Implementation science is the study of methods to promote the application of research findings in health care across clinical, organizational, or policy contexts. It’s the way we make evidence-based care a reality. Reflecting on key takeaways from last year’s 13th Annual Conference on the Science of Dissemination and Implementation in Health, this first post is all about adaptations –an inevitable part of life.
From taking a new route to the office to avoid a road closure to swapping out a favorite recipe ingredient for an allergic guest, the ability to make changes to an established plan is crucial for achieving a desired outcome.
Nowhere is this more apparent than in the health care setting. Since no two individuals are exactly alike, adaptations are fundamental for providing culturally appropriate, socioeconomically sensitive, equitable, and clinically effective care.
In this first post of the blog series, we highlight insights from a panel of experts on how to implement impactful strategies designed to meet the needs of unique and varied populations.
Understand the role of adaptations in complex interventions
An adaptation is a change or modification to a program or strategy. Adaptations can be intentional or unplanned. They may occur for everyone who receives the intervention or they may be more individualized, explained Shannon Wiltsey Stirman, Ph.D., a clinical psychologist at the National Center for PTSD and associate professor at Stanford University, during the panel.
Intentional and structured adaptations aren’t necessarily better than modifications made on the fly, she said. Both have their role in complex settings. Instead, positive or negative results of an adaptation must be understood in relation to the core elements of the intervention in question.
“Core elements are parts of the intervention that are empirically or theoretically associated with the desired outcome,” said Wiltsey Stirman. “They are the parts of the intervention that are effective and necessary. Core elements might not be the same in all contexts, and you might use different methods, or forms, to achieve the same function based on your environment, resources, and populations.”
Keeping the core elements of an intervention in mind, no matter what form they take, is essential for avoiding “drift,” added Ana A. Baumann, Ph.D., a research assistant professor at the Brown School of Social Work, Washington University in St. Louis.
“Drift occurs when an adaptation is in conflict with fidelity, so that the intervention simply doesn’t work as well after making adaptations that turn out not to be helpful,” she said.
Drift can be difficult to recognize before it has taken hold, which is why intervention designers should build in opportunities to identify, assess, and evaluate adaptations at regular intervals throughout the program.
“Balancing the two opposing forces of planned and reactive adaptations, and documenting them along the way, will be very important to achieving the outcomes you planned for,” said Baumann.
Exhibit 1. Key Terms
A change or modification to a program or strategy.
The degree to which an intervention (particularly its core elements or functions) is delivered as intended. Fidelity to core elements is critical to successful translation of evidence-based interventions into practice.
When an adaptation is in conflict with fidelity.
Think creatively about adapting to circumstances while maintaining fidelity
The COVID-19 pandemic dramatically disrupted health care services and threw many established interventions off track. To continue providing care to patients, health care providers urgently needed to develop creative adaptations.
“Home visits for patients became a lot less feasible when COVID hit,” said Wiltsey Stirman. “Some people decided to switch their home visits to video calls. Some designed a process where one person sits in their car with a mask on and the other talks to them through an open window at a distance.”
“As long as there’s some form of visit, you could consider the adaptation to be fidelity consistent, and we don’t have to tell people that they have to suspend treatment until after COVID is over.”
The Department of Veterans Affairs (VA) took this approach to ensure the continuation of services for patients, said Christopher Miller, Ph.D., an investigator at the VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR) and assistant professor in the Harvard Medical School Department of Psychiatry.
“COVID-19 prompted a huge spike in the use of telehealth to replace in-person visits, but many veterans and their families don’t have access to tools that would allow them to participate,” Miller said. “The VA decided simply to send iPads to people who don’t have them. It was worth addressing the technology disparity while saving on preventable health care spending down the line.”
“I know that’s not a possibility for all interventions, but it’s a great example of taking a lot of the adaptation burden off of the practitioners and clinicians by simply eliminating one of the biggest hurdles for patients, which is access to technology.”
Thoroughly document adaptations using standardized methods
All adaptations must be documented in a way that allows the implementation and clinical team to understand what happened, why it happened, and how it impacts the core elements of the program.
“If we document adaptations well, we create accountability and the chance to learn from our failures and successes,” said Wiltsey Stirman. “We want to develop a shared language and common understanding about applying and recording our work to support continuous improvement.”
But tracking adaptations can be burdensome if the documentation process is not well implemented, cautioned Borsika A. Rabin, Ph.D., M.P.H., Pharm.D., co-director of the UCSD Dissemination and Implementation Science Center.
“You have to think about how to build documentation into your study from the very beginning,” she said. “You can streamline the process by using information that you would already collect and matching up adaptation data collection strategies with those data elements.”
Intervention designers can use a combination of interviews, self-reporting, and direct observation to collect information on how adaptations are working in the clinical setting, Rabin advised. Asking the right questions, such as whether an adaptation is being made for everyone or just for specific groups, can help to illuminate the real-world impact of any changes.
Evaluate the impact of adaptations with key outcomes in mind
Detailed documentation is the foundation of a meaningful evaluation of adaptations and how they contributed to – or detracted from – ideal outcomes.
Developing a larger pool of documentation on adaptations and their impacts can contribute to more in-depth research and new programs to address unmet needs in vulnerable populations, said Wiltsey Stirman.
“We need to use existing frameworks, like the Model for Adaptation Design and Impact (MADI), to structure our evaluations and share knowledge using a common language,” she said.
“It is also key to talk with your stakeholders and find out which outcomes are likely to be most important to them,” she added. “It could be a measurable clinical change, but they might also be interested in engagement rates, satisfaction, and acceptability. Understanding their high-value criteria and using those as a lens for evaluation will make it easier to pinpoint the strategies that can produce results in the future.”
Researchers and clinicians will need to keep these best practices in mind as they work together to deploy effective complex interventions. By balancing structure with creativity and documenting adaptations appropriately, health care organizations will be better prepared to support the uptake of effective interventions.
In next week’s post on the AcademyHealth blog, we will continue our Implementation Science series by examining the ins and outs of implementation facilitation in a virtual setting.
This blog post highlights quotes and learnings from the panel “Planning, Documenting, and Evaluating Adaptations for the Implementation of Complex, Real-World Interventions in the age of COVID-19” presented at the 13th Annual Conference on the Science of Dissemination and Implementation in Health on Dec. 15, 2020. A full recording of the panel is available here.