Implementation Science in Surgery: Translating Outcomes to Action.

Abstract

In 2017 alone, the United States spent more than $182 billion in health care–related research and development.1 Research suggests that it takes approximately 17 years to transition outcomes data into clinical practice. Nonetheless, there have been recent efforts to promote the accelerated integration of research into health care.2 For example, the Dissemination and Implementation Initiative created by the Agency for Healthcare Research and Quality was developed to distribute funds for researchers translating evidence into practice with the goal of improving health outcomes.3 Formalized systems of implementation science will maximize the impact of newly discovered scientific information. Implementation science is defined as a systematic approach to assimilate evidence-based science into practice and policy.4,5 Although dissemination science is fundamental to implementation, it is not the same as implementation science. Dissemination science describes the process and extent to which evidence-based ideas are distributed to stakeholders, providers, and policymakers, but it does not encompass the process by which the science is integrated into the health care system through practice and policy. Both the dissemination and implementation of science may be a strategy for quality improvement and the promotion of high-value care. This article focuses on providing a general framework of implementation science. In addition, we discuss barriers and strategies to promote the use of implementation science in surgery. MODES OF EVIDENCE TO IMPLEMENT INTO PRACTICE Surgical research encompasses a wide variety of clinical topics ranging from analyses on novel surgical techniques to policy research focused on improving the value of care. Figure 1 illustrates the various types of research evidence that can be implemented into practice. Evidence that can be implemented into practice and policy includes research on (1) technique and equipment, (2) improving quality and reducing cost, (3) patient-centered care, and (4) professional development. Although there is some overlap within these categories, classifying the research may aid in identifying the necessary framework needed to integrate evidence into clinical practice.Fig. 1.: Domains of research to implement into practice and policy.Technique and Equipment Applying innovative techniques and using new medical equipment may help surgeons perform operations with greater efficiency and quality, ultimately improving patient care. For instance, a hand-held three-dimensional scanner has been used to assist in the intraoperative symmetric assessment for patients undergoing reduction mammaplasty. In a study by Yang et al., the authors found that patients who underwent reduction mammaplasty with this three-dimensional scanner had reduced variance/difference in breast volume and increased measures of satisfaction.6 Although additional research may further encourage the integration of this tool into practice, preliminary evidence supports the use of this tool to improve patient outcomes and surgeon experience. Other scientific evidence in this category may include new surgical techniques for microvascular flap procedures, medications reducing scar formation, intraoperative devices, and other tools used to augment patient preferences into clinical planning. Improving Quality and Reducing Costs Surgical research focused on health care policy targets disparities in care, reducing discretionary spending, lowering overall cost of care, and determining the most efficient and effective ways to deliver surgical care. In an analysis of the Michigan Collaborative Hand Initiative for Quality in Surgery, our research group evaluated the use of electrodiagnostic testing for patients undergoing carpal tunnel release. We found that variables at both the practice and surgeon levels were responsible for variation in the use of such testing before a diagnosis of carpal tunnel syndrome.7 Given the costs and discomfort associated with these tests, initiating institution-based policy focused on providing surgeons clear guidelines on when to order this diagnostic test may be an avenue to implement this evidence into care for patients undergoing carpal tunnel release. Furthermore, in a systematic review and meta-analysis of risk factors of readmission after plastic surgery procedures, Tapking et al. found that patients undergoing head and neck reconstruction with diabetes, anemia, arterial hypertension, prior radiation therapy, or perioperative blood transfusions were at an increased risk for readmission.8 These preliminary data on readmissions can be used to develop a calculator to assess the risk of readmission after plastic surgery procedures and tailor follow-up care according to that level of risk. Patient-Centered Care As health care continues to progress toward precision medicine, incorporating patient preferences becomes more important. Plastic surgeons have applied a diverse array of experimental methods to further investigate patient-centered care ranging from qualitative studies to conjoint analyses.9–12 In an analysis of the needs of patients requiring plastic and reconstructive surgery after complex skin cancer treatment, the authors interviewed patients receiving care from surgeons for reconstruction after basal cell carcinoma, cutaneous squamous cell carcinoma, or lentigo maligna to learn about their experiences and needs regarding care. The participants explained that tailored health care information, collaboration among subspecialists, coordinated follow-up visits, and shared decision-making throughout the entire perioperative period were integral components to their care. Given that certain patients receiving reconstructive care after trauma or a cancer diagnosis require attention from multiple medical subspecialists, interdisciplinary clinics may help provide postoperative care to these patients in a way that aligns with their preferences and needs. This policy may reduce the cost of care for patients and discourage the practice of medicine in silos. Professional Development Formalized strategies to promote intellectual independence and professional development are important to foster a balanced, rewarding, and successful career in surgery. In an analysis of plastic surgery residents’ decision-making on a career for or against academic plastic surgery, the authors found that many residents lost interest during their training, and loss of autonomy was reported as the most common reason for a lack of pursuit.13 Deliberate efforts to endorse mentorship, career counseling, and research may remedy this. Future research on the feasibility of such programs and the impact on career trajectory may help other programs implement strategies that reshape the current paradigm of surgical training and promote innovation from an early stage. CONCEPTUAL FRAMEWORKS Summarized Model Implementation science frameworks are well documented in the scientific literature.14–20 Nilsen categorizes the models into three main types: those that describe and guide translation into practice, those that explain what influences the implementation strategy, and those that focus on evaluating the implementation strategy.21 We present a consolidated framework in Figure 2 to illustrate the general models used to guide implementation sciences. Our model summarizes the main findings from others in the literature and highlights aspects that are relevant to translating surgical evidence into policy. In this model, we describe four main aspects of implementation science: (1) strategy and engagement, (2) preparation, (3) implementation, and (4) quality improvement.Fig. 2.: Implementation science conceptual framework.In the strategy and engagement phase, implementation scientists should consider who will enact the strategy, identify the specific actions to be taken, specify the target population, set a timeframe, measure outcomes, and determine how to justify the implementation strategy to stakeholders.22 The preparation phase permits implementation scientists to secure the proper resources needed to manifest the particular strategy and define the specific actions to achieve the goal. In the implementation phase, the specific steps of the plan are executed, appropriate parties are engaged, and systems for data collection and reporting are established to allow for the final phase, quality improvement. The quality improvement phase permits implementation scientists to measure outcomes, report outcomes, and adjust the strategies to ensure the goal is met. Example Unplanned hospital visits have been used by the Centers for Medicare & Medicaid Services to penalize hospitals with greater-than-average readmission rates compared to the national average. Nonetheless, this policy applies only to patients being readmitted for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass, and elective total hip and knee arthroplasty.23 Numerous researchers have used this program to research readmissions for plastic surgery procedures, yet there are little to no initiatives focused on implementing this into practice.24–26 Research has shed light on the specific patient characteristics associated with an increased risk of return and examined diagnoses on return to care. Thus, informing plastic surgeons of their trends in readmissions and/or reasons for an unplanned visit to the emergency department may pose an opportunity to improve the quality of care for patients receiving plastic surgical care at a particular institution. For example, if one surgeon experiences greater rates of postoperative wound complications compared to others at an institution, that surgeon can tailor patient education protocols to better guide patients on managing their wounds postoperatively. Furthermore, surgeons can be informed of potential disparities in their care (eg, disparities attributable to socioeconomic status) to help guide patients to available resources that may improve their care. Figure 3 is used to showcase the various aspects of the conceptual framework as it pertains to a specific example.Fig. 3.: Example of implementation science in plastic surgery.IMPLEMENTATION SCIENCE PRIORITIES Research priorities are set by a variety of organizations to ensure that essential yet underattended topics are investigated. This strategy is used by the National Institutes of Health, Agency for Healthcare Research and Quality, and other entities within medicine and beyond.27,28 A similar framework has been used to identify specific steps that policymakers can take to convert recent evidence into action. The Lancet Commission on Global Surgery was launched in 2014, comprising an international multidisciplinary team of commissioners who came together with the goal of identifying recommendations for providing safe, low-cost, high-value surgical care to individuals in low- and middle-income countries. The commission set forth recommendations on developing and improving the surgical system in areas of the world that possess minimal resources. In addition, the commission provided various indicators that can be used to measure the progress of the global interventions.29 This strategy can be adopted by individual institutions, national surgical societies, and other stakeholders to identify recent, high-level evidence that can be implemented into practice with specific recommendations on how to accomplish them. GUIDELINES Providing specific frameworks to adopt a particular practice or policy may help institutions more easily integrate new evidence. For example, telemedicine has been identified as a potential tool to assess a variety of medical conditions. In a study by Wallace et al., the authors conducted a three-phase trial to evaluate the use of a telemedicine tool in assessing acute plastic surgical conditions, specifically, for wound assessment, burn injuries, minor fractures, and replantation. The authors found that telemedicine reduced the number of patients in the prospective cohort study who were unable to be seen because of a lack of capacity, and substantially fewer patients were required to present to the institution for further assessment.30 This system can improve access to care for patients in areas with fewer resources and increase the efficiency of the institution while preserving patient care. For institutions with steps to implement such a program, the evidence can more easily be integrated into care. National surgical societies can encourage implementation science by developing a team of experts to pilot the integration of new scientific evidence in different aspects of care. This collaboration may facilitate the development of clear guidelines with specific steps to integrate new scientific evidence into clinical care. BARRIERS TO IMPLEMENTATION The Surgical Outcomes Club developed a panel of leaders in implementation science to identify key messages and potential challenges for implementation science in the field of surgery. Institutional regulations and a lack of expertise in implementation science were identified as the main two challenges.31 Institutions and organizations should be equipped with the appropriate resources needed to integrate science by incorporating experts with proper implementation science training. Implementation science requires surgeons, policymakers, and other members of the health care team to be informed of recent scientific advances. Although there are efforts from institutions to facilitate the dissemination of science by permitting trainees and faculty to attend relevant educational conferences and protecting research time, institutions should be encouraged to expand opportunities for faculty and trainees to participate in continuing medical education and research. In addition, stakeholder engagement plays an important role in successful implementation science, as all parties must understand why a new policy is being implemented and its exact benefit.32,33 Stakeholders may include patients, surgeons, insurance companies, hospital administrators, national surgical societies, and other members of the health care team. Methods to engage stakeholders and incorporate their feedback must be deliberate and incorporated into all aspects of implementing the evidence into practice. CONCLUSIONS Despite the efforts by national organizations, researchers, and surgeons to encourage innovation, formalized systems of implementation science are needed to ensure new scientific evidence has an impact. Institutions should be encouraged to establish a team of implementation scientists to promote the uptake of new scientific evidence into care for their patients. Identifying priorities to highlight new and impactful scientific evidence that can be integrated into care may guide individuals in their efforts to engage with implementation science. Furthermore, national surgical societies can collaborate with institutions to fund and support the implementation of certain science into care, which can be used as a template for institutions if the program is successful. ACKNOWLEDGMENT The authors appreciate the peer review and edits from Michael Stokes, MA, MBA, staff vice president of communications at the American Society of Plastic Surgeons.