The implementation of evidence into practice, even today, where science plays a role in much of our lives, is an elusive task. This challenge in health care is perhaps most vividly demonstrated in the back pain field, where numerous studies show that evidence-practice gaps haven’t improved over the last two decades or more. Implementation science is a discipline of research that aims to tackle this issue. Unfortunately, the state of implementation science relevant to back pain is in its infancy. In our chapter of the Best Practice and Research Clinical Rheumatology Low Back Pain special edition we brought together a group of researchers from different fields, including public and population health, implementation and behaviour science, and of course back pain, to cast a critical eye on implementation science research focusing on back pain. We then formulated recommendations to progress high quality implementation research in the field.
What do we mean by implementation?
A challenge for many navigating this area is that many terms are used interchangeably. For example, knowledge translation, research translation, translational research, implementation, dissemination and implementation science are terms often used interchangeably, but can mean very different things. To provide some orientation, an important distinction in our review was that we focussed on implementation science or research. Implementation is defined as the use of strategies to increase adoption or integration of evidence-based health care, or processes to change routine practice within a specific setting. Implementation science or research is thus the study of implementation strategies or approaches, in particular to understand the effectiveness of implementation strategies.
What to look for in implementation research?
A number of frameworks can help guide implementation research. We highlighted three main categories of implementation frameworks. First ‘process models’, which focus on understanding the process of translating research into routine practice. Second formative or ‘determinant frameworks’, which aim to explain or understand what influences whether a practice is implemented or not, for example the barriers or enablers of implementation in a setting. This research should inform the selection of relevant implementation strategies that target the barriers or enablers of implementation. Finally, ‘evaluation frameworks’, these can guide research designed to assess the effectiveness of implementation strategies.
In our review, we assessed if implementation trials used any recognised framework to guide the development of the study. We also assessed studies on a range of quality indicators. The risks of bias in implementation trials are as important as those in trials of patient treatment, so we expected the same quality criteria (i.e. concealed randomisation, outcome blinding etc). However, we also included indicators based on items from the Standards for Reporting Implementation studies of complex interventions (StaRI) guidelines. For example, if the implementation strategy was based on formative evaluation to identify appropriate barriers or enablers, or if the strategy was mapped to a mechanism by which the strategy would work. Finally, we synthesised the evidence on which implementation strategy has been found to be effective in the low back pain field.
What is used in implementation research for back pain?
We found only 18 back pain implementation studies in the back pain field. Most of these were RCTs, but only 3 studies used an implementation science model in the development of implementation strategies; 10 studies reported on the barriers they were targeting; and only 4 studies assessed what impact any changes, elicited from targeting clinician level behaviours, had on patient-level outcomes. We only found three studies that reported on the costs of the intervention, and no studies assessed unintended or adverse events of the strategy. Importantly, despite implementation strategies often being complex interventions, we found that no study used a recognised taxonomy to describe the intervention strategy. This is an important finding that suggests the replication of this research or its use in practice is limited.
In terms of what worked, implementation strategies of audit and feedback and reminders were effective in increasing low back pain care by clinicians, whereas other tested strategies of education and training, and providing clinicians with resources were not.
Advancing the low back pain field
Compared to the volume of research conducted in back pain, implementation research in this field is scarce. Most implementation studies suffer from poor reporting of the intervention and there is little evidence for what works.
All of this considered, there is a clear need to improve the both the focus and quality of implementation research in the back pain field. Routine use of the StaRI guidelines for reporting implementation research, guidelines that are endorsed by the Equator Network, is one way to immediately improve the quality and potential use of implementation research.
Given the number of ongoing trials in back pain, we think that one way to increase the volume implementation research would be to utilise effectiveness-implementation hybrid designs in parallel with these trials. A hybrid design is where implementation outcomes are assessed within a pragmatic trial of a patient intervention. Such designs can be used to inform the feasibility of future implementation (if the effectives of the treatment is unclear), through to rigorously testing both the effects of treatments targeting patient outcomes, and the effects of a parallel implementation strategy.
About the authors
Rebecca Kate Hodder
Rebecca is a Hunter Medical Research Institute Research Fellow in the School of Medicine and Public Health at the University of Newcastle and a Health Promotion Program Manager at Hunter New England Population Health. She is a registered psychologist with both a Bachelor’s Degree and Masters in Psychology, has recently submitted her PhD and has over 10 years’ experience as a Health Promotion Research Practitioner. Ms Hodder’s research projects span public health interventions to address preventable risk factors for chronic diseases; understanding the intersection between musculoskeletal pain and health risk behaviours; and implementation science and the translation of evidence-based guidelines into routine practice.
Luke is an Associate Professor in the School of Medicine and Public Health at the University of Newcastle and a Health Promotion Program Manager at Hunter New England Population Health. He has worked as a consultant for the World Health Organisation, Australian Commonwealth and State governments and has over a decade of experience in the application of evidence to address priority public health issues. A focus of his current work is conducting trials to improve the implementation of evidence-based interventions to promote health.
About Chris Williams
Chris is a NHRMC Clinical Research Fellow (ECF), population health physiotherapist and aspiring implementation scientist. He leads the Hunter New England Musculoskeletal Health Program, which he established in 2013 with the Hunter New England Population Health, at the Hunter New England Local Health District and Hunter Medical Research Institute, University of Newcastle. The program is a research-practice partnership that focuses on enhancing the organisation of clinical and population health services for chronic pain and associated health risks and chronic disease. Chris’s research interests include the use of novel methods to conduct efficient research trials in real world contexts to test intervention strategies that target patient level and health service level (implementation) outcomes. In 2016, Chrisestablished (with Steve Kamper) the Centre for Pain, Health and Lifestyle, a multi-institutional collaboration, which aims to improve musculoskeletal health and co-morbid health problems across the lifespan, particularly in childhood and adolescence. Chris has qualifications in Exercise Science and Physiotherapy, and completed his PhD in 2013 at the George Institute for Global Health and University of Sydney.
Rebecca Kate Hodder, Luke Wolfenden, Steven J. Kamper, Hopin Lee, Amanda Williams, Kate M. O’Brien, Christopher M. Williams (2017). Developing implementation science to improve the translation of research to address low back pain: A critical review. Best Pract Res Clin Rheum 30(6); 1050–1073