A Significant Milestone for Palliative Care: Imperative for Dissemination and Implementation Research

To him/her who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his/her cup of joy is full when the results of his/her studies immediately find practical applications.

– Louis Pasteur

I have recently assumed a new identity as a dissemination and implementation researcher. One of my mentees tells me that this has always been my identity, that I just didn't know it. It reminds me of my response when I am asked if I always knew that I wanted to do palliative care. I knew that it was the type of medicine that I wanted to practice, but it wasn't until the field of palliative medicine gained momentum that I realized that how I wanted to practice had a name. One of my mantras as an investigator is that research should address problems that are identified as high priority by the affected communities, be readily applicable to real-world practice, and be rapidly shared back with the communities that contributed to the research. Participating in the first National Institutes of Health (NIH) Training Institute for Dissemination and Implementation Research in Health in early August 2011 was a bit like attending my first hospice and palliative care meeting many years ago. My eyes were opened to a whole new language, methodology, and research community that felt “like home,” even though I was the only palliative care researcher in a training cohort dominated by researchers focusing on traditional public health-related issues such as obesity, health disparities, chronic disease management, mental health, and screening and prevention.

The fact that palliative care can now consider dissemination and implementation research is a testament to the growth of the palliative care evidence base. Palliative care research has evolved and matured from being primarily descriptive to encompassing conduct of rigorous efficacy and effectiveness trials. Despite the exponential growth in evidence, there remains a gap between research and practice. How else to explain persistence of ineffectively treated pain despite the existence of effective treatments and the lack of universal access to hospice and palliative care despite demonstrated benefit? Palliative care research has reached a significant developmental milestone–having sufficient evidence to contemplate conduct of dissemination and implementation trials. It is time for palliative care, as a field, to equally prioritize rigorously studying the most effective ways of disseminating and implementing existing evidence into practice and generating new evidence.

Just as our field often struggles with definitions and language, the field of dissemination and implementation research is plagued by a lack of standard terminology. What is called dissemination and implementation research in the United States is variously referred to as “knowledge translation and integration,” “population health intervention research,” or “scaling up.” The NIH defines dissemination as “the targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread knowledge and the associated evidence-based interventions.” Implementation, in contrast, is “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings.” ¹ Dissemination and implementation are closely related, comprising a continuum of the translation of evidence into practice. Implementation research is active, supporting movement of evidence-based effective health care into routine use. ²

The palliative care research and clinical community must gain both expertise in and partner with dissemination and implementation science investigators to apply these methods to our growing body of evidence. We must identify for which relevant palliative care issues we have sufficient existing evidence to warrant scaling up through rigorous dissemination and implementation. For those areas in which there is not yet sufficient evidence, we must design efficacy and effectiveness trials for dissemination and implementation, building in from the beginning study elements that facilitate the rapid translation of evidence into practice. We have a moral imperative to do so. Dissemination and implementation of evidence into practice is necessary to achieve a return on investment in our research enterprise and to positively affect outcomes in a broader population. We must conduct dissemination and implementation trials that are rigorous, relevant, and practical. We have to effectively get our existing evidence out into practice as soon as we can; our patients and their families don't have the time to wait.

Two papers in this month's Journal of Palliative Medicine describe efforts to implement novel palliative care clinical programs, one an advance care planning intervention for heart failure patients and the other implementation of a novel state-funded pediatric palliative care program.^3,4 It is exciting to see papers that describe implementation of evidence-based strategies—expanding what had been demonstrated to be effective locally to a broader population or, in the words of dissemination and implementation research, scaling up. Both of these papers include key elements of implementation research: testing the implementation of an intervention with demonstrated effectiveness, adaptation to the context in which the intervention is being tested, transparency in describing the implementation components, and rigorous measurement of implementation effectiveness. Future studies would do well to be informed by existing dissemination and implementation science conceptual frameworks and theoretical approaches.

I encourage those interested in enhancing care for people with serious illness to tap into the growing resources for dissemination and implementation research, including the National Cancer Institute (NCI) Implementation Science program, Knowledge Translation Canada, the journal Implementation Science, the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI), and the Agency for Healthcare Research and Quality (AHRQ).^5–9 We owe it to those who fund our research; the patients, families, and health care providers who participate in our studies; the broader population in need; and society to make sure that the best evidence is being effectively and efficiently translated into practice.