by Nicholas L Berlin, MD MPH (@NickBerlin_MD)
At the University of Michigan, Dr. Paul Cederna often asks faculty, residents, and visiting professors to describe barriers to dissemination and uptake of novel, evidence-based approaches in plastic and reconstructive surgery. In a complex health care system with many stakeholders, it is clearly not enough to generate an idea or hypothesis and to provide compelling evidence to support it. In fact, the initial steps of identifying a specific problem, offering a solution, and generating evidence may take years, if not decades, for motivated surgeons and researchers. All aspects of plastic surgery demand rigorous study to ensure patient safety prior to widespread adoption. However, as the evidence accumulates supporting the efficacy and safety of any new approach, the next challenge becomes the diffusion and uptake of this approach in appropriate clinical scenarios.
As plastic surgeons aim to restore both form and function to patients suffering from complex clinical problems, they draw upon their comprehensive training and clinical understanding to generate innovative solutions. Reconstructive patients are often evaluated by many other surgical and non-surgical specialists prior to formal evaluation and treatment by plastic surgeons. To maintain a competitive advantage in addressing these challenges, it remains crucial that we continue to generate and implement innovative solutions. Given our increasingly complex health care system and the ongoing need to maintain competitive advantages in areas of practice overlap, plastic surgeons will find the lessons of a growing field, implementation science, as a valuable framework for promotion and adoption of novel evidence-based interventions in their local settings.
The science of implementation provides a specific set of tools, methods, frameworks, and study approaches aimed to achieve dissemination of new practices within local settings. In a recent JAMA Surgery article entitled, “What surgeons can learn from the emerging science of implementation,” the authors argue that application of a conceptual model from implementation science (Figure) will improve uptake and dissemination of novel interventions.
After selection of an intervention, surgeons should assess their context in a systematic manner during the pre-implementation phase. The context is categorized into inner and outer settings. The inner setting is comprised of the leadership members and their capacity and commitment for sustainable change within a hospital and health care organization, as well as all available resources, and the quality of communication among stakeholders. The outer setting is the health care system, at large, including existing networks and connections with other organizations. More broadly, the outer setting also includes any competing interests that may impede the ability to implement an intervention, such as external political, economic, and social influences that may affect how a new intervention is perceived.
The next step of this model is the implementation phase, which is defined as an iterative process of execution, evaluation, refinement, and adaptation. This phase should also include an objective method of evaluating outcomes, including both measures of quality and cost. Improved outcomes will lend further support for added value from implementation of a new intervention into a local health care system.
Although the model promoted by these authors is largely theoretical, plastic surgeons aiming to promote and implement evidence-based interventions will find it valuable. Consider how this model applies to the promotion and uptake of peripheral nerve decompression to prevent ulcer formation and amputation for diabetic patients with peripheral neuropathy. Plastic surgeons should understand and take advantage of existing referral networks and patterns for diabetic patients, the outer setting, to promote peripheral nerve decompression. They may seize opportunities to present and discuss these interventions with primary care physicians, endocrinologists, and other physician thought leaders in the ongoing treatment of these patients. Furthermore, it is also crucial for surgeons to overcome a commonly held perception among primary care physicians and other non-surgical colleagues that surgery should be last resort for this patient population. Then, as more patients undergo peripheral nerve decompression procedures, plastic surgeons should evaluate their results, refine their approaches, and promote their ongoing successes within their local systems.
The emerging science of implementation offers new paradigms for surgeons aiming to usher in the novel advances of plastic surgery into their local health care system. Many other emerging areas of plastic surgery, such as composite tissue allotransplantation, tissue engineering, motor and sensory control of prostheses, innovative approaches to wound healing, super microsurgery, gender confirming surgery, 3-dimensional surgical planning, and novel approaches to cosmetic surgery will benefit from the application of this model and other aspects of the emerging science of implementation. As the next generation of plastic surgeons, we must continue to identify and overcome obstacles to the successful dissemination and uptake of our innovative interventions. Our patients and the future of our field will continue to depend upon it.
Brooke BS, Finlayson SRG. What Surgeons Can Learn From the Emerging Science of Implementation. JAMA Surg. 2015;150(10):1006-1007.
Conceptual Model for Applying Implementation Science to the Adoption of Evidence-Based Surgical Interventions. This step-by-step model is adapted from the Consolidated Framework for Implementation Research and describes key domains that are part of the pre implementation and implementation processes. From: What Surgeons Can Learn From the Emerging Science of Implementation. JAMA Surg. 2015;150(10):1006-1007.