Research to Practice Translation
Research to practice translation is the process of adapting principles and findings from scientific investigation in order to apply them in real-world practice (Sung et al. 2003; Woolf 2008). The translational process typically proceeds through a series of phases: T1 (translation of fundamental research findings to develop new practical applications), T2 (adaptation of efficacious treatments into a form that is effective in usual practice settings), and T3 (dissemination and implementation of research-tested interventions so that they are taken up widely by care systems and become usual practice). Although T1, T2, and T3 are all part of research to practice translation, the phrase connotes an emphasis on the later stages, particularly T3. The problem addressed is the slow and incomplete uptake of scientific discoveries into clinical and public health practice. Barriers that impede translation include lack of resources for practitioner training, resistance to change, competing institutional priorities, and lack of infrastructure to support new practices.
A bifurcation between basic and applied research has characterized US science policy since the mid-1940s. In the wake of World War II, Vannevar Bush, Science Advisor to President Franklin D. Roosevelt, wrote an advisory entitled “Science: The Endless Frontier.” In it, he advocated for major federal investment in basic science research as the engine that would drive the postwar economy. Bush drew a distinction between basic research, motivated fundamentally by curiosity and a quest for understanding, versus applied research, motivated by the need to solve practical problems. He contended that new insights from basic research are the prime mover of technological and medical progress. Because major advances result from discoveries in remote, unexpected scientific domains, it is virtually impossible to predict which basic scientific inquiries will produce major advances. Consequently, Bush aimed to protect unfettered, curiosity-driven pursuit of scientific understanding from being constrained by worries about whether the knowledge to be gained had any practical use. Arguing that industrial and medical progress would stagnate if basic research were neglected, he succeeded in prompting major federal investment in basic research, including creation of what was to become the National Science Foundation.
Over the next half century, it gradually became apparent that the insights emerging from basic science research were not being translated into practical applications. An analysis by Balas and Boren (2000) indicated that, even after 17 years, only 14% of research knowledge is adopted into practice. By 2001, the Institute of Medicine (IOM) used the term “chasm” to describe the gap between scientific knowledge and actual clinical practice. There was also growing realization that Vannevar Bush’s contention that “applied research invariably drives out pure” drew too sharp a dichotomy. In a 1996 book entitled, Pasteur’s Quadrant, Donald Stokes presented a fourfold table, whereby research could be either low or high on both quest for fundamental understanding and considerations about use. Stokes argued that the most generative, valuable research falls into Pasteur’s Quadrant, inspired simultaneously both by the need to solve a practical problem and by curiosity to understand how nature works. A consequence of these realizations has been some realignment of budget allocations at the National Institutes of Health (NIH) to support greater investment in translational and applied research. In fiscal year 1998, the NIH allocated 31% of its budget to applied research and 57% to basic science (Institute of Medicine [IOM] 1998). By fiscal year 2007, the amount allocated to applied research was 41%, increasing to 48% by fiscal year 2016 (National Science Board 2004; NIH 2016).
New Research Approaches to Facilitate Translation
Although T1 translation remains a concern, attention has focused increasingly on blockages later in the pipeline. There has been major federal investment in comparative effectiveness research to address a T2 blockade: determining which treatments work best in usual practice, as contrasted with research settings. Moreover, a further translational phase (T3 – implementation) has been recognized, acknowledging the need to overcome system-level obstacles that impede uptake of best research-tested practices into institutions and health-care systems (Westfall et al. 2007) (see also entry on “Translational Behavioral Medicine”). Practice-based research and community-based participatory research (CBPR) are two research approaches now being applied to learn how to overcome implementation barriers (Woolf 2008).
An insight that is driving attention toward later phase translation is the desire to scale evidence-based interventions to bring their benefits to more of the population. A highly efficacious treatment available to very few will have less public health impact than a less effective treatment available to many (Glasgow et al. 2006). Stated differently, population-level impact is the product of efficacy and reach (Abrams et al. 1996).
Comparative Effectiveness Research
The US Agency for Health Research and Quality (AHRQ) defines comparative effectiveness research (CER) as the conduct and synthesis of research that compares the benefits and harms of different strategies to prevent, diagnose, treat, and monitor health conditions in “real-world” settings. CER is a T2 research strategy that addresses practitioners’ need to know the relative merits of treatment options available to them. CER takes two main forms: (1) systematic evidence reviews that evaluate benefits and harms of treatment options for different groups of people on the basis of preexisting research and (2) new studies that generate evidence about the effectiveness of health-care practices in usual practice. The most common CER methodologies have been randomized controlled trials (RCTs) (60% of total CER), followed by systematic reviews (14%), and retrospective observational studies (6%). The most common CER interventions have been pharmacological (34% of total CER), delivery system (20%), and behavioral (16%) (Department of Health and Human Services [DHHS] and Federal Coordinating Council for Comparative Effectiveness Research 2009).
The aim of T3 or implementation research (IR) is to learn how to overcome barriers that limit the uptake of evidence-based practices into usual care. A core insight is that “if we want more evidence-based practice, we need more practice-based evidence” (Green and Kreuter 2005). Few practitioners or health-care system administrators appreciate being admonished by academic researchers for not following scientific practices. Many respond that the research evidence they are being asked to follow is rarefied: derived from patients, clinicians, and settings different from those in the contexts where they work. They advocate making translational processes more bidirectional, so that an understanding of the practice context informs the genesis of relevant research.
Because primary care is the gateway by which most of the population accesses health care, it offers a major channel to deliver evidence-based care to the public. In 1999, Congress enabled the Agency for Health Research and Quality (AHRQ) to establish practice-based research networks (PBRNs) that engage groups of experienced, practicing clinicians in framing research questions whose answers could improve the practice of primary care (Green and Hickner 2006). By helping practices collaborate to address quality improvement questions with rigorous research methods, AHRQ hopes that PBRNs can produce research findings that are more immediately relevant to clinicians and therefore readily assimilated into everyday practice.
Patient-Centered Outcomes Research Institute (PCORI)
Despite a voluminous body of medical research, too often the evidence doesn’t answer questions that patients, clinicians, and insurers face routinely. To address this challenge, Congress authorized the Patient-Centered Outcomes Research Institute (PCORI) as part of the Patient Protection and Affordable Care Act of 2010. PCORI is charged to identify critical unanswered questions about health care, fund comparative effective research (CER), and disseminate the results in ways that end users will find most valuable. This means engaging patients as partners in the research endeavor by learning which approaches to care are most responsive to patients’ concerns, circumstances, and preferences. The resultant patient-centered research reconfigures the direction of the translational pipeline that has historically flowed from researcher to practitioner to patient. By engaging patients, providers, insurers, and payers together as stakeholders in the research process, PCORI facilitates collective engagement in the process of expanding evidence-based practice and health-care quality (Selby et al. 2015).
Community-Based Participatory Research
Whereas both patient-centered research and community-based participatory research (CBPR) engage end users in the production of research, CBPR goes a step further by integrating social action into the research motivation. CBPR aims explicitly to reduce health disparities, overcome social injustice, and improve community well-being. In contrast, social action is not a required part of the research funded by PCORI. Guided by a core set of values, CBPR builds on community strengths and resources; facilitates collaboration, co-learning, and capacity building; and balances investment in knowledge generation with a long-term commitment to action that supports equity and benefits the community (Israel et al. 2008). A guiding principle of community-based participatory research is that culture, religious values, and economic factors specific to a community are integral to any decision about best practices. Consequently, multiple community stakeholders, rather than just a core research team, need to participate in all aspects of the research enterprise so that the resulting findings are relevant, responsive to stakeholder concerns, and therefore implemented. An underlying premise of this approach is that an equitable standing and distribution of power between researchers and the community is most likely to empower the community to implement emergent evidence-based practices as part of a long-lasting community commitment to health-care improvement (Muhammad et al. 2015).
Educating Researchers and Practitioners About Translation
Research to practice translation is still an evolving field with the overarching goal of improving health-care practice. Several training resources are available about research to practice translation. First, the NIH Office of Behavioral and Social Science Research (OBSSR) offers a residential summer training institute on Dissemination and Implementation Research in Health (https://obssr-archive.od.nih.gov/scientific_areas/translation/dissemination_and_implementation/index.aspx). Another OBSSR-funded resource that can be accessed remotely and free of charge is the Evidence-Based Behavioral Practice (EBBP) site available at www.ebbp.org. Among the interactive online learning modules available at ebbp.org are several dedicated to (a) shared decision-making with individuals, (b) collaborative decision-making with communities, (b) stakeholder perspectives about research and evidence-based practice, and (c) implementation. Finally, a third set of resources involve several new scholarly journals: The Journal of Translational Medicine (2003), Science: Translational Medicine (2009), and Translational Behavioral Medicine (2011).
References and Further Reading
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- Balas, E. A., & Boren, S. A. (2000). Managing clinical knowledge for health care improvement. In J. Bemmel & A. T. McCray (Eds.), Yearbook of medical informatics (pp. 65–70). Stuttgart: Schattauer Publishing Company.Google Scholar
- Bush, V. (1945). Science, the endless frontier: A report to the president by Vannevar Bush, director of the office of scientific research and development. Washington, DC: United States Government Printing Office.Google Scholar
- Department of Health and Human Services & Federal Coordinating Council for Comparative Effectiveness Research. (2009). Report to the president and the congress [Internet]. Washington, DC: HHS; [cited 2011 Jan 11]. Available from http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf
- Glasgow, R. E., Klesges, L. M., Dzewaltowski, D. A., Estabrooks, P. A., & Vogt, T. M. (2006). Evaluating the impact of health promotion programs: Using the RE-AIM framework to form summary measures for decision making involving complex issues. Health Education Research, 21(3), 688–694.CrossRefPubMedGoogle Scholar
- Green, L. W., & Kreuter, M. W. (2005). Health program planning: An educational and ecological approach (4th ed.). Boston: McGraw Hill.Google Scholar
- Institute of Medicine Committee on the NIH Research Priority-Setting Process. (1998). Scientific opportunities and public needs: Improving priority setting and public input at the national institutes of health. Washington, DC: National Academies Press.Google Scholar
- Muhammad, M., Wallerstein, N., Sussman, A. L., Avila, M., Belone, L., & Duran, B. (2015). Reflections on researcher identity and power: The impact of positionality on community based participatory research (CBPR) processes and outcomes. Critical Sociology, 41(7–8), 1045–1063.CrossRefPubMedGoogle Scholar
- National Institutes of Health. (2016). FY 2012 – FY 2017 distribution of budget authority percentage for basic and applied research. [Internet] from: https://officeofbudget.od.nih.gov/pdfs/FY16/Basic%20and%20Applied%20FY%202002%20-%20FY%202017%20R2%20-%20V.pdf. Retrieved 7/2/2016.
- National Science Board. (2004). Science and engineering indicators 2004 (NSB 04–01). Arlington: National Science Foundation, Division of Science Resources Statistics.Google Scholar
- Stokes, D. (1997). Pasteur’s quadrant: Basic science and technological innovation. Washington, DC: Brookings Institute.Google Scholar