Translational Science: Let us put our money where our mouth is

Marc-Aurel Martial

PhD Student University of Utah College of Nursing

How much attention is devoted to implementing scientific discoveries?

One of the first English idioms I learned after arriving in the US while playing billiard with my uncle is “Put your money where your mouth is.” As I reviewed the literature on translational science and one of its components, implementation science, the gap between scientific discoveries and public health gains startled me. Often between 1% and 5% of individuals may benefit from scientific discoveries (Glasgow, et al., 2012). Yet, spending on implementation research in 2002 was only 1.5% of the biomedical research funding (Woolf, 2008). I couldn’t stop thinking about this idiom in relation to the current global discussion about translational and implementation science because of the low amount of attention and resources that is devoted to implementing scientific discoveries.

How things have been and still are

Initially the term "translational research" was used to define both the transformation of knowledge from natural sciences to produce new biomedical treatments and the implementation of treatment options into clinical practice (Woolf, 2008). This has been coined “bench-to-bedside” research (Woolfe, 2008). The Institute of Medicine differentiated these two phases of translational research as T1 (biomedical research that produces new treatments) and T2 (implementation research). The National Institutes of Health (NIH) defined implementation science as “the study of methods to promote the integration of research findings and evidence into healthcare policy and practice.”

While both T1 and T2 research are important, most people think that translational research refers to T1 (Woolf, 2008). For every dollar spent on biomedical research in 2010, only pennies were apportioned to implementation research (Glasgow, et al., 2012) despite the fact that only 50% of patients in the US receive recommended health services (Woolf, 2008). For example, only half of individuals with high blood pressure are being successfully treated (Glasgow, et al., 2012). The concept of accountability for the implementation of interventions and the resulting outcomes has evolved. Accountability for patient outcomes has shifted from the patient to the healthcare provider.

How things will be (are becoming)

The definition of translational science has been expounded from the two phases (T1 and T2) to include additional phases of research to provide greater clarity. So, the scope has shifted to “bench-to-bedside” and “bedside-to-community.” For instance, Dougherty & Conway (2008) presented three types or phases of translational research. The first phase (T1) focuses on translation from basic sciences to clinical efficacy, while the second phase (T2) and third phase (T3) focus on, respectively, translation of clinical efficacy to clinical effectiveness and translation of clinical effectiveness to the delivery of health services. According to Drolet & Lorenzi (2011), these three phases (T1-T3) are “translation chasms” or gaps between four landmarks in the evolution from basic scientific knowledge, to proposed human application, to proven clinical application, to clinical practice, which ultimately leads to public health gains. The Institute of Translational Health Sciences (ITHS) proposes five phases of translational research which are problem identification (T0), discovery research (T1), health application to access efficacy (T2), science of dissemination and implementation (T3), and evaluation of health impact on real world populations (T4).

There is a growing recognition that implementation science can benefit more people than basic scientific research that aims to produce new interventions (Woolf, 2008). For example, more strokes can be prevented if the focus is on aspirin administration to patients who meet criteria than on developing newer anti-platelets (Woolf, 2008). There is an assumption that implementation research should be expanded beyond clinical settings and clinical providers (Woolf, 2008). Some scientists view new interventions and implementation like a serum and a syringe and believe just as doing more research on the serum will not yield to a better syringe, doing more research on new interventions will not produce better implementation methods. The concept of accountability for patient outcomes is shifting from the provider to the health services system. There is greater understanding that health systems are not prepared to achieve their goals and resources at various levels need to be aligned to better support providers.

Driving forces leading to the shift

Implementation science emerged from shifting accountability to organizations and evaluating the implementation of planned policies (Lobb & Colditz, 2013). It focuses on methods that accelerate the successful implementation of interventions. Increased funding and interest in closing the gap between scientific discoveries and public health gains are fueling the advancement of implementation science (Lobb & Colditz, 2013). For example, as seen in the two figures below, implementation teams that utilize implementation drivers can implement 80% of new interventions effectively over three years; without a team, only 14% of new interventions are implemented in seventeen years. The NIH, the European Commission, and the United Kingdom have made translational research a priority (Woolf, 2008). For example, the NIH has established translational research centers, initiated the Clinical and Translational Science Award, and funded translational research programs at academic institutions. Additionally, private institutions have developed similar programs.     

Facilitators to implementation

Skilled teams that employ implementation drivers are the linchpin to achieving sustainable  integration of new and effective interventions into clinical practice and delivering outcomes that are socially significant. The formula for successful implementation of innovations that yields meaningful public health gains is the product of effective interventions, sound implementation methodology, and enabling contexts. The stronger each component is, the stronger the result will be.  

Barriers to adoption

Although certain disciplines, such as sociology, and organizational behavior have used implementation science for many years, its application to public health questions is new (Lobb & Colditz, 2013). Therefore, there are few small and fragmented studies with inadequate coordination efforts and insufficient communication of results and lessons learned. Additionally, little agreement exists on methodological approach for the field. Caseload and the lack of factors such as financial resources, knowledge, time, perception of utility, and motivation threaten the implementation of innovations. Finally, certain characteristics of an intervention such as its high cost or the failure of the research design to be representative of the target population may inadvertently hinder adoption of a new intervention (Lobb & Colditz, 2013). For instance, a case study in rural West Virginia points out several contextual barriers to implementation of evidence-based interventions, including the challenge of rural residents to walk long distances to receive an evidence-based intervention.

Potential impact

Implementation research has the tremendous potential to reduce the gap between knowledge and practice. It promises to close the access and disparity chasms. It is likely to reduce morbidity and mortality more than the discovery of new diagnostic and treatment options (Woolf, 2008). The consequences of inadequate translation of research from “bench-to-bedside” and “bedside-to-community” are too costly in terms of losses of human lives and “billions of research dollars” (Drolet & Lorenzi, 2011). Now is the time to put our money where our mouth is by allocating more funding to implementation science so that we may achieve, in a future not too distant, greater public health gains from extant scientific discoveries.

Recommended readings/links

1.      Drolet, B.C. & Lorenzi, N.M. (2011). Translational research: understanding the continuum from bench to bedside. Translational Research, 157(1), 1-5. doi: 10.1016/j.trsl.2010.10.002

2.      Glasgow, R. E., Vinson, C., Chambers, D., Khoury, M. J., Kaplan, R. M., & Hunter, C. (2012). National Institutes of Health Approaches to Dissemination and Implementation Science: Current and Future Directions. American Journal of Public Health, 102(7), 1274–1281. doi:10.2105/AJPH.2012.300755

3.      Lobb, R. & Colditz, G.A. (2013). Implementation Science and its Application to Public Health. Annual Review of Public Health, 34, 235-251. doi: 10.1146/annurev-publhealth-031912-114444
4.      Woolf, S.H. (2008). The Meaning of Translational Research and Why It Matters. Journal of American Medical Association, 299(2), 211-213. doi: 10.1001/jama.2007.26

5.      T-Phases of Translational Health Research at https://www.iths.org/investigators/definitions/translational-research/

6.      Learn Implementation at http://nirn.fpg.unc.edu/learn-implementation

7.      Dougherty, D. & Conway, P.H. (2008). The “3T’s” Road Map to Transform US Health Care: The “How” of High-Quality Care. Journal of American Medical Association, 299(19), 2319-2321. doi: 10.1001/jama.299.19.2319

8.      Frequently Asked Questions About Implementation Science at http://www.fic.nih.gov/News/Events/implementation-science/Pages/faqs.aspx

This work is by Marc-Aurel Martial is licensed under a Creative Commons Attribution 4.0 International License