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Fast lane from the lab to the public

The emerging field of implementation science seeks to accelerate the application of evidence-based knowledge

Alexandre Affonso

It takes an average of 17 years for evidence-based healthcare knowledge to be utilized in hospitals and pharmacies. The delay, caused by logistical or cultural obstacles and the slow pace at which innovations are assimilated by medical services, was calculated in an article published in the year 2000 by Andrew Balas and Suzanne Boren of the University of Missouri, USA, and became a symbol of the gap between research and practice. It is frequently cited by scientists eager to see their findings put to good use while they are still relevant and by research-funding agencies and authorities uncomfortable with the delay in translating public investment into quality of life. The figure of 17 years has also become one of the incentives for an emerging discipline known as implementation science, a field of study that seeks to facilitate the dissemination of evidence-based practices, identifying obstacles to their adoption and testing the efficiency of interventions designed to remove these obstacles. Its methodologies could be useful for initiatives in education and management, but it is in public health that they have been most applied. Implementation research varies in terms of ambition—some studies propose changes to hospital work routines while others aim to improve protocols for dealing with diseases that affect millions of people, such as diabetes, AIDS, and mental illness (see examples).

It often involves quantitative and qualitative studies, weighing up costs and benefits and recommending training for practitioners. Before devising solutions, however, barriers need to be accurately identified and research stages rigorously monitored. Audits must be carried out before and after any intervention to analyze its consequences, good or bad. Another aspect is the direct involvement of patients, their families, and community members in the research design. “Establishing the effectiveness of a clinical innovation is not sufficient to guarantee its uptake into routine use. The relatively new field of implementation science has developed to enhance the uptake of evidence-based practices and thereby increase their public health impact,” explained Mark Bauer, professor emeritus of psychiatry at Harvard University, in an article published in 2020. Bauer is in charge of implementation projects at hospitals for war veterans in Boston, USA.

The field has grown in consistency over the last two decades thanks to the formation of dedicated research centers in countries such as the UK, Canada, Australia, and the USA, as well as the emergence of specialized journals. In Brazil, academic work in the area is still incipient, but researchers from several states have been developing studies and interventions based on the concepts of implementation science since last decade.

What is it?
Studies of methods that could reduce the gap between research and practice, supporting and accelerating the application of evidence-based knowledge.

• Identify the most effective routes between research results and practical application in disciplines such as education, psychology, management, and most notably, healthcare
• Assess how interventions are adopted and applied in real-world situations to gain an understanding of their effectiveness in different contexts

Why it is important
A study published in 2000 found that good scientific evidence takes an average of 17 years to become routine practice in healthcare. Removing barriers to the application of research results increases the chance that they will benefit the population

One project was able to increase the number of cities that add fluoride to drinking water in the state of Mato Grosso do Sul from 19 to 25 in 2021. “Water fluoridation is required by law and the benefits for preventing cavities are widely known, but there are hurdles that delay its implementation outside major cities,” explains Rafael Aiello Bomfim, a dentist and researcher at the Federal University of Mato Grosso do Sul, which coordinated the initiative in partnership with the state’s Regional Dentistry Council. He explains that one of the principles of implementation science is identifying and involving all of a problem’s stakeholders in the search for a solution. “We identified 14 different stakeholders, including sanitation companies, public representatives, and the State Health Department, which regulates the concession of water services. Then we took specific actions with those with the most power in the process,” he says. A stakeholder committee was created, which was advised on the scientific evidence regarding fluoridation and the expected impact. Removing the barriers was not difficult. “Companies generally don’t want to make changes that involve an increase in operating costs. But there was also no motivation to implement water fluoridation because the regulatory agencies were not monitoring the issue,” he explains. The experience was described in an article published in the Journal of Public Health Dentistry in December.

Some Brazilian studies in implementation science are part of international collaborations, such as a project started in 2018 that was cofunded by FAPESP and the Global Alliance for Chronic Diseases (GACD), an association comprising funding agencies from 13 countries that aims to tackle diseases such as diabetes and cancer. The objective of this specific research is to test the efficiency of interventions designed to reduce the stigma suffered by patients with mental illness seeking treatment at basic health centers in Ribeirão Preto, in the interior of São Paulo State. “Practitioners have difficulty dealing with this group of the population, which makes these patients even more vulnerable,” says the project’s coordinator, Carla Ventura of the Ribeirão Preto School of Nursing at the University of São Paulo (USP).

Ventura’s team has already interviewed 300 health professionals from six health centers in the city and 600 of their patients with psychiatric disorders. The proposed interventions will be implemented at three of these six centers, while the other three will serve as a control group. The strategies to be adopted are still under development. The idea is to hold workshops and art activities with family health team professionals. “As well as medical practitioners, patients will also actively participate in the workshops. Allowing those who suffer from stigma to share their experiences is essential to improving communication between all parties,” she explains. The approach was conceived in 2014 by the Center for Addiction and Mental Health at the University of Toronto in Canada. Ventura learned about the initiative while spending time at the Canadian university in the same year. In 2017, the GADC and FAPESP issued a joint call for research proposals and she submitted a project in collaboration with a Canadian colleague, Akwatu Khenti. The call schedule was delayed due to the pandemic.

The GACD is one of the research institutions that disseminates the most implementation science. Founded in 2012 and based in London, it coordinates activities that aim to prevent and treat chronic noncommunicable diseases on a global scale. Given the enormous volume of scientific evidence yet to be applied in practice, the GACD has focused on supporting implementation studies for diseases such as diabetes, cancer, heart and respiratory diseases, and mental illness. It has funded 110 projects worldwide, but only three involve Brazilian scientists. The lack of familiarity with this new field of science among researchers in the country has been a major obstacle.

Alexandre Affonso

FAPESP has been a member of the GACD since 2017 and has so far launched four joint calls with the institution. Last year, a call for proposals on cancer failed to identify any suitable studies among 20 proposals submitted, nine of which were preselected by the foundation. “When GACD representatives reviewed the proposals, they didn’t recommend approval of any of them. They were good, but they didn’t adopt appropriate methodologies for implementation studies,” explains Rui Maciel, an endocrinologist from the Federal University of São Paulo (UNIFESP) and a member of the FAPESP scientific board’s adjunct panel for life sciences. In December, FAPESP and the GACD launched a new joint call for research on chronic noncommunicable diseases. With the goal of involving well-established groups, up to three proposals will be selected as thematic projects, which receive funding for five years and are intended for teams that work on pioneering knowledge.

Some Brazilian groups have overcome this type of difficulty by seeking implementation science expertise abroad. Rosana Teresa Onocko-Campos, a doctor from the School of Medical Sciences (FCM) at the University of Campinas (UNICAMP), is heading a project funded by FAPESP to integrate primary care and mental health networks in the municipality of Itatiba, São Paulo, using a theoretical framework developed in the UK. The study was started in 2019 by request of Itatiba’s former health secretary Fabio Luiz Alves, a researcher at FCM. “Itatiba has the volume of services it needs, but they don’t coordinate well enough with one another,” explains Onocko-Campos. “Forty percent of patients entering the system via mental health facilities are not referred for other primary healthcare problems, such as high cholesterol, diabetes, or hypertension.” More than 6,000 medical records have already been analyzed, leading to training for 120 health workers and the formulation of proposals for new training and service improvements. If the interventions are successful, permanent education programs will be created. “Thanks to the creation of a research management committee, we were able to continue with the proposal despite the fact that the city had three different health secretaries and two mayors in the period,” says Onocko-Campos.

Alexandra Affonso

“I don’t know if implementation science will become a new science. Maybe it’s a language that we need to learn and systematize,” suggests Carlos Alberto Treichel, a nurse currently on a postdoctoral fellowship at FCM with a grant from FAPESP. He has been involved in the Itatiba project since doing his PhD in public health at UNICAMP, which included an exchange period at King’s College London’s Centre for Implementation Science, created in 2014. The UK, with its universal public healthcare system, is a perfect setting for implementation research. “Hospitals there have centers to help incorporate innovations through implementation studies,” highlights Treichel. At the London institution, he was involved with an initiative created to systematize knowledge related to this science, which led to the development of the Implementation Research Tool. The tool includes a checklist for identifying the appropriate theoretical framework for the research, using the primary concepts of implementation science and results monitoring (see graphic).

Many of the obstacles faced by implementation research are behavioral. As an example, Treichel mentions that doctors and technicians at health centers often do not fill out children’s vaccination cards. “They have a lot to do at the health center and many forget to ask. One intervention that proved effective was the creation of an electronic medical record system that only allowed the appointment to be ended after the vaccine card has been completed.” Identifying the barriers that an implementation study may face is not always easy. Antonio Luiz Pinho Ribeiro, a cardiologist from the Federal University of Minas Gerais (UFMG), led an attempt to implement a support model for ambulances dealing with suspected stroke victims that ultimately proved to be unfeasible. “The first responder needed access to a tablet, which turned out to be an insurmountable barrier. They are too busy to use a tablet,” he explains. Another system, which aimed to help nurses caring for hospitalized diabetes patients and also required the use of tablets, saw more positive results—but involving nurses alone was insufficient. The entire support team had to join the effort. “The hurdles can relate to different stakeholders. It may be the patient, the lack of structure in the healthcare system, or resistance to innovation among health workers,” he says.

The cardiologist heads a telemedicine program based at UFMG’s Hospital das Clínicas, which went national 11 years ago and now offers remote electrocardiography services in more than 1,000 cities across 12 Brazilian states. “We started developing new applications at the telehealth center thanks to funding from FINEP [Brazilian Funding Authority for Studies and Projects], which required implementation studies.” In 2012 Ribeiro was also awarded a visiting professorship at the University of Southampton, England, where he met James Batchelor, director of the institutions Clinical Informatics Research Unit, and the pair began collaborating. In 2019, Batchelor and Ribeiro secured funding from the GACD and the UK’s Medical Research Council for a digital health study monitoring patients with hypertension and diabetes at 34 basic health centers in Vale do Mucuri, Minas Gerais. Employees at half of the centers will be given special software and training for treating and managing their patients. At the other half, patients will receive the current standard care. Hospital Albert Einstein in São Paulo is a partner in the project.

Alexandre Affonso

The advent of implementation science is a consequence of a movement that began placing a greater emphasis on evidence-based medicine in medical education and professional practice. “There are so many studies highlighting solutions confirmed by science that it is impossible to absorb them all,” says Vilanice Alves de Araújo Püschel, a researcher at USP’s School of Nursing. In 2016, she was given permission to apply a methodology in Latin America that was developed by Australian institution JBI (formerly known as the Joanna Briggs Institute), linked to the University of Adelaide, comprising a series of tools designed to help health professionals incorporate the best scientific evidence into healthcare. Today, she leads a course at the School of Nursing that has already trained six groups. The first part of the course is face-to-face. After familiarizing themselves with the theoretical framework, each student chooses an implementation topic—JBI has a collection of over 500 topics with highly robust scientific literature on each of them. “These range from evidence that self-care is beneficial to patients with diabetes, to ways of preventing people in hospital from having falls or resolving conflicts between health teams, among many others,” says Püschel. Once the first phase of the course is over, the students return to their institutions to apply the measures. A few months later, they return to present reports on their implementation.

Thoracic surgeon Juliana Ferreira participated in 2019, establishing an implementation project in the public hospital where she worked in Juiz de Fora, Minas Gerais. The aim was to apply best practices for inserting central venous catheters in adult patients, a medical procedure in which a catheter is introduced into a large vein to provide saline and medication. “The hospital had an ultrasound device, which is essential to safely performing a central venous puncture, but there was a problem: most practitioners were not trained in placing ultrasound-guided catheters,” explains Ferreira. As part of the project, she had to build a practice dummy herself because the hospital could not afford to buy one. “After training physicians and medical residents, 100% of central venous puncture procedures are now guided by ultrasound, which has had a great impact on the quality of care.”

Alexandre Affonso

Six hospitals worldwide have been awarded seals of recognition by JBI, acknowledging the quality of their services and the use of evidence-based practices. The University Hospital at USP is the only Brazilian institution on the list. In 2013, it created an Evidence-Based Nursing Center (NUEBE) and sent one of its nurses to Australia to take the course at JBI—later, three professionals trained at the Australian institution began teaching the methodology to other services and teams at the hospital. One of the 17 projects involved the application of best clinical evidence in screening and detecting delirium in intensive care patients. A series of interventions to help patients maintain their sense of space and time were applied and evaluated, such as making sure they use their glasses and hearing aids, ensuring they have access to newspapers and television, allowing family members to stay, and controlling medications that may cause mental confusion. “JBI itself suggested we apply for the seal of recognition, since our partnership with them was so productive,” says Karina Sichieri, head of the Clinical Nursing Division at the hospital.

Antônio Ribeiro, from UFMG, notes that implementation studies will be crucial to improving the quality of services provided via Brazil’s public healthcare system (SUS). “The implementation gap exists worldwide, but in developing countries there are additional obstacles. Although SUS provides universal healthcare, we know that the quality is uneven.” Cleusa Ferri, a psychiatrist and epidemiologist from UNIFESP, agrees and emphasizes the importance of implementation science when planning public health actions to combat the effects of Brazil’s aging population. “Since 2017, the WHO [World Health Organization] has been pressuring governments around the world to create plans for dealing with the rising number of cases of dementia expected in the coming years,” she says. Ferri is head of the Brazilian arm of a UK-based study seeking to test the effectiveness of cognitive stimulation therapy—which has proven effective in clinical trials at improving quality of life and slowing the progression of the disease—in individuals with mild dementia in Brazil, India, and Tanzania. Ferri worked at University College London for more than a decade, where she met the project’s coordinator, psychologist Amy Spector. The study involves providing 14 therapy sessions to patients accompanied by family members, at which certain techniques are used to stimulate cognition, such as games and therapies based on reminiscence and old photographs. “As an epidemiologist, I was used to identifying problems, but not thinking about solutions. Implementation science helps us identify the options and make them viable.”

In pursuit of a seal of quality

The Hospital Sírio-Libanês (HSL) in São Paulo is committed to obtaining Magnet Recognition from the American Nurses Credentialing Center by 2025. The recognition has so far been awarded to 563 hospitals for their excellent nursing practices—but none of them are in Brazil. “Being a Magnet institution means implementing and maintaining excellent care,” says Wania Baía, a nurse and care director at HSL. One of the keys to obtaining certification is to adopt evidence-based practices in nursing. The hospital therefore began a partnership with JBI (formerly known as the Joanna Briggs Institute) in Australia, with a first mentoring course held in partnership with the institution in 2021. Eleven nurses and a physiotherapist participated in the initiative. Each of them developed a project for making improvements at the hospital. Their interventions included the application of best evidence to reduce pain in cancer patients, improve oxygen use, reduce waste, and decrease how frequently ICU patients are physically restrained. “Physically restraining patients is a widespread practice in Brazilian hospitals, but it can be harmful to their rehabilitation and it can have significant psychological impacts,” explains Regina Claudia da Silva Souza, an HSL nurse heading one of the strategies to obtain the recognition. “These initiatives are focused on reducing the gap between the best available scientific evidence and practices of excellence adopted as daily routine,” stresses HSL care manager Wellington Yamaguti.

1. Implementation research: network integration strategies in mental health in the city of Itatiba-SP (nº 18/10366-6); Grant Mechanism Research Grant – Public Policy Research; Principal Investigator Rosana Teresa Onocko Campos (UNICAMP); Investment R$472,674.52.
2. Cross-cultural validation, dissemination and evaluation of the use of a tool to improve the quality of implementation research projects: ImpRes Tool-BR (nº 20/14309-7); Grant Mechanism Postdoctoral Fellowship; Supervisor Rosana Teresa Onocko Campos (UNICAMP); Beneficiary Carlos Alberto dos Santos Treichel; Investment R$194,649.84.
3. Exploring stigma, discrimination and recovery-based perspectives toward mental illness and substance use problems among primary healthcare providers in Ribeirão Preto, Brazil: a randomized controlled trial (nº 17/50111-4); Grant Mechanism Research Grant – Public Policy Research; Principal Investigator Carla Aparecida Arena Ventura (USP); Investment R$370,180.16.
4. 1st International Symposium on Evidence-Based Practice Implementation (SIIES) (nº 19/00834-5); Grant Mechanism Research Grant – Scientific Conference Organization; Principal Investigator Vilanice Alves de Araújo Püschel (USP); Investment R$15,073.75.