Embracing Dissemination and Implementation Research in Cardiac Critical Care

Abstract

In both high- and low-resource settings, high-quality health care can be ensured when routine clinical practices are based on high-quality evidence that underpins trustworthy clinical practice guidelines (CPGs). The United States Institute of Medicine (IOM) has defined CPGs as statements that include recommendations for patient care that are informed by a rigorous systematic review of the evidence and an assessment of the benefits and harms of alternative care options [1,2]. Typically, however, many routine practices and guideline recommendations are based on insufficient or low-quality evidence, while others are based solely on expert opinion. For example, in a review of all CPGs issued by the American College of Cardiology and American Heart Association from 1984 to September 2008, Tricoci et al. [3] showed that recommendations based solely on expert opinion, case studies, or “standard of care” (level of evidence C) were the most frequently encountered. Although important improvements have been proposed in the CPG development process [4] since the publication of the IOM standards, many challenges persist, including gaps in available evidence and also CPG implementation. The field of cardiac critical care (CCC) is no exception to these challenges [5]. Embracing dissemination and implementation (D&I) research is one approach to improving the quality of care delivered in CCC. As shown in Figure 1, our conceptualization of implementation research begins with (1) a rigorous systematic review of available evidence to identify interventions and practices of proven effectiveness that can inform the writing of CPG recommendations [6], (2) the identification of gaps in the available evidence that can inform new knowledge generation in the pre-clinical and clinical translational research arena (T1 to T3), and (3) the identification of gaps in CPG implementation that can inform post-clinical D&I research (T4 translation research) [7,8]. In this schema, T4 research includes specific observational or interventional studies to identify strategies that lead to a sustained, increased uptake of evidence-based practices and deimplementation of “evidence-free” practices. From this perspective, 2 examples are presented whereby embracing D&I research can help accelerate improvements in the quality of care delivered in critical care settings. A third example that serves as a model for successful D&I research is also provided. FIGURE 1 The National Heart, Lung, and Blood Institute is committed to supporting rigorous systematic review and synthesis of available evidence to underpin a collaborative partnership model for developing clinical practice guidelines