Effectiveness and reach of the FLU-FIT program in an integrated health care system: a multisite randomized trial.

OBJECTIVES: We tested the effectiveness of offering home fecal immunochemical tests (FITs) during influenza vaccination clinics to increase colorectal cancer screening (CRCS). METHODS: In a clinical trial at Kaiser Permanente Northern California influenza clinics in Redwood City, Richmond, South San Francisco, Union City, and Fresno, we randomly assigned influenza clinic dates to intervention (FIT offered) or control (FIT not offered) and compared subsequent CRCS activity. RESULTS: Clinic staff provided FITs to 53.9% (1805/3351) of intervention patients aged 50 to 75 years. In the intent-to-treat analysis, 26.9% (900/3351) and 11.7% (336/2884) of intervention and control patients completed an FIT, respectively, within 90 days of vaccination (P ≤ .001). The adjusted odds ratio for completing FIT in the intervention versus the control arm was 2.75 (95% confidence interval = 2.40, 3.16). In the per protocol analysis, 35.4% (648/1830) of patients given FIT and 13.3% (588/4405) of patients not given FIT completed FIT within 90 days of vaccination (P ≤ .001). CONCLUSIONS: This intervention may increase CRCS among those not reached by other forms of CRCS outreach. Future research should include the extent to which these programs can be disseminated and implemented nationally.

Implementation and spread of interventions into the multilevel context of routine practice and policy: implications for the cancer care continuum.

The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.

An evidence integration triangle for aligning science with policy and practice.

Over-reliance on decontextualized, standardized implementation of efficacy evidence has contributed to slow integration of evidence-based interventions into health policy and practice. This article describes an "evidence integration triangle" (EIT) to guide translation, implementation, prevention efforts, comparative effectiveness research, funding, and policymaking. The EIT emphasizes interactions among three related components needed for effective evidence implementation: (1) practical evidence-based interventions; (2) pragmatic, longitudinal measures of progress; and (3) participatory implementation processes. At the center of the EIT is active engagement of key stakeholders and scientific evidence and attention to the context in which a program is implemented. The EIT model is a straightforward framework to guide practice, research, and policy toward greater effectiveness and is designed to be applicable across multiple levels-from individual-focused and patient-provider interventions, to health systems and policy-level change initiatives.

Primary prevention of type 2 diabetes: integrative public health and primary care opportunities, challenges and strategies.

Type 2 diabetes imposes a large and growing burden on the public's health. This burden, combined with the growing evidence for primary prevention from randomized controlled trials of structured lifestyle programs leads to recommendations to include caloric reduction, increased physical activity and specific assistance to patients in problem solving to achieve modest weight loss as well as pharmacotherapy. These recommendations demand exploration of new ways to implement such primary prevention strategies through more integrated community organization, medical practice and policy. The US experience with control of tobacco use and high blood pressure offers valuable lessons for policy, such as taxation on products, and for practice in a variety of settings, such as coordination of referrals for lifestyle supports. We acknowledge also some notable exceptions to their generalizability. This paper presents possible actions proposed by an expert panel, summarized in Table 1 as recommendations for immediate action, strategic action and research. The collaboration of primary care and public health systems will be required to make many of these recommendations a reality. This paper also provides information on the progress made in recent years by the Division of Diabetes Translation at the US Centers for Disease Control and Prevention (CDC) to implement or facilitate such integration of primary care and public health for primary prevention.

Policy-contribution assessment and field-building analysis of the Robert Wood Johnson Foundation's Active Living Research Program.

BACKGROUND: The Robert Wood Johnson Foundation requested this utilization-focused evaluation of its Active Living Research (ALR) program. This evaluation reports on the trajectory of influence of past and future ALR outcomes on field-building and policy contributions as well as on possible users of completed and disseminated ALR products. METHODS: In 2006 and 2007, key-informant interviews were conducted with 136 representatives of first-line potential users of ALR research products, including state physical activity and nutrition program coordinators, policymakers, scientists, and funders. Literature reviews, bibliometric analyses, and document reviews served to describe the context for ALR's work and the ways it could enhance its utility for field building and policymaking. RESULTS: The contributions of ALR to the emerging transdisciplinary field included leadership in the development of measurement tools, epidemiologic studies, implementation research, the translation of research to practice, and the communication of learned lessons to diverse audiences. ALR's contributions to policy discussions were found across a spectrum of policy-development phases that included describing the problem, raising awareness of alternative strategies for increasing physical activity, convening nontraditional partners, and evaluating policy implementation. CONCLUSIONS: Policy-relevant research can make contributions to policymakers' thinking but almost never causes a change by itself. Five years after the original authorization of ALR, there is ample evidence of its recognition as a resource by key players, its field-building influence, and its contributions to policy discussions. All these bear promise for a broader contribution to obesity prevention. Recommendations for increasing ALR's impact on policy and practice are offered.