Implementation science tailored to precision prevention

Implementation Science Tailored to
Precision Prevention
Graham Colditz, MD, DrPH
April 23, 2018
Department of Surgery
Division of Public Health Sciences

Disclosures
• I have no conflict of interests
• Talk – slides at
https://www.slideshare.net/GrahamColditz/IS-tailored-
to-precision-prevention
• Or bitly

OUTLINE
• Background
• Current environment of precision medicine
• Gap between evidence and implementation
• Models of implementation
• Considerations
• Future progress – Where are we going?

Goal of Implementation Science
Ensure that knowledge and materials produced by health
research actually lead to improved population health:
1. Reaching intended audience
2. Adapted to local circumstances
3. Implemented effectively, safely, equitably, and in a timely manner that
keeps patient at forefront of decision making

Key Terms
Precision medicine – uses information about a person’s genes,
environment, and lifestyle to prevent, diagnose, and treat disease
• Allows for more accurate prediction of which treatment and prevention strategies for a
particular disease will work in which groups of people
Precision prevention – tailored approach that considers genetic
variants, mechanisms, and environmental and lifestyle factors to reduce the
risk of disease
• Mainly related to reducing the risk of cancer
Pharmacogenomics – study of how genetic variations influence our
response to medications

Key Terms (continued)
Implementation science – study of methods to promote integration of
research findings and evidence into healthcare policy and practice
Dissemination research – scientific study of targeted distribution of
information and intervention materials to a specific public health or clinical
practice audience
• Intent is to understand how best to spread and sustain knowledge and the associated
evidence-based interventions
Implementation research – scientific study of the use of strategies to
adopt and integrate evidence-based health interventions into clinical and
community settings in order to improve patient outcomes and benefit
population health

Current Examples of Precision Medicine
Finding the
proper dose of
the proper drug

Genomics and
cancer

Regenerative
medicine

Molecular
profiling of
microbes

Personalized
diets

How is precision medicine/prevention explained to
patients?

Model of Precision Medicine (Rebbeck 2014)

Model of Precision Medicine (Rebbeck)
BUT, there
is a gap!

Gaps Between Evidence and Implementation
Colorectal Cancer Screening
• Goal of US National Colorectal Cancer Roundtable (NCCRT) to increase use of
recommended CRC screening tests to 80% by 2018
However…
• Overall screening among adults age 50 years and older is still around 62.6%
• Varies significantly by state with the highest still only 76% (Massachusetts) and the
lowest at 58% (Wyoming)
• Screening still very low among uninsured (25%) and immigrant populations (34%)
Genomic testing and guided treatment for lung cancer
Lynch syndrome screening in bowel cancer
BRCA testing in ovarian cancer

Consider Dissemination and Implementation Earlier
Need an earlier focus on…
• Who’s going to deliver the intervention
• Fit with ultimate patient population (consider context)
• Building on tests of training, support, adherence, mediators and
moderators to high quality delivery
• Hybrid designs

Model of Implementation Science
Conceptual model of implementation research (Proctor 2009)

Model of Implementation Science
Consolidated Framework for Implementation Research (CFIR)
(Damschroder 2009) – Provides/Considers Context

Barriers and Facilitators: Evidence to Implementation
Barriers
• Limited resources (money, staff)
• Time constraints
• Negative attitudes toward change
Facilitators
• Genuine interest from health system decision makers

Preliminary Results: Clinic Interviews, Illinois
Major patient level barriers:
• Lack of or insufficient insurance coverage for
colonoscopies
• Lack of transportation to get to/from
appointments
• Resistance to screening, in particular
colonoscopy
• Changing/inconsistent contact information

Preliminary Results: Clinic Interviews
Some of the improvements clinics suggested for screening
include:
• Ability to run reports of patients due for screening
• Tracking systems in EMR to better track patients referred for
screening
• Patient education
• Community outreach
• Videos to play in waiting room or patient rooms about CRC
screening
• Improved interfaces/information transfer with EMRs at other
sites (hospitals, etc)
• Traveling colonoscopists who could provide procedures locally

Consider Medically Underserved Population
Current focus not on intended population
Challenges:
• Access to internet/email
• Health insurance coverage
• Rural locations
• Health literacy

Minority groups have higher
percentage of those with below basic
health literacy
• 41% of Hispanics & 24% of Blacks
• 23% of those age 65-75 & 39% of those over age 75
• 27% of those on Medicare, 30% of those on Medicaid,
28% of those with no insurance
One “dose” does not fit all – Considering Health Literacy
77M adults have basic or below basic health literacy
• Only 12% have proficient health literacy

One “dose” does not fit all (continued)
Many studies demonstrate ways to address this
disconnect between health materials and
consumers
• Health insurance decision making
• Cancer treatment decision making
• Understanding genome sequencing preferences and results
• Informed consent language
• Discharge instructions
• Following clinical recommendations
• Postmastectomy Breast Reconstruction decisions

How do we move from current examples of precision
prevention like breast and colorectal approaches, to a more
comprehensive precision prevention and treatment approach?

Considerations
• Communication and context matter
• Tradeoff – for added measure
• Time for visit – testing and another visit
• Time for comprehension – health literacy – resources for
understanding the more complex “precision prevention
messages”
• Same strategy does not work everywhere (e.g. Victoria
vs. Missouri)

Conclusion
There is a paradox
• Costly
• Time-intensive
• Only works for small percentage of patients
• Still not always clear which variant to target
Let’s not exacerbate disparities, but HOW do
we do this?

Next Steps
Commonalities across many guidelines poorly
implemented, if at all
Identify when we need new strategies and when we
can adapt existing approaches?
How do we scale up once we have sufficient tool kit
How do we de-implement strategies no longer
supported by new evidence, science, etc.

Thank you
Graham Colditz
colditzg@wustl.edu

Levels of analysis
System
Academic institutions
Non-academic
institutions
Laboratory
Providers
Doctors
Nurses
Other Staff
IT staff
Laboratory staff
Patients
Patients’ families
ProblemStatement
Howwillweincreaseclinicalutilityofgenomicsequencingfor
underservedandruralpatientsandproviders
Genomic
testing
Interpret
results
Genetic
counseling
Implementation
Strategies
System
ORCHID
Providers
Training
CCT
Other Staff
Training
Patients
Decision making
support
CCT
Implementation
Outcomes
System
Readiness to change
Adoption
Penetration
Providers
Acceptability
Feasibility
Other Staff
Adoption
Patients
Acceptability
Reach
Service Outcomes
Safety
Equity
Patient-centeredness
Timeliness
Client Outcomes
Patients:
Participation
decision (yes/no)
Participants
% consenting to
secondary results
% who do initial
genetic
counseling call
%who access
germline info
%who hold a
follow up genetic
counseling call
NCI Guidelines
Health Equity Impact Assessment
Scoping, Potential impacts, Mitigation, Monitoring
Guideline
characteristics
Guideline
Factors
Individual Health
Professional
Factors
Patient Factors
Professional
interactions
Adapted from Proctor et al. (2011) and Feldstein and Glasgow (2008) and Health Equity Impact Assessment (2012)

Implementation science tailored to precision prevention

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