Billet publié sur Twitter/X le 26/03/2012 04:47

Résumé

A thorough understanding of developmental process and evidenced treatments should enable better service development and this could be a key contribution of implementation science. Recent years have seen a gathering momentum toward more direct linking between the world of science and its practical impact or effect. Signs of this can be seen in a number of areas, for instance in England the re-organisation of science research administration into a model based around a “translational pipeline” from lab to bedside, reflected institutionally in the structure of research funding bodies. In UK universities the prioritisation of research “impact” in evaluation of outputs, and efforts to define what impact can be. In the US, translational centres within NIH institutes, mandatory inclusion of impact in all new grants and a Clinical and Translational Science Award Programme to speed “the translation of basic science research into practical applications”. Many of the drivers for these initiatives are clear – they include a need for democratic accountability in publicly-funded science, as well as the political desire to capitalise on the potential economic benefits of scientific research. The dynamic is not new, and can raise tensions between the idea on the one hand of pure science as a self organising activity with incremental and medium term goals; and a political perspective on the other, prioritising short term economic benefits and suspicious of activity without obvious immediate applications. There is a need for freedom in science to build theories, pursue hypotheses and generate new insights often in unexpected directions; a ‘logic of scientific discovery” that has an internally consistent momentum that is in many ways rather separate from implementation and application. On the other it can be no bad thing for clinical research to have an aspect included from the outset that looks at how the demands of implementation might both be included in the design and evaluated in the outcome. In the clinical arena, the transitional pipeline and focus of implementation is of course into clinical application, particularly in relation to understanding disease and disorder and developing new interventions. However “transitional pipeline” is a deceptively simple metaphor here – implying a linear flow from fundamental research into practical application. The reality is more complex. In the context of our own focus on developmental science and psychopathology, the flow of innovation can go both ways. Fundamental research can be sparked by clinical experience and intervention just as much as the other way round. Rather than a translational “pipeline”, a better model might be some sort of bidirectional translational algorithm. Such translations, and the conditions that make them possible, are at the core of the epistemology of clinical practice (Green 2006a) and if it is the case that one activity may inform the other either way, what is the process by which this happens? Central to evidence-based medicine (Sackett et al., 2002) is an attempt to outline the steps of a detailed and specific translational algorithm between the body of basic science evidence around a problem and the unique experience of the clinician with the patient. Much lip service is given to EBM, but how often is it applied in this detail in practice? EBM algorithms and the application of the science base into the experience of the clinic with an individual patient are often not straightforward. Indeed this very complexity informs the emergence of an increasing body of “implementation science”, described further below. There are other ways in which the science informs practice that are often more informal or general – and I suggest in a way more pervasive. Theoretical models and orientations derived from current scientific research may have explicit or implicit effects on the general “clinical gaze” towards patients at a particular time. We are often said to be in an era of “micro-theory” rather than general psychological models, but take for example current general science models of gene–environment (G*E) interaction, applying across many areas of investigation. Approaching the patient with this general orientation results in a very different way of looking at, assessing and formulating clinical problems than an approach infused by, say, social determinants or learning theory alone. It requires an assessment and therapeutic approach that will be focused on interactions of this kind and their modification, rather than on uni-causal models. In a more detailed sense, the idea of “differential susceptibility” for instance could alter a whole approach, effecting areas of clinical enquiry, perhaps focusing on potential strengths as well as impairments related to vulnerability traits. I suggest that such “zeitgeist” effects, reflecting important science paradigms of the time, impact on clinical orientation and practice equally as much as the specific evidence base around a particular disorder. Notably, they grow out of debate and testing within the flow of basic science. At their most interesting they reflect the provocative effect of good science against consensus clinical thinking. But their influence is a by-product rather than the result of a targeted implementation policy. The primary aim of clinical trials is to make definitive tests of treatment effect and judge between treatments. However, the good ones often provoke strong disagreement about their findings, and their internal and external validity. Some of the most interesting debates of recent years have been in the contested interpretation of iconic trials such as the MTA, TADS and ADAPT trials for hyperactivity and depression. Such debates seem healthy, not least because they are at least grounded in sets of shared data and methodology rather than fixed prior positions. Perhaps these are one good way of working that translational leap from basic science understanding into something that can be useful with a patient. Institutionalised translation is increasingly influential; for instance in the UK the National Institute for Clinical Excellence (NICE) or Scottish Intercollegiate Guidance Network (SIGN); and including a plethora of other clinical decision algorithms and guidelines in the context of a more managed practice culture. In theory these will serve to distil the current state of basic science into guidance for practice. But this form of “committee-based translation” is of course influenced by many other factors too (perhaps particularly where the actual quality of the evidence base is poor); the dynamics within a committee including need for consensus, what committee members bring from their own practice, professional allegiances, political or cost imperatives and others. In a series of important articles, Eddy (1990) highlights the need to have clear critical appraisal of the status of such guidance, particularly in the light of their increasing influence on professional practice; to make distinctions between standards for rigid application, from which it would probably be malpractice to deviate; guideline’, where there is more flexibility; and options, when the evidence is more equivocal. Such distinctions are often now it is true made in committee but then just as often lost in a precautionary translation from the guidance document into local health policy and clinical practice on the ground (Green 2006b). Although recognising their real value, Eddy identifies the risk of clinicians using these as a substitute for thought rather than an aid to it, sometimes deferring too completely to external guidance in situations of uncertainty in ways that may restrict reasonable treatment options for patients. Against this background, implementation science is a recent discipline that studies more rigorously these translational algorithms. Woolf (2008) has contrasted two forms of translation research –“T1”, bench to bedside; “T2”, implementation in practice. “T1 struggles more with biological and technological mysteries, trial recruitment, and regulatory concerns. T2 struggles more with human behavior and organizational inertia, infrastructure and resource constraints, and the messiness of proving the effectiveness of ‘moving targets’ under conditions that investigators cannot fully control” (Woolf, 2008). He feels that: Public interest therefore requires T2 to come out from under the shadow of T1. It needs a new name; translational research is now too vague a term for T2 (or T1) and not using the same label for both endeavors would help to reduce confusion. More than a new name, however, T2 needs new recognition and emphasis. Policy makers and the academic research community must come to a clearer understanding of the distinction between inventing treatments and getting them used in practice. Those who fund research must weigh carefully the relative capacity of each research sphere to improve health and economic outcomes and should fund each endeavor accordingly. Disproportion has consequences, and the current policy of spending 1.5% of research dollars on health services research is probably costing lives. (Woolf, 2008) In the UK, following the Tooke Review, the government has appointed a Clinical Effectiveness Research Agenda Group (CERAG) to investigate this area. They define implementation research as: the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, and hence to improve the quality (effectiveness, reliability, safety, appropriateness, equity, efficiency) of health care. It includes the study of influences on healthcare professional and organizational behaviour. (Eccles et al., 2009a) This focus is similar to Woolf’s T2 and indicates a particular focus within translational thinking (and T2 itself is being further subdivided into a T3 and T4). The CERAG group focuses on implementation and change at the level of both practitioner and organization. Following Nutley et al. (2007), they make a separation between: a research-based practitioner model, in which research use is the responsibility of individual practitioners; an embedded systems research model, where research use is achieved by embedding research in the systems and processes of service delivery; and an organisational excellence model, where the key to successful research use lies in the development of appropriate structures, processes and cultures within local service delivery organisations (Eccles et al., 2009b, pp. 25–26) The research-based practitioner model links to the traditional function of clinical reviews and practitioner reviews in science journals. The emphasis is on the continuing professional development of the autonomous practitioner and a process of accessing, appraising and applying research information. A useful focus for implementation science study in this area will be on the barriers to change in practitioner practice and behaviour in the face of new information. Access to information as above is of course just one of these. There are others, such as professional allegiance, habit, familiarity, that influence whether a specific piece of research actually influences a clinician’s practice or not. Can journal reviews address such factors in implementation? Perhaps not easily – but if they don’t, where will such things be addressed? Consideration of them at the least may influence their drafting, since some barriers could be explicitly anticipated and addressed with evidence and argument. The importance of current science models could be drawn out. Both the embedded research and organisational excellence models are not traditional territory for the journal review article. However, all practitioners now work in teams and systems, and systems in various forms are increasingly influential on individual practice. Senior practitioners often run organisations and are responsible for the formulation of algorithms to guide multidisciplinary practice, in which the work of people of different backgrounds and experience needs to be integrated safely and effectively. How much of this kind of work can and should be informed by developmental science? Perhaps more than we have traditionally thought. A thorough understanding of developmental process and evidenced treatments should enable better service development – and this could be a key contribution of implementation science. For instance, a thorough understanding of the differential roles and limitations of parent training against medication in the context of ADHD or conduct disorder would inevitably inform system organization and challenge outmoded practice. In this complex arena, the JCPP Practitioner Review Series can continue to hold a pivotal role. Here is an opportunity for a particular topic of implementation to be discussed and made explicit. Readers like these Practitioner Reviews; they are often amongst the most cited and downloaded of JCPP articles. Their structure, aims and role stand in some contrast to basic science papers and reviews. To serve their translation needs, clinical practitioners need access to knowledge that is timely, contextually relevant, easily accessible in real time when needed, applicable, and adding value to clinical thinking and practice. They need to be able to start with a clinical problem and access a range of theoretical perspectives that will help them solve it. None of this is straightforward for a journal to provide. Practitioner reviews successfully fulfilling this function should be seen therefore as papers of a high order; needing to combine a number of different features. (1) A critical mass of mature basic science to be discussed around a particular topic; likely to include a core group of well-conducted, methodologically-sound randomised trials plus other high quality evidence. (2) Distillation of the basic theory underpinning the area and the extent to which the trials have either tested the theory or to which theory might itself indicate likely areas of practical clinical relevance (see Cartwright, 2011). (3) The existence of clinical guidelines and a critical analysis of their constitution and relevance. (4) Some indefinable addition of clinical wisdom, which can integrate these different ingredients into an offering for clinicians and services, and that can be summarised into key current clinical points or recommendations. (5) Transparency about the process of review, guidance selection, grading of evidence and the particular clinical bias or conflict of interest of the writer. The JCPP Practitioner Reviews are not intended to be formal clinical guidance but the good ones will integrate the best current consensus, acknowledging often its incompleteness and partiality but also that in clinical practice (and particularly in the moment with the patient), too much uncertainty and indecision may not be a good thing. Practitioner Reviews will therefore remain an indispensible part of a quality science journal such as JCPP, as exemplified in this issue by Ougrin and colleagues’ contribution on self-harm in adolescents (Ougrin et al.,2012); but how they are constructed needs to move with the times and may increasingly be underpinned with a translational science of its own, as well as reflecting advances in the evidence-base, clinical guidance and the systems of health care delivery. Practitioner Reviews will share with basic science articles a critical stance to received wisdom and resist over-simple consensus in complex arenas. They should point the way forward to the need for future science studies and how clinical requirements can generate new research initiatives. The Guidance notes for Practitioner Reviews have been updated in line with these thoughts and are available on the journal website – they also contain references to exemplars of effective past JCCP Practitioner Reviews. The Journal generally commissions Reviews, but also welcomes submissions along these lines. I am grateful to Sally Ozonoff and Edmund Sonuga-Barke for their comments on an earlier draft of this article. J.G. has declared that he has no competing or potential conflicts of interest relevant to this article.