Implementation science for cancer control: One center's experience addressing context, adaptation, equity, and sustainment.

Implementation science (IS) has great potential to enhance the frequency, speed, and quality of the translation of evidence-based programs, policies, products, and guidelines into practice. Progress has been made, but with some notable exceptions, this promise has not been achieved for cancer prevention and control. We discuss five interrelated but conceptually distinct, crosscutting issues important to accelerate IS for cancer prevention and control and how our Colorado Implementation Science Center in Cancer Control (COISC3) addressed these issues. These needs and opportunities include more fully addressing changing, multi-level context; guiding rapid, iterative adaptations; evaluating innovative approaches to engagement and health equity; greater attention to costs and economic issues; and sustainability. We summarize conceptual issues; evaluation needs and capacity building activities and then provide examples of how our IS center addressed these five needs for cancer prevention and control. We discuss changes made to address priorities of (i) guiding adaptations of implementation strategies to address changing context and (ii) working on issues identified and prioritized by our primary care partners rather than the research team. We conclude with discussion of lessons learned, limitations, and directions for future research and practice in IS to enhance cancer prevention and control as well as translational behavioral medicine more generally.

Implementation science (IS) has made advances in translating research to practice but has not achieved the initial promise for cancer prevention and control (CPC). We discuss five crosscutting issues to enhance CPC that implementation and behavioral science are well positioned to address. These include more fully addressing changing, multi-level context; guiding rapid, iterative program adaptations; innovative approaches to engagement and health equity; greater attention to costs and economic issues; and sustainability. We then detail changes made in our research approach from studying specific interventions and strategies from the research literature to working on issues identified and prioritized by our primary care partners. In summary, progress in achieving lasting equitable improvements in health and healthcare will be greatly aided by use of flexible, accessible conceptual models, and approaches that help guide collaborators to design and adapt programs. We conclude with discussion of lessons learned, limitations, and directions for future research and practice of translational behavioral medicine.

RE-AIM implementation outcomes and service outcomes: what's the connection? results of a cross-sectional survey.

BACKGROUND: Implementation science and health services outcomes research each focus on many constructs that are likely interrelated. Both fields would be informed by increased understanding of these relationships. However, there has been little to no investigation of the relationships between implementation outcomes and service outcomes, despite general acknowledgement that both types of outcomes are important in the pathway to individual and population health outcomes. Given the lack of objective data about the links between implementation and service outcomes, an initial step in elucidating these relationships is to assess perceptions of these relationships among researchers and practitioners in relevant fields. The purpose of this paper is to assess perceived relationships between Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outcomes and service outcomes, testing five a priori hypotheses about which perceived relationships may be strongest. METHODS: A cross-sectional online survey was administered to a convenience sample of implementation scientists, health services researchers, and public health and medical practitioners from a variety of settings. Respondents provided information on their discipline, training, practice and research settings, and levels of experience in health service outcomes research, implementation science, and the RE-AIM framework. Next, they rated perceived relationships between RE-AIM and service outcomes. Repeated measures analysis of variance were used to test a priori hypotheses. Exploratory analyses assessed potential differences in mean ratings across groups of respondents categorized by discipline, setting, and levels of implementation science, health services, and RE-AIM experience. RESULTS: Surveys were completed by 259 respondents, most of whom were employed in academic and medical settings. The majority were doctoral-level researchers and educators or physicians. Reported levels of experience with implementation research, health services research, and the RE-AIM framework varied. The strongest perceived relationships overall were between Implementation/Fidelity and Effectiveness (as a service outcome); Maintenance and Efficiency; Reach and Equity; Adoption and Equity; Implementation/Adaptation and Patient-Centeredness; Adoption and Patient-Centeredness; and Implementation/Fidelity and Safety. All but one of the a priori hypotheses were supported. No significant differences in ratings of perceived relationships were observed among subgroups of respondents. CONCLUSIONS: This study is an initial step in developing conceptual understanding of the links between implementation outcomes, health services outcomes, and health outcomes. Our findings on perceived relationships between RE-AIM and services outcomes suggest some areas of focus and identify several areas for future research to advance both implementation science and health services research toward common goals of improving health outcomes.

The iPRISM webtool: an interactive tool to pragmatically guide the iterative use of the Practical, Robust Implementation and Sustainability Model in public health and clinical settings.

BACKGROUND: To increase uptake of implementation science (IS) methods by researchers and implementers, many have called for ways to make it more accessible and intuitive. The purpose of this paper is to describe the iPRISM webtool (Iterative, Practical, Robust Implementation and Sustainability Model) and how this interactive tool operationalizes PRISM to assess and guide a program's (a) alignment with context, (b) progress on pragmatic outcomes, (c) potential adaptations, and (d) future sustainability across the stages of the implementation lifecycle. METHODS: We used an iterative human-centered design process to develop the iPRISM webtool. RESULTS: We conducted user-testing with 28 potential individual and team-based users who were English and Spanish speaking from diverse settings in various stages of implementing different types of programs. Users provided input on all aspects of the webtool including its purpose, content, assessment items, visual feedback displays, navigation, and potential application. Participants generally expressed interest in using the webtool and high likelihood of recommending it to others. The iPRISM webtool guides English and Spanish-speaking users through the process of iteratively applying PRISM across the lifecycle of a program to facilitate systematic assessment and alignment with context. The webtool summarizes assessment responses in graphical and tabular displays and then guides users to develop feasible and impactful adaptations and corresponding action plans. Equity considerations are integrated throughout. CONCLUSIONS: The iPRISM webtool can intuitively guide individuals and teams from diverse settings through the process of using IS methods to iteratively assess and adapt different types of programs to align with the context across the implementation lifecycle. Future research and application will continue to develop and evaluate this IS resource.

MedCo: Enabling Secure and Privacy-Preserving Exploration of Distributed Clinical and Genomic Data.

The increasing number of health-data breaches is creating a complicated environment for medical-data sharing and, consequently, for medical progress. Therefore, the development of new solutions that can reassure clinical sites by enabling privacy-preserving sharing of sensitive medical data in compliance with stringent regulations (e.g., HIPAA, GDPR) is now more urgent than ever. In this work, we introduce MedCo, the first operational system that enables a group of clinical sites to federate and collectively protect their data in order to share them with external investigators without worrying about security and privacy concerns. MedCo uses (a) collective homomorphic encryption to provide trust decentralization and end-to-end confidentiality protection, and (b) obfuscation techniques to achieve formal notions of privacy, such as differential privacy. A critical feature of MedCo is that it is fully integrated within the i2b2 (Informatics for Integrating Biology and the Bedside) framework, currently used in more than 300 hospitals worldwide. Therefore, it is easily adoptable by clinical sites. We demonstrate MedCo's practicality by testing it on data from The Cancer Genome Atlas in a simulated network of three institutions. Its performance is comparable to the ones of SHRINE (networked i2b2), which, in contrast, does not provide any data protection guarantee.

Online Resources for Dissemination and Implementation Science: Meeting Demand and Lessons Learned.

A dramatically increased interest in dissemination and implementation (D&I) science, with relatively few training programs for D&I scientists, highlights the need for innovative ways to deliver educational materials, training, and resources. We described nine interactive, web-based D&I science resources appropriate for trainees and CTSAs. We used audience feedback and design thinking to develop resources iteratively. Primary target users are T3-T4 researchers, although T2 researchers can benefit from 'designing for dissemination' resources. Workforce development resources were used in D&I science workshops, as stand-alone, self-directed resources, and for consultations and trainings. We assessed resource design (purpose, functionality), usage, user experience and engagement. Educational resources addressed included: D&I science basics, pragmatic trials, getting proposals funded, designing for dissemination, and D&I science theory selection. We reviewed the purpose, functionality, status, and usage of these interactive resources. All resources engaged users; provided interactive feedback for learners; and linked users to additional learning resources. Online resources can be valuable for preparing clinical and translational mentees for research consultations, as follow-up training activities, and as D&I workforce development resources. The resources described are publicly available and we encourage their use, further development, and evaluation by CTSAs and other programs.

Care Transition Experiences of Older Veterans and Their Caregivers.

This study's main objective was to examine care transition experiences of older veterans and their caregivers. Fifty patients age 65 years and older, discharged from a Veterans Affairs Medical Center hospital, completed the Care Transitions Measure-15 survey three to four weeks postdischarge. Seven patients and six caregivers participated in semistructured interviews. Overall, the quality of care transitions was rated as good; however, some items were indicated as problematic for veterans. Themes that emerged included agreeableness, frustration with complex information, caregiver education, and the timing and methods of information delivery. These findings have implications for all clinical staff working with veterans, and particularly for social workers facilitating care transitions for veterans and their caregivers.

What is known about dementia care recipient violence and aggression against caregivers?

Aggression is a known behavior in dementia, but there is little in the literature about risk to home-based caregivers in situations where severe aggression is present. This article examines this issue with a focus on what is known and where further research is needed. Rates of severe aggression by dementia care recipients against caregivers are estimated at greater than 20%, and may be the strongest predictor of nursing home placement. Measures containing both assessment of behavior and objective measures of caregiver trauma are needed, along with interventions aimed at educating and protecting caregivers while respecting communicative properties of behavior.

Effect of extraction, pasteurization and cold storage on flavonoids and other secondary metabolites in fresh orange juice.

BACKGROUND: Fresh orange juice is perceived to be more wholesome than processed juice. Fresh juice may have nutrients and phytonutrients that differ from pasteurized or processed juice. RESULTS: 'Hamlin' and 'Valencia' oranges were extracted using a commercial food service juicer, pasteurized or not, resulting in fresh-commercial juice (FCJ) or pasteurized FCJ (FCPJ) for comparison with pasteurized processed juice (PPJ) in 2009, and gently hand-squeezed 'Valencia' juice (HSJ) in 2010 for nutrient and phytonutrient content. Regardless of pasteurization, FCJ/FCPJ contained 25-49% lower insoluble solids than the PPJ, while in HSJ the insoluble solids content was between that of FCJ and PPJ. The major orange juice flavonoid glycosides were twofold higher in PPJ than in FCJ/FCPJ and HSJ, indicating that the extraction and finishing process led to more peel tissue in the juice than fresh juice extraction methods. The total phenolic content (TPC) in the juices followed a similar pattern to the flavonoid glycoside content. The polymethoxylated flavones (PMFs), associated with peel oil, occurred at the highest levels in the FCJ/FCPJ and lowest in HSJ. Limonoids and alkaloids occurred at higher levels in PPJ and HSJ than in FCJ/FCPJ. CONCLUSION: The high peel oil content of FCJ/FCPJ resulted in higher PMF levels compared to PPJ and HSJ, while flavonoid glycosides, limonoids and alkaloids, which occur at high concentrations in the inner peel albedo, occurred at higher concentrations in PPJ.

Effect of extraction method on quality of orange juice: hand-squeezed, commercial-fresh squeezed and processed.

BACKGROUND: Fresh orange juice is perceived to be more wholesome than processed juice. Fresh juice may have flavor and nutrients that differ from pasteurized or processed juice. RESULTS: 'Hamlin' and 'Valencia' oranges were extracted using a commercial food service juicer, pasteurized or not, resulting in fresh-commercial juice (FCJ) or pasteurized juice (FCPJ) for comparison with pasteurized processed juice (PPJ) in 2009, and gently hand-squeezed 'Valencia' juice (HSJ) in 2010 for quality attributes. There was higher peel oil, lower pectin content, and less cloud loss in FCJ/FCPJ compared to PPJ and HSJ regardless of pasteurization. Titratable acidity was generally higher and the ratio of solids to acids lower in FCJ/FCPJ or HSJ compared to PPJ. FCJ/FCPJ had generally higher levels of most aroma volatiles than did PPJ and, overall, the highest esters and terpenes, while methanol and ethanol levels were highest in HSJ. For sensory evaluation, FCJ/FCPJ had more peel oil and PPJ more cooked flavor than other samples, while 'Valencia' HSJ was preferred over the other juices. CONCLUSION: High peel oil content and thermo-pasteurization process decreased cloud loss of orange juice. Extraction and finishing processes rather than pasteurization or oil content were major factors in influencing orange juice flavor quality.

Providing mental health services to older people living in rural communities.

Rural dwelling elders who experience mental health problems often have difficulty finding help since rural communities often lack adequate mental health service providers. This paper reports on the initial phase of a 5-year, interdisciplinary clinical research study that is testing the effectiveness of providing a home delivered, therapeutic psychosocial intervention, aimed at improving the emotional wellbeing and the quality of life of medically frail elders who live in rural communities. In the early phases of this study, the clinical research team encountered a number of interesting and often unanticipated challenges as it attempted to recruit study participants and provide services to them. In this article, we examine these challenges and share what we have learned so far about providing mental health services to elderly persons living in rural environments.