A Push for Practice Transformation

Scalable Outcomes

By burrowing deep into implementation science, Curran believes that researchers and clinicians can reduce the time frame of research findings getting to clinical care and improve the quality of delivering needed interventions. Dr. Cindy Stowe, UAMS College of Pharmacy dean, said that every step of the translation of research/evidence into practices that lead to improved cost-effective quality patient care is relevant and important. “Implementation science is a tool that expedites successful uptake and replication of practice advancement by identifying and amplifying successful strategies and mitigating barriers that inhibit practice model advancement,” she noted. “Colleges and schools of pharmacy must urgently embrace a collaborative approach to align and fortify our commitment to advancing this area of research.”

Implementation science is beginning to make inroads in the pharmaceutical and government communities, and it is taking hold in academia, though the process is slower than some hoped. It was only in recent years that the National Institutes of Health, other federal funding agencies and healthcare professional organizations embraced its adoption in research, healthcare practices and training, said Dr. Grace M. Kuo, dean at the Oregon State University College of Pharmacy, affiliated with Oregon Health and Science University.

Too often, pharmacy interventions are evaluated for effectiveness, but there is a conclusion of “insufficient evidence because results could not be reproducible or scalable,” Kuo said. With the implementation science approach, she noted, practice-based research benefits from including not only studies outside of the pharmacy but actual pharmacy practice too. “Implementation science encompasses both compounds of research and practice,” she said. In that way, implementation science becomes a “key strategy for pharmacy practice and curriculum advances.”

There is no greater time than now to initiate those formulas, Kuo continued. “Certainly COVID-19 has presented greater importance for pharmacists to demonstrate our value, not necessarily by generating more individual studies from individual practice sites, but by demonstrating scalable outcomes that impact large groups of the patient population and societal benefits,” she said. “Conceptual frameworks and approaches of implementation science can help pharmacists, researchers and administrators deliver consistent, highly reliable and best care by pharmacists to all patients, including screening, prevention and management related to COVID-19.”

While the field is still considered young, implementation scientists have been not only developing frameworks and strategies but also working with patients and providers to improve healthcare. One of the areas that Curran is exploring in implementation science involves working with rural pharmacies. “Rural pharmacists are often the most accessible and most trusted health professionals within these communities, and we are trying to leverage that,” Curran said. He is involved with the Rural Research Alliance of Community Pharmacies, or Rural-CP, described as the first multistate practice-based research network developed exclusively for rural community pharmacies. It bills itself as a network of 100 rural community pharmacies spanning five southeastern states, collaborating with colleges of pharmacy to identify and address “societal, community and professional questions” that relate to medication use and pharmacy practice.

Curran said interventions involving pharmacists and practitioners include medication and vaccines, but the network hopes to explore new directions such as mental health and trauma screening and alcohol abuse, as well as COVID-19 testing. “We’re trying to look into a wide range of possible interventions to maximize the unique place of pharmacies in rural communities.” Curran and his team are working on other projects as well, including using telehealth technology to integrate pharmacist interventions with rural primary care practices, with a focus on uncontrolled diabetes and hypertension.

Accelerating Change

Elsewhere, implementation science is being used to evaluate a healthcare initiative to improve standard payment models. The University of Minnesota and the UNC Eshelman School of Pharmacy are involved in a program with 12 regional pharmacy organizations encompassing 15 different pharmacies to provide medication management for patients of HealthPartners, a regional insurer based out of Minnesota. This initiative, the Health Partners in Excellence Program (PIE), focuses on how well pharmacies can improve diabetes hemoglobin A1C control, high blood pressure control and smoking cessation, which are common in many pay-for-performance models.

A unique aspect of this program is that it not only pays pharmacists for how well they achieve patient outcomes, but it also pays them for their ability to engage patients in the program. “One area where a lot of innovative pharmacy programs have fallen short is in their ability to reach patients that need care,” said Dr. Joel F. Farley, professor and Peters Endowed Chair in Pharmacy Practice Innovation, associate department head, Department of Pharmaceutical Care and Health Systems at the University of Minnesota College of Pharmacy. “Simply expanding payment is often not enough to incentivize pharmacists to provide clinical services. What is unique about the PIE program is that it provides a bonus incentive to pharmacies that meet quality outcome measures if they are able to provide medication therapy management to at least 40 percent of eligible patients attributed to their pharmacy.”

A UNC Eshelman School of Pharmacy blog about the “Slice of PIE” innovation describes implementation science as vital to its success. The university defines implementation science as “the study and application of strategies that promote the systematic uptake of research findings and other evidence-based practices into routine use.” University officials believe the approach can accelerate change by monitoring CMM (certified medical manager) patient care processes, and especially ensuring consistency in the delivery of CMM across 12 organizations and pharmacies.

According to the University of Minnesota, one of the biggest challenges—and opportunities—in healthcare is to ensure that patients are prescribed optimal medications for their needs. About 30 percent of prescriptions are never filled and about half of medications for chronic diseases are not taken as prescribed, which results in hospital admissions and about 125,000 deaths nationwide each year.

While there is much enthusiasm for implementation science around developing frameworks of care and data outcome measures, there is still confusion among researchers about what exactly it entails and how the process is being carried out not only in pharmacies but also in academia. Farley referred to his involvement in a North Carolina University payment model evaluation team when he was there. While many pharmacies were enrolled in the program, only a small number actually took part, he said. “It seems as though there are certain pharmacies that can incorporate this into their workforce and buy into the concept of providing clinical services,” Farley noted, “but there are some that have a bigger challenge with it and they never become engaged with the program.”

Curran conceded in a paper that “learners participating in introductory didactics on implementation science are often confronted with a dizzying array of information and recommendations to consider when thinking about or planning an implementation study.” But, this area of research continues to be a priority for UAMS, noted Stowe.

“UAMS resides in a state with a vibrant pharmacist community of entrepreneurs and innovators who provide accessible pharmacist-based health and wellness care and product delivery to their communities,” she said. “Long-standing focused efforts to advance pharmacist practice within health systems have been successful and transformational. Untapping the potential of community-based pharmacists’ care teams to transform healthcare delivery through their accessibility and expertise is long overdue.”

A Tool for Training

Oregon State University is among those jumping into implementation science. The university has been engaged in pharmacist or pharmacy-based research in the past, but now it is “exploring additional ways to support and promote scholarly work by adopting implementation science in our future research, clinical practice and educational endeavors,” Kuo said. “Because implementation science is an emerging tool for clinical practice and healthcare professional training programs, courses at pharmacy schools across the country are not readily available. It is not easy to find pharmacy faculty with this expertise at each school. Furthermore, it is challenging to add more courses at most pharmacy schools since the pharmacy curriculum is already packed with required courses.”

Like implementation science itself, which is an evolving field, educators are examining different ways to deliver its message in academic settings. “When teaching student pharmacists, I try to curate learnings from the science, so I talk about specific strategies and project design,” Curran said. Future programs could involve elective courses for pharmacy students, facilitating their participation in graduate-level courses from other degree programs, immersion and mentorship programs.

As Curran noted in papers on implementation science, some of the academic questions include: What kinds of research move into implementation science? How do I know if my research is ready to be examined with an implementation science lens? How do I know when my intervention is ready for implementation? Curran said a description of implementation science and “of its place among related fields can be difficult.”

“After I introduce the concept of ‘the thing’ (the intervention being explored), I then explain that effectiveness research, which most of my (students) are familiar with, is focused on whether the thing works—meaning that receiving it results in positive (or not) impacts on clinical/prevention/whatever outcomes,” Curran has written. “Over a year’s time, I experimented with using very simple language to get those points across. Concepts of the thing and do the thing have also been helpful in providing a quick explanation of implementation science to non-scientists.”

Ultimately, Kuo noted, “We want to train the next generation of pharmacists to effectively translate the best research evidence into practice and to generate best research ideas for practice.”

Joseph A. Cantlupe is a freelance writer based in Washington, D.C.