Disseminating MCCs Findings and Translating Them into Practice Change

Join Dr. Albert Siu, from Icahn School of Medicine at Mount Sinai, and Dr. Heather Whitson, Duke University School of Medicine, as they discuss dissemination of MCCs findings and translating them into practice change, policy, and better outcomes. They touch upon the specific dissemination and implementation barriers that exist for interventions to manage multiple chronic conditions (MCCs) and hybrid effectiveness implementation research designs and how they may be applied to research for MCCs.

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Transcript

Heather Whitson, MD: This is Heather Whitson and I'm here today with Dr. Al Siu, Professor of Medicine at Icahn School of Medicine at Mt. Sinai and the former Chair of Geriatrics there.

It's good to talk with you, Al. 

Albert Siu, MD: Likewise, Heather, and happy St. Patrick's Day. 

Heather Whitson, MD: Happy St. Patrick's Day. All right. Well, our podcast today is on Disseminating MCCs Findings and Translating Them into Practice Change, Policy and Better Outcomes.

So I wanted to talk with you a bit about MCC interventions. So MCC interventions are frequently complex because they obviously address multifaceted issues. 

Could you talk a little bit more about that and maybe even offer an example where you've seen that complexity create issues for dissemination?

Albert Siu, MD: Right. You know, it's ironic that we have really a crisis in this country of needing to test effective interventions for persons living with multiple chronic conditions. We've had a long [00:01:00] history in this country of developing models of care, of improved care, you know, and other interventions to improve various aspects of their care.

But we've had some difficulty disseminating these. And as you indicated, Heather, I think it's because these conditions are complex to begin with. Multiple is in the title and that, you know, necessitates complex interventions that are hard to put into place. 

The example that comes immediately to mind is something that I've been involved in for over a decade, and that my colleague Bruce Leff at [Johns] Hopkins has been involved in even longer, and that is Hospital at Home, an intervention that is really targeted towards individuals with multiple chronic conditions, who don't do well when they're hospitalized. Bruce wrote the seminal paper on Hospital at Home in 2005. [00:02:00] And here we are, 18 years [later] finally getting to the point of where Hospital at Home is on the cusp of being widely disseminated in this country - eighteen years later. 

Heather Whitson, MD: And I know that we are so passionate about our interventions and wanting them to be effective and not sit on a shelf or a website. Can you provide some tips for how to manage that and maybe in an example like that, What were some of the things that made the difference in those 18 years?

Albert Siu, MD: Well, Bruce and I actually have been reflecting on this and had been thinking about this. And we really think that we, in our work, and those of us in the field, need to be thinking about dissemination and implementation from the get-go, and how that might actually affect how we design our interventions to begin with, or our initial testing. And that were we to do that, we might [00:03:00] actually- or he might actually- have made some slightly different decisions 20 years ago when he started this work.

So that, I think that one of the lessons that we are taking away from this now, looking at this through the retrospective scope, is that we really need to bake in thinking about how would this be implemented in the real world. Not just in the context of some study that we might do [that] we might take down in two or three years when this is over and the paper's published. But how will this really be done in typical hospitals and clinics elsewhere in the country that are organized differently, that are staffed differently, that are subject to different regulations, et cetera? 

Heather Whitson, MD: Yeah, that's so interesting and so important.

You know, what are some of the resources that are out there that could help a new investigator, someone who might be sitting there today with the, just the beginnings of an idea for the next Hospital at Home sort of intervention? What [00:04:00] are some of the resources that could help them bake in those dissemination features from the start?

Albert Siu, MD: Well, you know, when Bruce started his work with Hospital at Home and when I joined him a few years later, the field of implementation science, I think was in its infancy as well, and in its development. I think that since then a lot of work has been done in implementation science, most notably as you know, in the VA.

And that includes, you know, work that has, you know, created frameworks to think about implemention. And the various facilitators and barriers that might exist towards implementing this black box that you're putting together as an intervention to improve the care for patients living with multiple chronic conditions. And that people have thought about how even perhaps our study designs need to take this into account. [00:05:00] And perhaps rather than our initial testing involving, you know, typical trials, looking at patient outcomes, we actually need to do hybrid designs that, yes, look at patient outcomes. But perhaps also look at implementation outcomes that would be of interest and that will become very important five years down the line, you know, when you're actually trying to do this in the real world. 

Heather Whitson, MD: Yeah, that makes a lot of sense. And hopefully the experiences of MCC researchers over the last few decades can also be a real resource to some of the up and coming stars of tomorrow for this problem. 

Albert Siu, MD: Right. I don't think that we want to see a seminal study to improve the care for patients living with multiple chronic conditions to sit in the Annals of Internal Medicine for 18 years before we get it out to the bedside, to the American public. 

Heather Whitson, MD: Right. Because the need [00:06:00] is clearly now. 

Albert Siu, MD: Right.

Heather Whitson, MD: So Al, I know that you also were very involved in the STRIDE Trial, a really important intervention study for our field. I wonder if you could talk just a little bit about some of your experiences navigating implementation challenges with STRIDE.

Albert Siu, MD: Right. So for those of you who are not familiar with STRIDE, this was, you know, a large multi-center trial involving many of us, you know, in the field of geriatrics that aimed to test a primary care-based intervention to prevent fall injuries in older persons who were at risk of serious fall injuries. 

And this is a population, Heather, you know that has multiple chronic conditions. It wasn't billed as such, you know, but that was, you know, the case. And we tried to build on the work that had been done by Mary Tinetti and many other investigators in the field [00:07:00] that had established the effectiveness of multi-component interventions to deal with this multi-component problem: falls with injuries.

And we really put the best minds in our field together to come up with what an intervention would look like that would address the various risk factors for fall-related injuries in older persons at risk. And this turned into a large, complex intervention that took a long time to actually implement in the practice.

The STRIDE Trial, I think, was conceived in the mid-2010 decade. And I think you know, that implementation science was just getting, you know, its work into the field at that point, and it was not common for trials to have a hybrid [00:08:00] design. In retrospect, you know, having been involved in the STRIDE Trial, I think we would've benefited from having a hybrid design that would've taken implementation issues into consideration from the start.

Now this was a multi-component intervention done in multiple sites. I think we had 10 sites and some 80 clinical practices involved. And as you can imagine, each of these practices were very different in terms of, you know, how they were staffed, how they were organized, how much room they had to accommodate, a one-hour intervention, et cetera.

And in retrospect, I wish that we'd had the opportunity to look at the implementation challenges, because I think that we might have come up with a result that was better than the result that was reported, you know, by the STRIDE group, which was basically a null trial. 

Heather Whitson, MD: Yeah. So interesting. And I think, I think [00:09:00] absolutely those lessons learned can be so important as we move forward .Your point is well taken. There's really no way to develop an intervention for multiple chronic conditions that doesn't have to, in some way be adaptable and personalized. It's such a heterogeneous problem. 

All right. Well, thank you so much for speaking with us today, and I just wanna say Dr. Siu as another MCC researcher, I thank you and I'm so appreciative of your contributions to this field.

It was a pleasure to speak with you today. Thanks. 

Albert Siu, MD: Likewise, Heather.