap (https://www.queri.research.va.gov/tools/QUERI-Implementation-Roadmap-Guide.pdf). However, the two fields are distinct, with QI focusing more on a specific health-system problem, while ImpSci focuses more on an evidence-based practice (https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-015-0089-9). It is similarly important to distinguish an implementation strategy from the EBP it seeks to implement. The implementation strategy is the strategy (which could be one method, or a “bundle” of methods) meant to facilitate the adoption of the EBP.
The utilization of ImpSci principles has improved intervention uptake and led to decreased evidence-practice mismatch in a number of patient care areas, such as diabetes prevention, patient safety checklists, HIV prevention and primary care mental health integration (Kilbourne 2020). As ImpSci initiatives become more integrated with social science principles, such as those of behavioral economics, growth of institutional centers for implementation of improved care such as the Penn Medicine Nudge Unit (nudgeunit.upenn.edu) have evolved. These centers utilize such concepts as gamification, social comparisons, financial incentives and active vs passive choice to influence health care provider and patient behavior and ultimately improve health on the population level.
ImpSci has previously been utilized in the research of neurological sciences, including epilepsy care and hydrocephalus, but remains an area of development potential within neurosurgical practice and research. Implementation science principles can also be utilized to tailor evidence-based practices for scale up on the front end of development.
For practicing neurosurgeons interested in implementing evidence-based practices within their practice or health systems, an important first step is identifying at which level the EBP needs to be adopted – health system level, clinic level, provider level, patient level, etc. Once the target of the implementation strategy is identified, a number of techniques can be considered, including educational efforts, incentives, system redesign, standing orders, etc. During this preplanning, consideration of determinants (barriers and facilitators of EBP implementation) is important, and it is in this area that ImpSci frameworks such as the CFIR may be helpful. After an implementation effort is underway, efficacy measurement is critical. BNoth quantitative and qulaitative data are required to improve the rollout of the intervention.
