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Dr. Hess: Hi, I'm Rachel Hess. I'm the Director of the Health System Innovation and Research Program at The University of Utah. I'm joined today on Scope Radio by Jacob Kean from Indiana University who is visiting with us. Today I wanted to talk a little bit about your work disentangling the essential component of an intervention.
Dr. Kean: Sure. One of the things that I've worked on in measurement development or fidelity measures, these are a set of indicators of the key ingredients of a treatment. A fidelity measure could be used by a supervisor or by a peer or by an outside evaluator to see if the key elements of a program are being delivered.
We were interested in this concept of fidelity measure being the key ingredients, these being things that would be important for intervention implementers to pay attention to. I met Susan Horn, became familiar with her approach to practice-based evidence. Practice-based evidence is an observational study methodology looking at in great detail the characteristics of a patient. Practice-based evidence provides a really nice opportunity to optimize a treatment for intervention setting.
Dr. Hess: Can you walk me through an example of how you've used these techniques to change the way that we think about implementation work?
Dr. Kean: Yes. Fidelity measures are something that can be disseminated to a clinical setting and discussed as a part of the initial implementation. Introducing the key ingredients to the treatment team and talking to them about their beliefs about whether or not those elements will be important in the intervention in their setting, the degree to which those are clinically important constructs outside of the intervention to general therapeutic techniques. It can be something that could be a framework for implementation. Knowing that these are the key ingredients will allow a treatment team to begin to look at how the intervention might work in a particular setting.
Dr. Hess: I know that you've done some work on taking sort of that gold-plated Cadillac intervention in Department of Defense areas and trying to say, how can we take it out of the best, most well staffed hospital system and take it down to really serve our returning veterans on a more general level. Can you tell me a little bit about that?
Dr. Kean: Sure. I've collaborated with colleagues at the San Antonio Military Medical Center who have developed a cognitive rehabilitation intervention called SCORE, and the intervention is really remarkable and driven by their clinical treatment experiences as well as the literature. One of the characteristics of the intervention itself is that it's very intense. Service members who are participating in the intervention are engaged 10 hours a week for six weeks. This is a result of the fact that folks would be on a medical leave while on active duty and have the time to be able to participate in that.
The inner and outer setting, if you use "C" for variables and thinking about implementation, we're great facilitators at SAMMC. It's a very high volume treatment facility, and it was the intervention and the team were assembled at a time when the wars in Afghanistan and Iraq were at their peak and so there was a great push for a solution to the problems that were facing veterans.
There still is a great push, I think, around the country and the Department of Defense and VA settings, but there are very few veterans who could commit for travel and other reasons to a treatment that's that intense. The skill levels and the perspectives of clinicians around the country vary from those in San Antonio, so it could very well be the case that you may see what's been called in the implementation literature as a voltage drop from the initial study to the subsequent implementation.
I think using a practice-based evidence approach allows us to look at the key ingredients of the treatment. I don't think that the voltage drop is inevitable. I think that we can find those things that are most important about the intervention, be sure that in any context those are delivered.
Dr. Hess: I find it really interesting that some of your background is in measurement and instrument development, where we also take large numbers of questions and try and them down to the essential ones to get at the idea that we're trying to measure. How do you think that your background in measurement has informed your work in practice-based evidence and fidelity?
Dr. Kean: I think that those principals of measurement are sort of akin to right care, right place, right person, right time. We're looking for the right items that differentiate the population that we're interested in and provide the information that's needed to the clinical providers. So, I think a lot of the principles that we're using in measurement certainly do carry over to optimizing interventions, particularly complex inventions in a clinical setting.
Dr. Hess: So really thinking about the components of the interventions that deliver the right care to the right person at the right time. I think that perspective is really important to bring home. What do you think the three key pieces are to doing successful behavioral interventional work in real life settings?
Dr. Kean: The first is probably respecting the clinical setting and respecting the constraints and the time of both the providers and the patients who need to get quite a bit out of all those interactions. I think secondly it's respecting the needs and preferences of both patients and providers, in addition to the constraints that they are operating under. Third, I think it's about being pragmatic and being able to articulate to both patients and providers the purpose of the intervention and what we hope to gain from it.
Dr. Hess: A lot of times people can look at implementation work and studies and say, "Of course we should just do that, it makes sense." Why do we just study it if it makes sense?
Dr. Kean: A lot of appeal and a lot of face validity I think, but getting into the details. In all of these interventions there are so many choices that are made that are relatively arbitrary in addition to the very principled ones. Sorting out, again, the key ingredients really helps us deliver more efficient care that's as or more effective than an unbundled package if you will.
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