I'M KATHERINE LAW FROM NATIONAL CENTER FOR COMPLIMENTARY AND INTEGRATIVE HEALTH OFFICE OF COMMUNICATIONS. THANK YOU FOR JOINING US AT NCCIH FOR A HOT TOPIC WEBINAR ON IMPLEMENTATION SCIENCE AND COMPLIMENTARY HEALTH INTERVENTIONS. THIS WEBINAR IS PART OF A SERIES OF HOT TOPIC WEBINARS BEING HOSTED BY OUR DIVISION OF EXTRAMURAL RESEARCH WHICH IS LED BY DR. EMMELINE EDWARDS. TODAY'S WEBINAR IS BEING LED BY DR. DAVE CLARK. BEFORE WE BEGIN, I WANT TO TOUCH BASE ON A FEW HOUSEKEEPING ITEMS. FIRST AS YOU CAN SEE ON OUR WELCOME SLIDE WE DO WANT TO THANK EVERYBODY WHO JOINED US VIA NIH VIDEO CAST FOR THIS WEBINAR. SECOND, WE WANT TO LET YOU KNOW THIS WEBINAR IS INDEED BEING RECORD AND WILL BE ARCHIVED FOR FUTURE VIEWING ON THE NIH VIDEO CAST SITE UNDER PAST EVENTS. I WOULD SAY IN A DAY OR TWO YOU CAN PROBABLY ZIP ON OVER TO THE VIDEO CAST SITE AND SEARCH UNDER PAST EVENTSES TO SEE IF IT'S BEEN POSTED. NEXT SLIDE PLEASE. IMPORTANTLY, IF YOU ARE A MEMBER OF OUR VIEWING AUDIENCE, IF YOU HAVE QUESTIONS THERE'S A COUPLE OF OPTIONS HOW YOU CAN SUBMIT THEM. FIRST YOU CAN USE THE NIH VIDEO CAST LIVE FEEDBACK FORM. THE LINK FOR THAT FORM IS ACTUALLY RIGHT BELOW WHERE YOU ARE WATCHING YOUR VIDEO. YOU SHOULD SEE A BUTTON THAT SAYS SEND LIVE FEEDBACK. OR SOMETHING SIMILAR. THAT'S THE BUTTON, IF YOU HIT THAT BUTTON YOU SHOULD BE ABLE TO GET FEEDBACK FORM AND EMAIL WILL COME INTO US. OR IF YOU WISH YOU CAN DIRECTLY EMAIL US AT NCCIHWEBINARQ@MAIL.NIH.GOV. SO DURING THE Q&A PORTION OF OUR EVENT WHICH WILL BE AT THE END, WE WILL TRY TO GET AS MANY QUESTIONS AS WE CAN BUT WE RECOGNIZE THERE ARE PROBABLY A LOT OF YOU AND PROBABLY MORE QUESTIONS THAN WE CAN HANDLE IN THE TIME THAT WE HAVE. IF IT'S POSSIBLE WE WILL TRY TO ADDRESS ANY QUESTIONS AFTER THE EVENT. YU MAY SUBMIT YOUR QUESTIONS AT ANY TIME DURING THIS EVENT AND IT WILL COME INTO THE WEBINAR QUEUE INBOX. WE'LL STAND WITH A BRIEF WELCOME FROM NCCIH DIRECTOR DR. HELENE LANGUAGE VIN AND SHE WILL TURN IT OVER -- LANGEVIN. >> THANK YOU, IT'S A GREAT PLEASURE TO WELCOME YOU TO THIS HOT TOPIC WEBINAR. WE HAVE A TERRIFIC LINEUP OF SPEAKERS TODAY. IT WILL BE A FUN EVENT. NCCIH HAS A GROWING INTEREST IN IMPLEMENTATION SCIENCE AND I WOULD DESCRIBE THIS THE WILD WESTERN FRONTIER OF CLINICAL RESEARCH. IT'S A VERY INTERESTING DEVELOPMENT IN OUR EVOLUTION OF THINKING ABOUT CLINICAL RESEARCH. IT'S NOT WHETHER STUDYING A GIVEN INTERVENTION IS BENEFICIAL OR NOT, IT IS LOOKING AT THE NEXT STEP. HOW CAN THESE INTERVENTIONS ACTUALLY INTEGRATED INTO OUR HEALTHCARE SYSTEM? HOW DO YOU STUDY THAT? SO IT'S A VERY INTEGRATIVE QUESTION. SO IT REALLY FITS WELL INTO THIS GROWING DEVELOPING ARRAY OF RANGE OF TYPES OF RESEARCH THAT NCCIH WANTS TO SUPPORT IN ORDER TO REALLY EXPAND OUR UNDERSTANDING OF NOT JUST THE EFFICACY BUT THE USAGE OF COMPLIMENTARY AND INTEGRATIVE HEALTH INTERVENTIONS. I'M GOING TO BE HANDING OVER TO DAVE CLARK WHO WILL GIVE US MORE BACKGROUND AND INTRODUCE OUR SPEAKERS. GREATLY APPRECIATE IT. I'M GOING TO SEE IF I CAN BE FIVE PERCENT SMARTER THAN THE MACHINE AND SHARE MY SLIDES. UNTIL YOU SAY OTHERWISE I'LL PRESUME IT'S GOING SWIMMINGLY. THANK YOU FOR JOINING US TODAY. >> JUST TO LET YOU KNOW YOU ARE ACTUALLY IN YOUR YOU NEED TOO SWAP YOUR DISPLAY SETTINGS. WE ARE SEEING YOUR SEEING THE SETTING WHERE YOU SHOW ONE SLIDE THEN THE NEXT SLIDE. >> HOW ABOUT THAT? >> YES. THAT'S WONDERFUL. THANKS, GAVE. DAVE. >> THANK YOU SO MUCH, KATHERINE. SO MAYBE FIVE PERCENT LESS SMART THAN THE MACHINE TODAY. THANK YOU AGAIN FOR BEING HERE TODAY AND BEING PART OF THIS IMPORTANT WEBINAR I'M DAVE CLARK, I WILL BE RUNNING THINGS. SO WHEN I STARTED AT THE NCCIH FEW YEARS AGO AND SINCE THEN I HAVE NOT DONE A PRESENTATION WHERE I HAVE NOT INCLUDED THIS SLIDE. IF YOU EVER SEE ME TALK ON BEHALF OF THE NCCIH BEFORE YOU HAVE SEEN ME WITH THIS SLIDE SOMEHOW AFFILIATED WITH MY TALK SO I'M SO GLAD TO BE ABLE TO HAVE THIS UP YET AGAIN AND RUN THROUGH. SO WHAT THIS IS, IT DESCRIBES THE PROGRESSION OF THE RESEARCH CONTINUUM WE DO AND HOW WE CONCEPTUALIZE THE FRAMEWORK FOR CLINICAL RESEARCH AT THE NCCIH. YOU CAN SEE THE ORANGE CIRCLE ON THE LEFT IT STARTS WITH BASIC AND MECHANISTIC WORK AND RUNS ALL THE WAY THROUGH THE GAMUT UP UNTIL YOU GET TO THAT LAST CIRCLE WHICH IS PRAGMATIC STUDIES IN DISSEMINATION. SO AS I CAME TO THE NCCIH AND MY BACKGROUND WORKING WITH IMPLEMENTATION SCIENCE I SAW AND SAID YOU KNOW, THERE'S SOMETHING MISSING. THERE'S SOMETHING THAT WE CAN ADD TO THIS TO MAKE IT A LITTLE BIT BETTER. AND TO HAVE A LANDING SPOT. SO FOR KIND OF A GENERAL BACKGROUND FOR THE NIH, NCCIH AS WELL, WE DO AN OUTSTANDING JOB OF ASKING THE QUESTION WHAT SHOULD WE DO, WHAT INTERVENTION SHOULD WE DO. WHAT INTERVENTION WORKS BEST, WHAT DRUG WORKS BEST, WHAT CAUSES A DRUG TO WORK OR NOT TO WORK. WHAT GENOTYPE OR PHENOTYPE BENEFITS FROM THE INTERVENTION. SO WE SPEND SO MUCH TIME AND EFFORT ASKING AND DOING A GREAT JOB BY THE WAY. IF YOU ARE IN THAT CAMP THAT DOES THIS FOR A LIVING PAT YOURSELF ON THE BACK FOR DOING A GREAT JOB OF THIS. BUT WE SPEND SO MUCH TIME ASKING WHAT, WE DON'T SPEND A LOT OF TIME ASKING HOW THE BULK OF THE RESEARCH WE DO NIH IS ASKING WHAT INTERVENTION WE SHOULD DO, IMPLEMENTATION STARTS TO ASK HOW DO WE GET THOSE INTERVENTIONS IN PLAY, NOW THAT WE SPENT TIME AN EFFORT BUILDING THE EVIDENCE BASE HOW WE GET THOSE EVIDENCE BASED PRACTICES INTO PLAY. I SUGGEST ONE OF CONCEPT CHOPPIZING IS MOVE THE FINISH LINE. NUMBER OF PEOPLE ON THIS CALL THAT THEY HAVE TRAINED IN THEIR RESEARCH AREA THEY WANT THEM TO DO IS MECHANISMS OF BASIC WORK. THAT'S LOVELY. BUT FOR THAT GROUP OF PEOPLE FOR MOST OF THEM, THAT'S FINISH LINE. I HAVE IDENTIFIED THE MECHANISM AND OFF TO MY NEXT PROJECT. SO THERE'S A DIFFERENT GROUP OF PEOPLE THAT ASK THE QUESTION ABOUT EFFICACY. FOR EFFICACY I MEAN DOES TESTING AN INTERVENTION UNDER IDEAL CIRCUMSTANCES, YOU CAN MINIMIZE ERROR BIAS AND CONFOUNDING SO AT THE END YOU WANT TO HAVE REAL STRICT LIMITATIONS ON INCLUSION EXCLUSION, HOPEFULLY AT THE END YOU CAN DRAW CAUSAL INFERENCE BETWEEN INTERVENTIONS YOU HAVE DONE AND OUTCOMES OR OUTCOMES OF INTEREST. A LOT OF TIME AND EFFORT HAS BEEN DEDICATED TO TALKING ABOUT THIS BIDIRECTIONAL COMMUNICATION BETWEEN THE BASIC MECHANISTIC WORK AND THE EFFICACY WORK. SO THAT'S NOT THE SUBJECT OF TODAY'S TALK. AND I'M SURE THERE'S PLENTY OF OTHER ARTICLES AND WEBINARS YOU CAN WATCH ON THAT TOPIC. SO BUT FOR MANY PEOPLE, THE EFFICACY THAT GETTING THAT TRADITIONAL RCT IS THE FINISH LINE AND THE NCCIH AND OTHER INSTITUTES AS WELL, I'M VERY PROUD OF THE WORK NCCIH HAS DONE LOOKING AT EFFECTIVENESS RESEARCH. SO NOW THAT YOU HAVE AN INTERVENTION OF DEMONSTRATED EFFICACY, WE HAVE MOVED THE FINISH LINE TO SAY NOW WE WANT TO KNOW NOT JUST DOES IT WORK UNDER IDEAL CIRCUMSTANCESES BUT DOES IT WORK IN REAL WORLD SETTINGS. SO WE HAVE A NUMBER OF DIFFERENT PROJECTS INCLUDING THE NIH DOD PAIN MANAGEMENT COLLABORATORY WHICH IS FOCUSED ON EFFECTIVENESS WORK AS WELL AS THE OTHER LABORATORY, THE HEALTHCARE SYSTEMS LABORATORY. I'M SUGGESTING THAT SHOULD NOT BE THE FINISH LINE WE CAN MOVE FURTHER NOT JUST TO BUILD THE EVIDENCE BASE BUT TO ENSURE THAT THE INTERVENTIONS WE HAVE DEMONSTRATED EFFICACIOUS AND EFFECTIVE MOVE INTO WIDESPREAD UPTAKE ADOPTION. SO I AM BORROWING HEAVILY FROM THE PROCTOR'S WORK ON THIS SLIDE. SO IF YOU HAVE HEARD OF NOLA TALK BEFORE THIS WILL SOUND FAMILIAR TO YOU. AND IT'S A SLIGHTLY DIFFERENT VIEW OF STUFF I TALKED ABILITY. IN TERMS OF IMPLEMENTATION RESEARCH THIS THESE TWO AIMS THE WHAT AND THE OUTCOMES, THIS IS THE USUAL. THIS IS WHAT THE NIH DOES. WE ARE REALLY GOOD AT THIS. SO WHAT I WANT TO START THINKING ABOUT IS HOW AND WHERE DOES IMPLEMENTATION FIT IN. NOW THAT WE ASKED WHAT, PRESUMING WE HAVE EVIDENCE BASED INTERVENTIONS, THE EBI AND EVIDENCE BASED PRACTICES, THEN WE ASK THE QUESTION HOW DO WE IMPLEMENT THEM SNOW HOW DO WE GET -- WHAT STRATEGIES ARE WE GOING TO TEST TO SEE IF WE CAN GET THIS -- THESE INTERVENTIONS OF KNOWN EFFECTIVENESS INTO TO PEOPLE THAT BENEFIT FROM THEM. THE OUTCOMES ARE DIFFERENT THAN WHAT YOU WOULD EXPECT. SO IN THE TRADITION AL ASKING WHAT, WE WILL LOOK AT PATIENT OUTCOMES. FOR IMPLEMENTATION RESEARCH THE FIRST SET OF OUTCOMES TO LOOK AT ARE THE IMPLEMENTATION OUTCOMES. IS IT FEASIBLE, ABLE TO DO INTERVENTIONS WITH FIDELITY, WHAT WAS PENETRATION LIKE WITHIN THE SYSTEM OR SYSTEMS WE ARE TRYING TO GET THIS INTO, WHAT DID ACCEPTABILITY LOOK LIKE. AND ON DOWN THE LIST. A IN ADDITION TO THAT WHAT WE WANT TO LOOK AT ARE SERVICE OUTCOMES. THE SERVICE OUTCOMES ARE TAKEN FROM THE IOM STANDARDS OF CARE, IOM IS NOW THE NATIONAL ACADEMIES BUT SO WE ARE LOOKING AT THESE DIFFERENT -- SO WE ARE TESTING IN HOW WHAT STRATEGIES WE ARE DOING, WE ARE LOOKING AT IMPLEMENTATION OUTCOMES AND SERVICE OUTCOMES. AND THEN INSTEAD OF THE USUAL LOOKING ACROSS WHAT DID WE DO INFLUENCE THE PATIENT OUTCOME WE ARE FOCUSING ON THE SENTENCER PIECE CORE OF IMPLEMENTATION SCIENCE. COMING UP WITH DEFINITIONS. THE DEFINITION IS TAKEN FROM THE NIH WIDE DISSEMINATION IMPLEMENTATION FUNDING OPPORTUNITY ANNOUNCEMENTS, IMPLEMENTATION SCIENCE IS THE SCIENTIFIC STUDY OF METHODS, STUDY OF METHODS TO PROMOTE INTEGRATION OF RESEARCH FINDINGS EVIDENCE BASE INTERVENTIONS AND HEALTHCARE PRACTICE AND POLICY. INTERVENTION IS FAIRLY BROADLY DEFINED. ANY PRACTICE IN POLICY ANY TOOL, ANYTHING THAT IS REALLY SUPPOSED TO HELP IMPROVE HEALTH OUTCOMES. I WANT TO -- I HAVE DONE A LOT OF TECHNICAL ASSISTANCE CALLS WITH PEOPLE WHO SAY GOSH DAVE I HAVE A GREAT IMPLEMENTATION IDEA. SO HERE ARE SOME OF THE COMMON MISCONCEPTIONS I WANT TO GET OUT OF THE WAY. IMPLEMENTATION SCIENCE IS NOT DISSEMINATION. THERE'S DIFFERENT THEY ARE DIFFERENT QUESTIONS, BOTH IMPORTANT QUESTIONS BUT DIFFERENT QUESTIONS. DISSEMINATION IS THE TARGETED DISTRIBUTION OF INFORMATION TO THE AUDIENCES THAT WILL BENEFIT FROM THEM. SO THE EXAMPLE THAT I TYPICALLY USE IS IF THERE IS AN EVIDENCE BASE PRACTICE AND IT'S NOT BEING USED AND WE ASK THE QUESTION, WHY ISN'T IT BEING USED? IF THE ANSWER IS NOBODY KNOWS ABOUT IT, THAT'S GOING TO BE A DISSEMINATION ISSUE. THAT PEOPLE ARE JUST NOT AWARE OF IT, HOWEVER, IF PEOPLE ARE AWARE OF IT AND PERHAPS EVEN THERE ARE CLINICAL PRACTICE GUIDELINES THAT RECOMMEND THIS AND PEOPLE STILL AREN'T USING IT, THAT'S AN IMPLEMENTATION QUESTION. IT'S A GROSS OVERSIMPLIFICATION BUT THAT'S THE GENERAL RULE OF THUMB TO USE. THE OTHER IMPORTANT DISTINCTION I WANT TO MAKE IN BASED ON NUMBER OF TECHNICAL ASSISTANCE CALLS I HAVE HAD IS THAT IMPLEMENTING INTERVENTION IS NOT THE SAME AS DOING IMPLEMENTATION SCIENCE. I HAVE HAD PEOPLE CALL AND SAY GOSH DAVE I HAVE THIS GREAT IDEA. I'M LIKE OKAY LAY IT ON ME. WHAT YOU GOT? THEY WILL SAY I WILL TAKE THIS INTERVENTION, PUT ANYTIME CLINIC AND SEE IF IT CHANGES IN HEALTH OUTCOME. I'M LIKE OH OKAY, BACK UP A LITTLE. YOU HAVEN'T TALKED ABOUT WHAT ARE YOUR -- WHAT STRATEGIES ARE YO GOING TO USE AND HOW ARE YOU TESTING THOSE STRATEGIES TO PUT THE INTERVENTION INTO THE CLINIC. THAT'S WHAT IMPLEMENTATION SCIENCE IS. IF YOU JUST GOING TO PUT THE INTERVENTION TO A CLINIC, IT'S AN IMPORTANT QUESTION BUT IT'S EFFICACY OR EFFECTIVENESS QUESTION. NOT IMPLEMENTATION SCIENCE QUESTION. THOSE OUT OF THE WAY, ALSO WANT THE MAKE SURE TO MENTION HYBRID DESIGNS. HOPE I'M NOT STEALING AMANDA'S THUNDER IF SHE GETS TO THIS LATER. HYBRID DESIGNS IF YOU CAN SEE AT THE TOP OF THE SLIDE, THERE ARE THE PIPELINE NICELY DONE INTO A PIPE LOOKING TYPE OF ICON. WE START WITH EFFICACY STUDIES, MOVE TO EFFECTIVENESS STUDIES AND IMPLEMENTATION, THERE IS A SPACE BETWEEN EFFECTIVENESS RESEARCH AND IMPLEMENTATION RESEARCH TO WHAT'S CALLED A HYBRID DESIGN. THE PAPER I REFERENCE WHICH IS NOTED AT THE END OF THE PRESENTATION DESCRIBES THREE TYPES OF HYBRID DESIGNS. HYBRID TECH ONE IS WHERE PRIMARY AIM IS EFFECTIVENESS. THAT'S REALLY WHAT YOU ARE LOOKING AT AND WHY DOING THAT YOU WILL START UNDERSTANDING THE CONTEXT FOR IMPLEMENTATION MAYBE TEST SOME STRATEGIES OR EXAMINE STRATEGIES YOU MIGHT WANT TO USE. TO IMPLEMENT. HYBRID TYPE TWO IS WHEN AIMS ARE IMPORTANT BETWEEN EFFECTIVENESS STUDY AND IMPLEMENTATION STUDY SO YOU ARE TESTING IMPLEMENTATION STRATEGIES WHILE DETERMINING EFFECTIVENESS OF THE INTERVENTION. CONCURRENTLY. A TYPE THREE DESIGN IS WHERE YOU ARE FOCUSED -- THIS IS IMPLEMENTATION SCIENCE STUDY BUT WHILE DOING YOU WILL MAKE SURE YOUR CLINICAL OUTCOMES ARE IMPROVING THE EFFECTIVENESS IS STILL THERE. THAT'S OOH A DIFFERENT THAN WHAT HI PUT IN QUOTE HERE IS PURE IMPLEMENTATION WHICH IS REALLY JUST ABOUT THE IMPLEMENTATION SCIENCE ONLY. IF YOU HEARD ME TALK BEFORE, HEARD ME TALK AGAIN YOU WILL HEAR ME SAY THIS OVER AN OVER. I ENCOURAGE YOU, CONSIDERING IMPLEMENTATION SCIENCE I CAN'T ENCOURAGE YOU STRONG ENOUGH TO THINK MULTIPLE ECOLOGICAL LEVELS. AND SO WHAT DOES THAT MEAN? FOR THE MOST PART WHEN I -- PEOPLE SAY GOSH DAVE I HAVE THIS IDEA FOR IMPLEMENTATION SCIENCE, GREAT, TELL ME ABOUT IT. I AM GOING TO TARGET THE PHYSICIAN PEN, METAPHORICALLY THE PEN, IT'S THE DOCTORS ORDERS ARE WHERE HEALTHCARE FLOWS FROM AND THEY COME UP WITH THIS TO DO LIST OF ORGAN TRAININGS, ADD INCENTIVES PUT MINORS IN ELECTRONIC HEALTH RECORD, IDENTIFY CHAMPIONS. I GOT BORED BY THAT LIST OF TO DO THINGS. WHILE THESE ARE STRATEGIES THESE ARE NOT GREAT STRATEGIES. THAT'S A SECRET HINT THERE FOR YOU. ANYWAY, THE PROBLEM THAT I WANT TO POINT OUT IS YOU ARE ONLY TARGETING PHYSICIAN. AND THERE'S A LOST OPPORTUNITY. SO LET'S PRETEND FOR A SECOND, I EVEN GIVE CREDIT TO SAY THAT YOUR TARGETING OF THE PHYSICIAN PEN WAS WILDLY SUCCESSFUL AND AS A RESULT YOUR PATIENT REFERRALS WENT THROUGH THE ROOF. CONGRATULATIONS. AS WE KNOW PATIENT REFERRALS DOES NOT MEAN PATIENT ATTENDS REFERRAL OR UPTAKES OR USES OR SUSTAINS INTERVENTION OF CHOICE. SO WHAT'S FREQUENTLY HAPPENS IS THE CARTOON ON THE RIGHT FROM THE FAR SIDE WHICH HAS TWO VIKINGS IN THE FRONT LOOKING AT EACH OTHER SAYING I HAVE GOT A TWO, THIS STRANGE FEELING GOING IN CIRCLES. WHAT YOU HAVE DONE BY ONLY TARGETING THE PHYSICIAN PEN IS YOU HAVE BULKED UP ONE SIDE OF THIS OF YOUR INTERVENTION STRATEGY WHILE NEGLECTING ALL THE OTHER POTENTIAL LEVERS YOU HAVE TO IMPLEMENT IN OTHER WAYS OF STRATEGY CAN TEST TO IMPLEMENT AT OTHER LEVELS. I ALSO BEFORE I GET TO THAT SLIDE, COVER THIS ONE. I ALSO WANT TO ENCOURAGE YOU TO THINK OUTSIDE. AND WHAT I MEAN BY OUTSIDE IS IF YOU GO TO THE LITERATURE ON IMPLEMENTATION SCIENCE, THE MAJORITY IS DONE IN EITHER DOCTOR'S OFFICE OR IN A HOSPITAL BASE OR HOSPITAL BASED CLINICS AND IT MAKES SENSE IF YOU THINK ABOUT IT, IF YOU WANT TO DO DISSEMINATION IMPLEMENTATION RESEARCH IN HEALTH YOU MIGHT WANT TO GO WHERE HEALTH HAPPENS. THOSE ARE LOGICAL CHOICES. MY POINT IS THAT THESE ARE NOT THE ONLY PLACES WHERE HEALTH OCCURS. I WANT PEOPLE TO THINK OUTSIDE THESE TRADITIONAL HEALTHCARE SYSTEMS AS SPECIAL AS YOU THINK ABOUT COMPLIMENTARY AND INTEGRATED HEALTH SYSTEMS. EXAMPLES, THE PICTURE US HEAR WHICH IS NOT EXHAUSTIVE LIST FOR ANY STRETCH, A FEW EXAMPLES, THERE IS A SENIOR CENTER COMMUNITY HEALTH CLINIC, THERE'S A SCHOOL AS WE CONTINUE WITH ERA OF COVID MORE STUFF IS BEING DONE REMOTELY. SO I WANT YOU TO THINK OUTSIDE ENCOURAGE YOU TO THINK OUTSIDE OF TRADITIONAL DOCTOR'S OFFICES IN CLINICS, WHEN YOU CONSIDER HOW YOU MAY WISH TO DOP AN TEST DIFFERENT STRATEGIES TO MOVE HEALTH INTO OTHER AREAS. SO HERE ARE SOME GENERAL NON-EXHAUSTIVE GENERIC QUESTIONS THAT MIGHT HELP YOU TO UNDERSTAND WHAT MULTIPLE LEVELS COULD MEAN. SO WE TALK ABOUT PROVIDER LEVEL WHAT CAN WE DO TO -- WHAT STRATEGIES WE CAN DO TO TEST INDIVIDUAL HEALTHCARE PROVIDERS WHAT CAN YOU DO TO ENGAGE PROFESSIONAL SOCIETIES, ARE THERE PATIENT LEVEL STRATEGIES WE CAN TEST TO GET PULL STRATEGIES FOR EXAMPLE IF A -- IF YOU WANT TO DEIMPLEMENT OPIOID PRESCRIBING FOR THIRD MOLAR EXTRACTS AND YOU TARGET THE DENTIST IN THAT CASE, COULDN'T YOU ALSO TEST STRATEGIES TO HAVE PATIENTS REFUSE OPIOID WHEN OFFERED OR TO HAVE A CONVERSATION WITH THEIR PRACTICE TO SAY IS THIS THE RIGHT MEDICATION. THERE ARE WAYS TO BE ABLE TO INTERVENE. WHAT STRATEGIES CAN YOU DO TO GET THEM INVOLVED. THEN I HAVE SOME OTHER ONES I WON'T GO THROUGH THESE EACH ONE INDIVIDUALLY, I WANT YOU TO ENCOURAGE YOU TO THINK THERE'S HER THAN JUST THE PROVIDER'S PEN. I AM SO HAPPY TO SHOW THIS TO YOU, THIS -- THE COMING OUT PARTY SO TO SPEAK OF THE NEW NCCIH FRAMEWORK FOR CLINICAL RESEARCH WHICH IS CHANGED THE FIRST THREE, THE ORANGE, GREEN AND BLUISH GRAY BLUE HAVE STAYED THE SAME BUT WE RECONFIGURED THE LAST TWO AND ADDED THE SIX CIRCLE SO WE NOW SAID THE NEXT STRATEGY IS EFFICACY FOLLOWED BY EFFECTIVENESS AND PRAGMATIC STUDIES AND AFTER THAT IS TO GET INTO DISSEMINATION IMPLEMENTATION SCIENCE. I HAVE ALSO FOR YOU SOME HELPFUL ARTICLE. IF YOU HAVE BEEN LISTENING TO THIS PRESENTATION YOU SAY GOSH I WOULD REALLY LIKE TO KNOW MORE ABOUT IMPLEMENTATION SCIENCE, HERE ARE JUST A FEW TOP NOTCH PAPERS TO READ THROUGH SO GET A SENSE OF THEM. PLEASE REFER TO CHECK IN ON PUBMED. I ALSO WANT TO POINT OUT QUICKLY THAT THE NCCIH HELD AN EXPERT PANEL MEETING LISTENING SESSION IN DECEMBER OF 2019. THE MEETING SUMMARY IS OFFICIALLY GONE LIVE. MY THANKS TO THE TEAM FOR HELPING MAKE THAT HAPPEN. SO FEEL FREE TO CHECK ON THAT LINK TO READ THAT AT YOUR LEISURE.% I'M GOING TO STOP HERE AND KIND OF TALK ABOUT HOW THE REST OF THE WEAPON FAR WILL GO BEFORE TURNING IT OVER TO OUR NEXT SET OF SPEAKERS. SO WE HAVE HAD WELCOME FROM DR. LANGEVIN. GONE THROUGH IMPLEMENTATION SCIENCE ABOUT COMMON DEFINITIONS; WE HAVE COMING UP AFTER THAT IS GOING TO BE TWO PIECE PRESENTATIONS, DR. WAYNE WILL TALK ABOUT MIND BODY MOVEMENT INTERVENTIONS, WHAT ARE SOME EXAMPLES OF COMP MEMBER TEAR HEALTH INTERVENTIONS THAT ARE WHAT STAGE ARE THEY IN TERMS OF WRITING THIS FOR MOVING TO IMPLEMENTATION SCIENCE, THEN TURN THINGS OVER TO DR. MIDBOE WHO WILL TALK ABOUT CHALLENGES AND OPPORTUNITIES ABOUT INTEGRATING COMPLIMENTARY INTERVENTIONS IN TRADITIONAL HEALTHCARE SETTINGS. AFTER THAT WE'LL HAVE A LIGHTENING ROUND FROM SOME OF MY NIH COLLEAGUES TO TALK ABOUT IMPLEMENTATION SCIENCE PORTFOLIOS, THEIR CENTERS, THEIR INSTITUTES AND THEN WE WILL HAVE A MODERATED Q&A SESSION BEFORE WRAPPING THINGS UP. SO I AM GOING TO STOP SHARING SO THAT ROBERT CAN GET UP THE NEXT SLIDE SET. I WILL DO -- IF I CAN FIND MY NOTES, INTRODUCTIONS. ROBS BRING UP THE NEXT SLIDES. THANK YOU. ALLOW ME TO DO INTRODUCTIONS TO OUR NEXT TWO SPEAKERS AND TO MAKE THE TRANSITION SEAMLESS I WILL DO THOSE INTRODUCTIONS BOTH RIGHT NOW FIRST PETER WAYNE, RESEARCHER AND PRACTITIONER IN FIELD OF INTEGRATIVE MIND BODY AND MEDICINE. ASSOCIATE PROFESSOR OF MEDICINE AT HARVARD MEDICAL SCHOOL AND DIRECTOR FOR THE OCHER SENT FOR INTEGRATIVE MEDICINE HARVARD MEDICAL SCHOOL AND BRIGHAM AND WOMEN'S HOSPITAL. PRIMARY FOCUS OF DR. WAYNE'S RESEARCH IS EVALUATING HOW MIND BODY AND RELATED INTEGRATIVE MEDICINE PRACTICES CLINICALLY IMPACT AGING IN CHRONIC HEALTH CONDITIONS IN UNDERSTANDING THE PHYSIOLOGICAL AND PSYCHOLOGICAL MECHANISMS UNDERLYING OBSERVED THERAPEUTIC EFFECTS. HE SERVED AS A PI OR PRINCIPLE OR CO-INVESTIGATOR ON MORE THAN 25 NIH FUNDED STUDIES. HIS RESEARCH EVALUATED IMPACT OF THERAPY SUCH AS TAI CHI ACUPUNCTURE, CHIROPRACTIC CARE ON DIVERSE MEDICAL ISSUES INCLUDING BALANCE DISORDERS, PARKINSON'S DISEASE, HEART FAILURE CANCER BACK PAIN, MIGRAINE HEADACHES AND AGING. IMMEDIATELY FOLLOWING DR. WAYNE'S PRESENTATION WE WILL HEAR FROM AMANDA MIDBOE. HEALTH RESEARCH PSYCHOLOGIST WITH IMPLEMENTATION SCIENCE HEALTH INFORMATICS EXPERTISE. DR. MIDBOE IS A PRINCIPLE INVESTIGATOR AT THE CENTER FOR INNOVATION TO IMPLEMENTATION WHICH IS A STANFORD AFFILIATED RESEARCH CENTER AT THE VA PALLO ALTO HEALTHCARE SYSTEM. SHE ADDRESSES THE OPIOID EPIDEMIC TO AVENUES TO ACCESS TO EVIDENCE BASED TREATMENTS FOR CHRONIC PAIN OPIOID USE DISORDERS WALES AS PREVENTING OVERDOSE IN VETERANS. SHE SERVED AS CO-INVESTIGATOR ON 20 VA FUNDED RESEARCH STUDIES, QUALITY IMPROVEMENT PROJECTS AND NATIONAL IMPLEMENTATION SCIENCE PROGRAMS. DR. MIDBOE'S WORK EVALUATE HOD TO BEST IMPLEMENT EVIDENCE BASED PRACTICES RELATED TO THE OPIOID EPIDEMIC IN RURAL BASED CLINICS AND COMPLEX HEALTHCARE SYSTEMS. DR. MIDBOE ALSO SERVING AS LEAD EXPERT ON IMPLEMENTATION SCIENCE FOR THE NIH VA DOD PAIN MANAGEMENT LABORATORY. THE PAIN MANAGEMENT LABORATORY IS THE PRAGMATIC CLINICAL TRIALS TESTING EFFECTIVENESS TO NON-PHARMACOLOGICAL PAIN MANAGEMENT INTERVENTIONS. MOST OF THE PROJECTS ARE PEER EFFECTIVENESS STUDIES WHILE SOME BLEED INTO HYBRID TYPE ONE MODEL SO GRATEFUL TO HAVE DR. MIDBOE'S EXPERTISE AND LEADERSHIP. SO WITH THAT, I AM NOW GOING TO STOP TALKING AND TURN THINGS OVER TO PETER WAYNE. PETER, YOU HAVE THE FLOOR. >> THANK YOU, CAN YOU iCAN YOU SEE MY SLIDES? BEAUTIFUL. I WANT TO BEGIN BY THANKING DR. CLARK AND OTHER ORGANIZERS OF THIS EVENT AND AHOW DELIGHTED I AMBITHE OPPORTUNITY TO PARTICIPATE TODAY. MY GOAL IS TO PROVIDE AN OVERVIEW OF MIND BODY MOVEMENT INTERVENTIONS AND SOME OF THE OPPORTUNITIES AND CHALLENGES THAT THEY AFFORD WITHIN TODAY'S LARGER DISCUSSION OF IMPLEMENTATION SCIENCE. FULL DISCLOSURE I'M A REAL NEOPHYTOREGARDING IMPLEMENTATION SCIENCE. EXCITED TO LEARN FROM THE OTHER PARTICIPANTS TODAY. THIS SLIDE SIMPLY DISCLOSES THAT I OVERSEE A COMMUNITY BASED SCHOOL AND MY ACTIVITIES THERE DON'T INVOLVE ANY RESEARCH. SO WHILE THERE'S SOME OF THE MIND BODY INTERVENTIONS I WILL TALK ABOUT GO BACK HUNDREDS IF NOT THOUSANDS OF YEARS, IT'S ONLY RECENTLY THAT THEY HAVE BEEN DESCRIBED BY MEDICAL COMMUNITY AS A UNIQUE TYPE OF INTERVENTION. DISTINCT FROM CONVENTIONAL EXERCISE AND RELATIVELY SEDENTARY MEDITATIVE PRACTICE. I'LL BEGIN BY TRYING TO DEFIND MIND BODY MOVEMENT INTERVENTION AND HIGHLIGHT THE UNIQUE FEATURES THAT I THINK UNDERLIE SOME OF THE THERAPEUTIC EFFECTS. I'LL THEN DISCUSS SOME OF THE METHOD LOGICAL CHALLENGES ASSOCIATED WITH THE STUDY OF MULTI-COMPONENT MIND BODY MOVERMENT INTERVENTIONS WHICH HAVE IMPLICATIONS HOW TO INTERPRET CLINICAL EVIDENCE TERMS OF EFFECTIVENESS TO DATE BUT ALSO HOW WE THINK ABOUT THE DESIGN AND CONDUCT OF IMPLEMENTATION STUDIES MOVING FORWARD. I WILL THEN PROVIDE HIGH LEVEL SUMMARY OF CLINICAL EVIDENCE OF TWO OF THE MOST STUDIED MIND BODY MOVEMENT INTERVENTIONS TAI CHI AND YOGA WITH A FOCUS ON THE MOST WELL EVIDENCE APPLICATIONS THAT I THINK ARE RIPE OR MATURE ENOUGH TO MOVE INTO THE IMPLEMENTATION RESEARCH STAGE. I WILL SUGGEST COUPLE OF SPECIFIC CONSIDERINGS FOR IMPLEMENTATION RESEARCH THAT ARE PARTICULARLY WELL ALIGNED WITH THESE MULTI-MODAL INTERVENTIONS. SO LINDA LARK AND COLLEAGUES AT UNIVERSITY OF ARIZONA WERE AMONG SOME OF THE FIRST RESEARCHERS TO CONSIDER MIND BODY MOVEMENT THERAPIES AS A UNIQUE CLASS OF INTERVENTION. THEY USE MEDITATIVE MOVEMENT. THEY EMPHASIZE IN ADDITION TO ASSORTMENT SOME FORM OF MOVEMENT OR POSTURES OR BODY POSITIONING, YOGA TAI CHI EMPHASIZE EXERCISING WHAT THEY CALL CLEAR OR CALM STATE OF MIND. WITH A GOAL OF DEEP STATE RELAXATION AND DEEP BREATHING. THEY USE THE DEFINITION TOADDING MEDITATIVE MOVEMENT FOR MORE STATIONARY MIND BODY PRACTICES. BUT I THINK THIS DISTINCTION IS FUZZY AT TIMES BECAUSE WE KNOW THAT PRACTICES LIKE ZEN MEDITATION HAVE GREAT EMPHASIS ON POSTURE DURING THE PRACTICE OF MEDITATION. (INAUDIBLE) AND HER COLLEAGUES TOOK MORE HOLISTIC OR WHAT I THINK ECOLOGICAL APPROACH. WHAT THEY CALL MIND BODY MOVEMENT, MIND BODY AND BODY CONTEMPLATIVE PRACTICE. THEY EMPHASIZE THESE PRACTICES ARE MORE THAN JUST THE ADDITIVE EFFECTS OF RELAXING WHILE MOVING AND THEY SAID THERE THERAPEUTIC EFFECTS CAN BE VIEWED FROM WHAT THEY CALL AN EMBODIED OR INACTIVE COGNITIVE FRAMEWORK. WITHIN THAT MODEL MENTAL AND PHYSICAL EXPERIENCES CO-CREATING ONE ANOTHER. THESE BOTTOM UP TOP DOWN PROCESSES INTERACT. ACCORDINGLY TEMPLATE PRACTICES ARE START TO LEVERAGE THIS BY TARGETING MULTIPLE PSYCHOPHYSIOLOGICAL PROCESSES IN A COORDINATED KIND OF WAY. SO THIS ECOLOGICAL OR EMBODY COGNITIVE FRAMEWORK IS NICELY HE WILL STRAITED BY TAI CHI AND IMPACT ON RISK OF FALLING SO TAKE A FEW MINUTES WITH THIS SLIDE. FIRST THIS SLIDE NICELY ILLUSTRATES TAI CHI I CALL A MULTI-MODAL INTERVENTION. THERAPEUTIC COMPONENTS. SO THERE'S MUSCULOSKELETAL PIECE OF WEIGHT BEARING AND STRENGTHING FLEXIBILITY, COGNITIVE PIECES IN TERMS OF MINDFULNESS AND ATTENTION, IMAGERY AND VISUALIZATION AND PLACEBO GENIC EFFECTS. BREATHING, SOCIAL INTERACTION. SO THIS IS RICH NUMBERS OF INGREDIENTS EMBEDDED IN THESE COMMONLY IN THESE INTERVENTIONS. THIS DIAGRAM EMPHASIZES AS -- MODEL SUGGESTS THAT THESE ARE NOT INDEPENDENT. THEY INTERACT. SO ONE MIGHT MANAGE AFTER DOING SOME NICE STRETCHING EXERCISES AND YOGA CLASS ONE FEELS A LITTLE MORE RELAXED IN THE BODY AND MIND A LITTLE MORE INTRACEPTIVELY AWARE OF WHAT'S GOING ON AND PAYING ATTENTION TO THE BODY. THOSE QUALITIES MIGHT CHANGE HOW ONE FEELS HOW THEY BREATHE. BREATHING MORE DEEPLY AND COMFORTABLY AND FEELING RESTFUL IN THE BODY CHANGE HOW YOU FEEL LIKE YOU ARE PART OF THE GROUP AND HOW YOU INTERACT WITH THAT. IT IS A COMPLEX INTERDEPENDENT SET OF THERAPEUTIC COMPONENTS. I THINK THE WAY THIS AFFECTS BALANCE IN PARTICULAR IN FALLS, I WILL TALK MORE ABOUT THE FALL DATA IN A FEW MINUTES. THERE'S GOOD EVIDENCE FOR TAI CHI AND PREVENTING FALLS. THIS DIAGRAM HIGHLIGHT THIS IS IS DIFFERENT THAN STUDYING TYPICAL PHARMACOLOGICAL AGENT. THERE YOU HAVE SSRI OR ASPIRIN, VERY SPECIFIC MOLECULE TARGETING VERY SPECIFIC RECEPTOR. THEREFORE AFFECTING THE SYSTEM FROM THAT ONE POINT. HERE WE HAVE MULTIPLE POTENTIAL THERAPEUTIC COMPONENTS TARGETING MULTIPLE PROCESSES THAT UNDERLIE A CHRONIC CONDITION POOR BALANCE. JUST TO HIGHLIGHT A FEW, WE KNOW, THESE ARE BASED ON GOOD RANDOMIZED TRIALS, TAI CHI IS KNOWN TO IMPROVE LOWER EXTREMITY STRENGTH TO CHANGE RECEPTION AND PROPRIOCEPTION SOULS OF THE FEET WHICH HELPS WITH BALANCE, REFLEX AND RESPONSE TO PERTURBATIONS WHEN YOU SLIP. MULTIPLE COGNITIVE DEVELOPMENTS THAT CONTRIBUTE OR BALANCE TO INCLUDING FEAR OF FALLING AND EXECUTIVE FUNCTION. ET CETERA SO YOU GET THE IDEA THIS IS A MULTI-COMPONENT INTERVENTION WORKING IN HE ECOLOGICAL WAY. THIS RICHNESS AFFORDS IT POTENTIALLY UNIQUE ADVANTAGES OVER UNIMODAL INTERVENTION BUT ALSO RESULTS IN THE CHALLENGES IN DESIGNING BOTH CLINICAL AND PROBABLY IMPLEMENTATION STUDIES. THERE ARE LOT OF EXAMPLES OF MIND BODY MOVEMENT PRACTICES MOST ARE NOT VERY WELL EVIDENCE YET OR AT LEVEL WE WANT TO FEEL CONFIDENT ABOUT INVESTING A LOT IN IMPLEMENTATION. I'LL FOCUS ON TAI CHI AND YOGA BUT A FEW OTHERS. THE MOVEMENT THERAPY PILATES. I WAS TOLD TO EMPHASIZE THIS IS NOT THE NATIONAL INSTITUTE OF AGING WHERE THEY HAVE A DANCE PARTY BUT THIS IS MINDFUL DANCE PROGRAM, RUNNING CAN BE MINDFUL, THERE'S SPECIAL EXERCISES AROUND THAT. -- IS AN INTERESTING ONE GAINING POPULARITY ESPECIALLY IN EUROPE THAT COMES OUT OF PHILOSOPHY OF ANTHROPOSIFY. THERE'S TWO OR LARGE SCALE RANDOMIZED TRIALS IN GERMANY NOW SO WE WANT TO KEEP AN EYE ON THOSE COMING DOWN THE PIPELINE. SO BEFORE TALKING ABOUT THE EVIDENCE OF TAI CHI AND YOGA, THOUGHT IT WOULD BE NICE TO DISCUSS COMMONALITIES AS WELL AS MAYBE SOME DIFFERENCES. SO THEY ARE BOTH MULTI-MODAL PRACTICES, THEY BOTH ORIGINATE IN ASIA. TAI CHI AND CHINA AND YOGA IN INDIA, THEY INCLUDE LOW TO MODERATE AEROBIC COMPONENT, MULTIPLE COGNITIVE COMPONENTS BREATHING AND SOMETIMES SMATTERING OF PHILOSOPHY, A LIFESTYLE TYPICAL CLASS. BOTH INCLUDE RICH DIVERSITY OF SHAPES AND MOVEMENT PATTERNS AND TAX MUSCULOSKELETAL SYSTEM IN DIFFERENT WAYS TAUGHT IN DIFFERENT GROUPS INCLUDING HIGH PSYCHOSOCIAL SUPPORT. IF I HAD TO MAKE A DISTINCTION, THIS IS A GENERALIZATION I MAY GET SOME HATE MAIL FROM THIS, BUT YOGA TENDS TO BE LITTLE MORE FOCUSED ON HOLDING FOR MORE PROLONG PERIOD STATIC POSTURES. THERE'S FLOW YOGA WHICH HAS DIFFERENT EMPHASIS. THIS MIGHT AFFORD GREATER BENEFITS FOR MUSCULOSKELETAL FLEXIBILITY IN CONTRAST TAI CHI WHICH EVOLVED FROM MARSHALL ARTS IS MORE UPRIGHT DYNAMICALLY. AS A RESULT OF THAT MAY AFFORD MORE BENEFITS FOR BALANCE AND PRACTICAL ACTIVITIES OF DAILY LIVING LIKE LIFTING AND PUSHING AND AGILITY RESPONSES TO THINGS OUT IN THE REAL WORLD. SO IN ADDITION TO THE TYPICAL PROBLEMS WE SEE IN ALL OUR TRIALS, POWER, BLINDING, CONCEALMENT PROPER STATISTICAL ANALYSES, THERE'S A COUPLE OF CHALLENGES INHERENT IN THESE MULTI-MODAL MOVEMENT INTERVENTIONS THAT I THINK ARE WORTH MENTIONING BECAUSE I THINK THEY -- AS I SAY BEFORE THEY AFFECT HOW WE INTERPRET THE EVIDENCE TO DATE AND LIMITATIONS OF THAT BUT ALSO HOW WE THINK FORWARD IN TERMS OF IMPLEMENTATION STUDIES. ONE IS PLURALISM INHERENT IN THESE PRACTICES AND THE OTHER IS TEACHING QUALITY. SO UNLIKE DRUGS I MENTIONED BEFORE WHICH IS REPLICATED WITH PRETTY GOOD FIDELITY ACROSS FACT FACTORIES AND DIFFERENT PARTS OF THE WORLD THERE'S PLURALISM WITHIN THESE MIND BODY PRACTICES. THEY ARE TYPICALLY COMPOSED OF MANY DIFFERENT SCHOOLS OF THOUGHT OR LINEAGES IN TAI CHI, CHEN STYLE WU STYLE, THESE REFER TO NAMES OF THE CHAIRS MATTIC LEADERS AND SIMILARLY LOTS OF SCHOOLS IN YOGA, AND WITHIN EACH OF THOSE IN A TYPICAL CLASS YOU MIGHT LEARN DIFFERENT SETS FOR EXAMPLE EVEN WITHIN THE I DON'T THINK STYLE DIFFERENT CHOREOGRAPHIES. TO ADD THE THAT DIVERSITY, MODERN MEDICAL RESEARCH DEVELOPED MORE SIMPLIFIED PROGRAMS SOMETIMES THAT ARE ADOPTED TO SPECIFIC POPULATIONS OR CONDITIONS. ONE OF THE CHALLENGES AND INTERPRETING THIS IS WELL IS RARELY ARE DETAILS OF THESE PROTOCOLS INCLUDED IN THESE PEER REVIEW PUBLICATIONS. AND EVEN LESS RARE NATURAL WHY THEY USE THIS YOGA FOR THAT CONDITION. SO I THINK IT'S IMPORTANT TO APPRECIATE THAT THIS HETEROGENEITY LIMITS THE CONCLUSIONS WE CAN MAKE IN META ANALYSIS HOW GENERALIZABLE IS ACROSS ALL THE STUDIES. AND I THINK IT POSES CHALLENGES THAT I LOOK FORWARD TO DISCUSSING WITH THE PANELISTS LATER TODAY. TEACHING IS REALLY IMPORTANT. WE ALL GONE TO CLASS WHERE THERE'S A GOOD TEACHER A BAD TEACHER CAN MAKE A BIG DIFFERENT, IF WE ARE TRYING TO SET UP A BIG RANDOMIZE TRIAL OF MIND BODY MOVEMENT INTERVENTION ONE OF THE BIG CONCERNS WE HAVE IS HOW WE FIND A NUMBER OF GOOD TEACHERS AND TEACH THEM IN A CERTAIN WAY. DEPENDING ON WAY WE DO THE INTERVENTIONS. ADDING TO THESE CHALLENGES OF VARIABILITY AND QUALITY OF TEACHING IS THERE'S NO SINGLE ACCREDITATION BODY FOR TAI CHI OR YOGA ACROSS THE UNITED STATES IN ACUPUNCTURE THERE IS, OBVIOUSLY BECOME A PHYSICIAN YOU HAVE TO PASS BOARDS AND GET LICENSES BUT THOSE DON'T EXIST WITH A COMMON SET OF SKILLS THAT ARE MONITORED. THERE'S SURPRISINGLY LITTLE RESEARCH REGARDING THE IMPACT OF TEACHER CHARACTERISTICS AND THERAPEUTIC OUTCOMES. THAT'S VERY IMPORTANT AND A BIG GAP IN OUR KNOWLEDGE. THINKING HOW WE RECRUIT AND TRAIN AND ASSURE CALL AND FIDELITY OF TEACHING, BOTH INTERPRETING THE CURRENT DATA BUT LOOKING FORWARD TO IMPLEMENTATION IS SOMETHING WE SHOULD PROBABLY DISCUSS AS A GROUP. SO MY GOAL PULLING THE EVIDENCE TOGETHER WAS NOT TO DO A PRECISE COMPREHENSIVE SCOPE REVIEW, THAT WAS BEYOND THE SCOPE OF TODAY'S PRESENTATION. BUT WHAT I WAS LOOKING FOR AS DR. CLARK MENTIONED IS REALLY GOOD EXAM PARTICULARS FROM THE TAI CHI AND YOGA LITERATURE RIPE FOR IMPLEMENTATION RESEARCH AND FURTHER DISSEMINATION. THE WAY I DID THIS WAS I DID EMPIRICALLY CURIOUS TO GET BACK INTO THE LITERATURE OF ANALYSIS OF THE META ANALYSES AND SYSTEMATIC REVIEWS THAT WERE PUBLISHED IN THE LAST FIVE YEARS IN PUBMED LOOKED ALL THE COCHRAN REVIEWS, LOOKED FOR RECENT LARGE SCALE TRIALS AND HIGH IMPACT JOURNALS AND DISCUSSIONS WITH MY COLLEAGUES WHOSE ARE LEADING TAI CHI AND YOGA RESEARCH TO ASK THE SPECIFIC QUESTION. WHAT IS WELL EVIDENCES AND WORTHY OF FURTHER IMPLEMENTATION RESEARCH. AND I WAS QUITE SURPRISED HOW MUCH IS AVAILABLE IN LAST FIEFS YEARS FOR TAI CHI IN PUBMED ALONE THERE WERE 92 SYSTEMATIC REVIEWS. AND 96 FOR YOGA. MEDIAN NUMBER OF STUDIES, IN THESE WERE 11 OR 12 NOT ALL RANDOMIZE TRIALS. COCHRAN REVIEWS, 20 HAVE BEEN DEVOTED TO INCLUDE TAI CHI SOMETIMES AS SUBGROUP ANALYSIS AND BROADER MIND BODY INTERVENTION OR EXERCISE REVIEWS. THREE SPECIFIC TO TAI CHI IN TERMS OF YOGA, 48 WERE AVAILABLE THROUGH COCHRAN AND 12 SPECIFIC TO YOGA. SOME GENERAL OBSERVATIONS, THERE'S A LOT OF VARIABILITY IN THE QUALITY IN THIS INCREDIBLE GROWTH OF META ANALYSES AND SYSTEMATIC REVIEWS EVEN WITHIN PARTICULAR ANALYSIS OF META ANALYSIS, THIS HIGH HETEROGENEITY BETWEEN STUDIES EVALUATED DEGRADING THE QUALITY OF EVIDENCE TO INTERPRETATION. LOTS OF STUDIES WITH SHORT DURATION SO HARD TO KNOW HOW THIS WILL PLAY OUT IN THE REAL WORLD OVER LONG TIME. ONE THING I WANT TO HIGHLIGHT, MANY META ANALYSES ARE HIGHLY POPULATED, SOMETIMES MORE THAN 80% OF THE STUDIES ARE BASED IN ASIA. AND THINKING ABOUT FOR EXAMPLE TAI CHI FOR OSTEOPOROSIS. THIS RAISES SOME PROBLEMS. WE KNOW BONE TURN OVER PROCESSES AND METABOLISM ARE DIFFERENT IN ASIAN WOMEN THAN IN AFRICAN AMERICAN CAUCASIAN OR HISPANIC WOMEN. SO THE TRANSLATABILITY OF THOSE STUDIES TO OUR POPULATIONS IS DIFFERENT. ALSO THE WAY THEY TEACH IN THESE DIFFERENT CULTURES MIGHT BE DIFFERENT ET CETERA. I THINK WE HAVE TO BE CAUTIOUS ABOUT INTERPRETING. MY CONCLUSION AND ALSO WHAT SEEMS TO COME FROM COCHRAN REVIEWSES AND MY COLLEAGUES IS THERE WERE TWO WHITE CONDITIONS, ONE FOR TAI CHI ONE FOR YOGA. SO TAI CHI FORMAL PREVENTION AND YOGA FOR LOWER BACK PAIN. EVERYBODY HERE APPRECIATES THAT STUDYING FALLS IN ELDERLY IS A HUGE PUBLIC HEALTH ISSUE. WE KNOW ONE OUT OF THREE ADULTS OVER THE AGE OF 65 FALL EACH YEAR, IN ADDITION TO THEIR INDIVIDUAL SUFFERING. ONE OF FIVE WILL HAVE A FRACTURE, DIED BECAUSE OF SEQUEL LAY, HUGE BURDEN TO THEM AND FAMILIES AND HUGE ECONOMIC BURDEN TO SOCIETY IN TERMS OF MEDICAL CARE COSTS. THESE ARE ONLY GOING UP BECAUSE OF OUR AGING SOCIETY. THERE'S ACTUALLY ROBUST EVIDENCE, I WAS SURPRISED, I NEITHER WAS COME BACK TO IT REALLY IMPRESSED BY THE QUALITY OF EVIDENCE OF TAI CHI FORMALS. THERE'S A 2019 COCHRAN REVIEW BY SHARINGTON, THIS LOOKED AT ABOUT SEVEN OR EIGHT STUDIES PRIMARILY OLDER ADULTS THAT ARE COMMUNITY DWELLING, RELATIVELY HOLDER ADULTS. YOU CAN SEE INCIDENT RISK RATIOS ARE ABOUT SUGGEST ABOUT 20% REDUCTION IN FALLS. POOLED ACROSS STUDIES. THERE'S SOME OTHER REALLY GOOD META ANALYSES THAT ARE BROADER, THIS ONE BY WONG AND COLLEAGUES. AND INCLUDES OTHER POPULATIONS THAT HAVE HISTORIES OF FALLS INCLUDING THOSE WITH NEUROLOGICAL CONDITIONS LIKE PARKINSON AND STROKE AND WHAT THEY FOUND WAS THAT THE INCIDENT RISK RATIO IS CLOSER TO 30%. IF YOU ARE INTERESTED IN THIS I RECOMMEND LOOKING AT A RECENT ARTICLE BY SAM NYMAND, BRITISH RESEARCHER, REALLY NICE COMPREHENSIVE REVIEW OF META ANALYSES. AND I THINK HE CONCLUDES AND I AGREE, MODERATE TO HIGH QUALITY THAT HAVE TAI CHI PREVENTS FALLS IN COMMUNITY SETTINGS. I DON'T MENTION THERE'S LITTLE DATA ABOUT PREVENTING FALLS FOR PEOPLE WHO ARE HOSPITALIZED OR LIVING IN ASSISTED LIVING FACILITIES. ONE RECENT STUDY WORTH HIGHLIGHTING IS SERIES OF PAPERS IN JAMA, INTERNAL MEDICINE AND NETWORK. OPEN NETWORK BY (INAUDIBLE) LEE AND THIS SPECIFICALLY STUDIES TAI CHI FOR BETTER BALANCE, A SPECIFIC PROTOCOL. THIS IS ROBUST TRIAL, THREE ARMS COMPARING TAI CHI PROTOCOL TO WHAT IS A MULTI-MODAL EXERCISE. SO SOME RESISTANCE TRAINING, BALANCE TRAINING, SOME AEROBICS AND COGNITIVE TRAINING. THE CONTROL IS SEATED STRETCHING. I WANT'S SIX MONTHS INTERVENTION. WHAT YOU CAN SEE HERE IS AFTER THE SIX MONTHS THE INCIDENT RISK RATIO IS REALLY AFFECTED SO THIS MEANS THAT 58% REDUCTION IN FALLS, WHEN YOU COMPARE TAI CHI OF STRETCHING, EVEN TO THE MULTI-MODAL COMPARISON IS ABOUT 30% REDUCTION. ALSO IMPRESSIVE WAS THAT IF THEY LOOK AT THESE OUTCOMES AT 12 MONTHS, INTERVENTION WAS SIX MONTHS BUT THEY FOLLOWED UP FOR 12 MONTHS. PARTICULARLY FOR SERIOUS INJURIES AND THERE'S 75% OF REDUCTION IN FALLS. LEE'S GROUP IS FEW WHO HAVE DONE IMPLEMENTATION RESEARCH. THIS IS EARLIER STUDY USING A SIMILAR PROTOCOL. THEY IMPLEMENTED IT IN OR TRIED IT OUT IN 35 SENIOR CENTERS IN OREGON, 48 PROGRAM, WELL ADOPTED BY 89% CENTERS OVER THAT PERIOD OF TIME. GOOD COMPLIANCE IN TERMS OF PETEING COMPLETING IT AND THEY REPLICATED WHAT THEY SAW IN CLINICAL TRIALS. YOU SEE STUDY FALL, 49% REDUCTION IN FALLS. THERE'S OTHER CONDITIONS THAT SHOW SOME PROMISE FOR TAI CHI. NO TIME TO GO INTO IT NOW BUT SOME OF THE ONES THAT STRUCK ME ARE CANCER SYMPTOMS, VARIOUS SYMPTOMS CANCER PARKINSON, GOOD EVIDENCE OSTEOARTHRITIS OF THE KNEE NETWORK AND BACK PAIN ARE PROMISING AS WELL AS COGNITIVE DECLINE AND SLEEP IS ALSO PROMISING. THERE IS A NICE SCOPING REVIEW THAT JUST CAME OUT BY BARTLETT IN CANADA AND I RECOMMEND LOOKING AT THIS IF YOU WANT TO GET A SENSE OF WHERE THE QUALITIES DATA IS. OF COURSE BACK PAIN IS ANOTHER PUBLIC HEALTH ISSUE AND MAKES SENSE TO LOOK AT NON-PHARMACOLOGICAL TREATMENT, IT'S A HUGE MORBIDITY DISABILITY HUGE MEDICAL COST ASSOCIATED WITH BACK PAIN. IMPORTANTLY IN THIS ERA MAYBE SPEAKING TO 'MAN DA'S WORK AS WELL HIGH RISK OF OPIOID MISUSE AND AMERICAN COLLEGE OF PHARMACY, PHYSICIANS RECOMMEND NON-PHARMACOLOGICAL POSITIONS INCLUDING YOGA AS A FIRST LINE TREATMENT. BY AND LARGE THE EVIDENCE FOR OWE GOO AND BACK PAIN IS NOTAS ROBUST AS TAI CHI IS FORMALS. SUSAN WYLAN DID A NICE REVIEW IN CHOCK RAN, 12 TRIALS, THIS IS A LITTLE DATED BUT ONE OF THE MOST RIGOROUS SUMMARIES. AND AT SIX MONTHS YOU SEE THIS MODERATE AFFECT SIZE WITH MODERATE QUALITY EVIDENCE. AT 12 MONTHS DOWN TO SMALLER EFFECT SIZE AND LOWER EVIDENCE, IMPORTANTLY THERE'S VERY SMALL EFFECTS ON PAIN. THIS IS AT CHANGES ON HUNDRED POINT SCALE. SO THESE ARE VERY SMALL AND PROBABLY OUTSIDE OF RANGE OF CLINICALLY MEANINGFUL. BUT THERE ARE NEW STUDIES THAT COME OUT, I WANT TO POINT ONE OUT, ONE A NICE STUDY BY ROBERT SAPER HERE AT BOSTON MEDICAL CENTER. A THREE ARM STUDY COMPARING YOGA TO PHYSICAL THERAPY TO EDUCATION CONTROL, IMPORTANTLY THIS HAS RECRUITED A VERY RACIALLY DIVERSE POPULATION INCLUDING LARGE NUMBERS OF AFRICAN AMERICAN AND HISPANIC PEOPLE SO IT'S IMPORTANT CONTRIBUTION TO OUR KNOWLEDGE BY INCLUDING DIVERSITY HERE. THE STUDY WAS DESIGN AS A NON-INFERIORITY STUDY, IS YOGA NON-INFERIOR TO PHYSICAL THERAPY MORE THE GOLD STANDARD FOR LOWER BACK PAIN IN TERMS OF NON-PHARMACOLOGICAL INTERVENTIONS. THE MAIN FINDING WAS YOGA WAS FOUND INFERIOR WITH RESPECT TO DISABILITY AND PAIN. WITHIN THOSE NON-INFERIOR BOUNDS. BUT THEY DID FIND THAT YOGA WAS NOT SUPERIOR. TO EDUCATION. HOWEVER IN SOME SECONDARY ANALYSES WHICH I THINK ALSO REVEAL IMPORTANT PARTS OF THE EVIDENCE THEY DID RESPONDER ANALYSIS, RESPONDERS DEFINED THOSE WITH GREATER THAN 30% RESPONSE BASELINE IN TERMS OF DISABILITY HERE. YOU CAN SEE THE 48% YOGA PARTICIPANTS HAD A POSITIVE RESPONSE VERSUS ONLY 23% OF THE EDUCATION. ODDS RATIO WAS -- STATISTICALLY SIGNIFICANT AND IMPORTANTLY THEY ALSO SHOWED THIS IMPACTED MEDICATION USE. YOU CAN SEE 12 MONTHS THERE WAS SIGNIFICANT REDUCTION IN YOGA AND PHYSICAL THERAPY. COMPARED TO THE EDUCATION GROUP. THERE ARE OTHER CONDITIONS OBVIOUSLY WHERE THERE'S SOME PROMISE FOR YOGA. THE EVIDENCE IS NOT AS DEVELOPED AS IT IS FOR LOWER BACK PAIN BUT CANCER SYMPTOMS SHOW UP IN LOTS OF GOOD REVIEWS. KRAMER AND OTHERS HAVE BEEN GOOD AT POOLING TOGETHER STUDIES IN GOOD VERY SOUND WELL DESIGNED META ANALYSES. COPD SHOWS QUITE GOOD PROMISE IN TERMS OF BREATHING AN ASTHMA, THERE IS A RECENT STUDY THAT CAME OUT BASED A AT THE MASS GENERAL HOSPITAL IN PSYCHIATRY DEPARTMENT BY SIMON AND COLLEAGUES, (INAUDIBLE) PART OF THAT SUGGESTING POSITIVE EFFECTS IN TERMS OF GENERALIZE ANXIETY DISORDER, STUDIES IN NECK PAIN. ONE THING I WANT TO SAY IN THINKING ABOUT MIND BODY MOVEMENT FROM MUSCULOSKELETAL ISSUES IS THAT NOT -- IT'S NOT UNCOMMON THAT THESE EFFECT SIZES ARE AT BEST MODERATE. AND THEY ARE INTERCHANGEABLE. SEEMS ACUPUNCTURE HAS EQUIVALENT EFFECT TO CHIROPRACTIC OR SPINAL MANIPULATION TO YOGA. WHAT HAPPENS IFYOU COMBINE? ARE THERE ADDITIVE OR SYNERGISTIC EFFECTS IN THERE'S ALMOST NOTHING IN THE LITERATURE SUGGESTING THAT. SO MAYBE YUM STREAM IN EFFECTIVENESS AND PRAGMATIC RESEARCH AREA, THIS IS AN AREA WE SHOULD PUT MORE ATTENTION TO. ONE APPROACH, I WANT TO GO BACK TO THE TWO METHOD LOGICAL CHALLENGES, FINISH UP BUT ONE APPROACH MY GROUP HAS DONE TO ADDRESSING THE ISSUE OF PLURALISM AND SOME DEGREE FINDING GOOD TEACHERS IS TO RELY ON COMMUNITY BASED INTERVENTIONS IN OUR PRAGMATIC CLINICAL TRIALS. THIS IS FROM A STUDY OF POST MENOPAUSAL WOMEN, WITH OSTEOPENIA, AND WE WANTED TO STUDY THEM OVER A NINE YEAR PERIOD SO IT'S HARD TO BRING THEM TO THE HOSPITAL ON A TUESDAY NIGHT ON A REGULAR BASIS FOR EXAMPLE. THIS IS VERY NOT PRACTICAL. WE DECIDED TO ACTUALLY USE EXISTING COMMUNITY BASED TAI CHI SCHOOLS. ALL THROUGHOUT THE BOSTON AREA. WE HAD VERY CLEAR ELIGIBILITY CRITERIA FOR THE SCHOOLS THAT HAD TO BE IN BUSINESS FOR A LONG TIME, TEACHERS FOR EXAMPLE TEACHING FOR TEN PLUS YEARS. THEY HAD TO COMPLY WITH SAFETY CONCERNS, HAD TO BE WILLING TO COMMUNICATE WITH STUDY TEAM ET CETERA. AND BUT THESE SCHOOLS WERE NOT ONE PARTICULAR PROTOCOL. SOME ARE YOUNG STYLE, SOME THE WU STYLE, ET CETERA. REFLECTED PLURALISM OF TAI CHI AND THIS IS WHAT I THINK IS RELEVANT FOR THE DISCUSSION TODAY. USING THIS APPROACH WHICH I DON'T THINK IS THE ONLY ONE DUE BUT IT AFFORDS SOME KIND OF GENERALIZABILITY. WE FEEL COMFORTABLE WITH OUR RESULTS GENERALIZABLE NOT JUST TO OTHER SCHOOLS IN THE BOSTON AREA THAT WE DID INCLUDE BUT ELIGIBLE. BUT TO OTHER CITIES ACROSS THE COUNTRY. IT ALSO ALLOWED US TO DO RAPID RAMP UP AND DR. CLARK MENTIONED THIS AS IMPLEMENTATION ISSUE. WE DIDN'T HAVE TO FIND TEACHERS AND TRAIN THEM THIS IN THE PROTOCOL AND MONITOR THEY WERE FOLLOWING THE PROTOCOL WITH EFFORT. THIS IS WHAT THEY DID. THEY WERE GOOD TEACHERS TO START WITH. AND THAT LED TO A QUICK RAMP UP. THERE WERE CONVENIENCE HAVING THESE ALL AROUND THE CITY, MADE IT EASY FOR PEOPLE TO CONTINUE CLASS. I THINK THESE PROGRAMS ARE ALL STILL THERE, THEY ARE SUSTAINABLE BY PICKING EXISTING SCHOOLS, AS OPPOSED TO CREATING A NEW PROGRAM AND SENIOR CENTER. IT'S MORE LIKELY TO BE STABLE OVER TIME. WE DIDN'T REALIZE AT TIME, NOT SURE IF I'M GETTING THE RIGHT BUT SOME DEGREE THIS WAS A HYBRID DESIGN BECAUSE IT WAS EXPLORING ISSUES OF EFFECTIVENESS BUT AT THE SAME TIME THEY GAVE US PRELIMINARY DATA ON RECRUITMENT OF SITES, WHAT RECRUITMENT OF PATIENTS WOULD BE ACROSS THESE SITES, RETENTION OF SITES AND PATIENTS HOW WELL THEY STUCK WITH THE PROTOCOLS, THEY DO AT THEIR SCHOOL, VERY PRACTICAL THINGS ABOUT BUILDING WRITING CONTRACTS AND FORMAL PARTNERSHIPS WITH THESE NON-ACADEMIC SITES. THE OTHER THING THAT DR. CLARK MENTIONED COUNT DENTALLY INCLUDED IS THIS IDEA OF USING VIRTUAL INTERVENTIONS. EVEN BEFORE COVID THIS IS JUST SOMETHING THAT WE HAVE ALL BEEN THINKING ABOUT BECAUSE IT'S AN OPPORTUNITY TO REACH PEOPLE WHO DON'T HAVE ACCESS TO METROPOLITAN AREAS. FOR EXAMPLE, TO GET INSTRUCTION IN A CAREFUL WAY. I THINK THE SHORT ANSWER IN TERMS OF EFFECTIVENESS RESEARCH RIGHT NOW IS THAT IT'S STILL UNDERSTUDIED. I THINK WHILE WE ARE GETTING SOME GOOD DATA ON DELIVERING VIRTUAL NEUROLOGY VISITS AND MEDITATION SEATED, THERE MAYBE EVEN ADDITIONAL SAFETY CONCERNS. I'M JUST ABOUT DONE HERE. AND I WANT TO SAY WE HAVE A COUPLE OF TRIALS GOING ON. I WON'T SAY MUCH BUT NCCIH IS FUNDING ONE AND WE HAVE WAYS OF USING WIRELESS SENSORS IN THE COMMUNITY TO MONITOR SAFETY AND QUALITY PERFORMANCE TO MAKE SURE THAT WHAT THEY ARE LEARNING IN A VIRTUAL ENVIRONMENT PARALLELS WHAT THEY MIGHT LEARN IN COMMUNITY BASED WAY. SO TO PULL IT ALL TOGETHER I THINK IT'S FAIR TO SAY THAT MIND BODY INTERVENTIONS ARE PROMISING FOR ENHANCING A LOT OF DOMAINS OF HEALTH, AND MAYBE IT'S THE MULTI-COMPONENT NATURE OF THESE INTERVENTIONS THAT AFFORD UNIQUE ADVANTAGES. AND I THINK SPECIFICALLY TODAY TAI CHI FORMALS AND YOGA AN BACK PAIN ARE WELL EVIDENCE AND GOOD CANDIDATES BUT THERE ARE OTHER MULTIPLE CONDITIONS THAT WEREN'T FURTHER RESEARCH -- WARRANT FURTHER RESEARCH. THE USE OF COMMUNITY BASED PRAGMATIC INTERVENTIONS IS ONE OPTION TO CONSIDER BUT KEEP IN MIND WE DID NOT DO THAT, THEY USED SEVEN INTERVENTION AND ALSO IN ROBESPIERRE'S PAPER, IN HIS BACK PAIN STUDY HE SUGGESTED THAT THE INTERVENTION THEY DID WOULD BE DIFFERENT THAN WHAT WOULD HAPPEN IN TYPICAL SCHOOLS AND PEOPLE WITH CHRONIC BACK PAIN NEED MORE FOCUS PROTOCOL. TELEDELIVERY IS OBVIOUSLY PROMISING, WARRANTS ADDITIONAL RESEARCH. I STILL WANT TO PUT IN A PLUG THOUGH WE ARE MOVING TO THE END OF THE TRANSLATIONAL SPECTRUM I THINK IT'S REALLY IMPORTANT TO KEEP THE OTHER END GOING. WE NEED DISMANTLING AND MECHANISM STUDIES, CURRICULUM DOSAGE TEACHING METHODS AND MIND BODY MOVEMENTS. AS WE OPTIMIZE THOSE, THOSE ARE GOING TO INFORM THE QUESTIONS WE ASK AND HOW WE DELIVER THINGS IN THE PATIENT SITES. SO THANKS FOR LISTENING. SO SAD TO MIGHT BE ABLE TO SEE PEOPLE IN THE AUDIENCE THESE DAYS. >> I AM PRESUMING THEY ARE ALL CLAPPING AND STANDING OVATION HERE. THAT WAS A GREAT PRESENTATION. THANK YOU SO MUCH. IF I CAN GET YOU TO STOP SHARING AND TO AMANDA, IF YOU WANT TO JUMP IN, AS YOU ARE DOING THAT, AMANDA, I'M NOT SEEN THE QUESTIONS YET THAT ARE COMING IN BUT I AM PRESUMING, MY PSYCHIC IS TELLING PEOPLE ARE ASKING IF THE SLIDES WILL BE AVAILABLE. IT IS NOT OUR PLAN TO MAKE THE SLIDES AVAILABLE BUT THIS IS AS KATHERINE LONG MENTIONED AT THE BEGINNING ARCHIVED SO YOU CAN WATCH AT YOUR LEISURE AND PAUSE AT ANY SLIDE OR SLIDE THAT YOU LIKE. AMANDA, TURNING OVER TO YOU. ONE SECOND. STILL MUTED. THANK YOU VERY MUCH FOR THAT ASSIST. APPARENTLY IF I SHARE MY SCREEN, MY OPTION TO UNMUTE GOES AWAY. I'M ALWAYS LEARNING. THAT WAS REALLY FASCINATING TO HEAR. AND TO GET THAT UP TO DATE COMPREHENSIVE SUMMARY ON CIH INTERVENTIONS PARTICULARLY AROUND TAI CHI AND FALL FOR LOW BACK PAIN, I DEFINITELY KNOW LESS ABOUT THOSE AREAS IN TERMS OF EVIDENCE. SO THIS IS REALLY INTERESTING FOR ME. THEN ONE LITTLE SWITCH HERE. PERFECT. SO I'M ALSO EXCITED TO BE PART OF THIS TODAY, SET OF PRESENTATIONS. AND TALK HEAVILY ABOUT IMPLEMENTATION SCIENCE AND HOPEFULLY LEAVE IN SOME DISCUSSION ESPECIALLY DURING THE Q&A SESSION OF WHERE WE MAY BE ABLE TO GO. SO TODAY I WOULD LIKE TO TALK ABOUT KEY DOMAINS THAT I BELIEVE ARE CRITICAL TO SUCCESSFUL IMPLEMENTATION TRIALS AND GRANT PROPOSALS. PARTICULARLY HIGHLIGHTING CHALLENGES AND OPPORTUNITIES IN CIH INTERVENTIONS. I KNOW WE HAVE LIMITED TIME TODAY SO MY PLAN IS REALLY TO PIQUE YOUR INTEREST AND HOPEFULLY GET YOU THINKING ACROSS MULTIPLE DOMAIN WHILE PRORIDING A LOT OF RESOURCES THAT YOU CAN FOLLOW-UP ON IN YOUR OWN TIME. PROVIDING. AND FOR ANYONE WHO IS FEELS LIKE THEY ARE AN EXPERT IMPLEMENTATION SCIENCE HOPEFULLY I'M NOT TOO REDUNDANT, IT'S A NICE REFRESHER BUT ALSO I WILL GIVE YOU SOME EXTRA RESOURCES YOU DIDN'T KNOW ABOUT. NO DISCLOSE INSURES. THE OVERARCHING GOAL OF MY PRESENTATION IS DESCRIBE BREADTH NOT TOO IN DEPTH, A BREADTH OF DOMAIN RELEVANT TO IMPLEMENTATION SCIENCE STUDIES AND THE REASON I'M ALSO GOING FOR BREADTH IS BECAUSE OF SOME OF THE GRANT REVIEW PANELS THAT I HAVE SAT ON THE LAST COUPLE OF YEARS I NOTICED EVEN WITH SEASONED RESEARCHERS NEWER TO IMPLEMENTATION SCIENCE OR SHIFTING THEIR AREA OF RESEARCH IN THAT DIRECTION THEY WERE MISSING A LOT OF KEY DOMAINS IN THEIR PROPOSALS AND I WANT THE MAKE SURE THIS IS OUT THERE AS WE THINK ABOUT HOW TO DO IMPLEMENTATION SCIENCE WORK IN CIH INTERVENTION. I'M GOING TO HIGHLIGHT A LITTLE BIT TOWARDS THE END. WHERE I HOPE THIS WILL SEGUE NICELY INTO AFTER THE PRESENTATION AFTER ME IN THE Q&A TALK MORE ABOUT CONCRETE WAYS TO DESIGN AN IMPLEMENTATION TRIAL FOR CIH INTERVENTION BUT I WILL DISCUSS OPPORTUNITIES AND CHALLENGES WITH A GIVEN CIH INTERVENTION. SO THE BREADTH OF DOMAINS I WILL BE COVERING TODAY INCLUDE THESE FIVE DOMAINS. I WANT TO HIGHLIGHT MINORITY OF THE STUDY DESIGNS THAT ARE OUT THERE I THINK RELEVANT FOR THIS AUDIENCE, RELEVANT FOR CIH INTERVENTIONS BUT THEY ARE BY NO MEANS EXHAUSTIVE. I WANT TO HIGHLIGHT THE USE OF MIXED METHODS I NOTICE ALSO IN SOME OF THE GRANTS REVIEW OVER THE YEARS IS USUALLY ONE SIDE STRONG ONE METHOD AND NOT SO MUCH THE OTHER. QUALITATIVE OR QUANTITATIVE AND DON'T ALWAYS INTEGRATE THEM SO I WILL TALK ABOUT USE OF MIX METHODS AS WELL AS HIGHLIGHTS AND RESOURCE FOR HOW TO OPTIMALLY USE MIX METHODS. AND I WANT TO HIGHLIGHT YOU WILL WANT TO SERIOUSLY THINK ABOUT WHAT STAGES OF IMPLEMENTATION YOU WILL BE TARGETING. IT IS INTERESTING WHEN I SEE GRANT PROPOSALS I FEEL LIKE HAY SKIP OVER PRE-IMPLEMENTATION OR DEVELOPMENTAL STAGE. THEY JUST WANT TO GET THE THING IN. PRACTICE OR THEY UNDERESTIMATE AMOUNT OF TIME SO I WANT TO SPEND TIME ADDRESSING THERE ARE DIFFERENT STAGE AND DIFFERENT WAYS PEOPLE HAVE CONCEPTUALIZED THE STAGES OF IMPLEMENTATION AND I'M SURE THERE WILL BE MORE WORK ON THAT IN THE FUTURE. I ALSO WANT TO ADDRESS COMMON PITFALLS IN SELECTION OR SOMETIMES LACK OF SELECTION OF THEORIES MODELS AND FRAME WORKS IN GRANTS INCLUDING -- I WON'T GET TOO INTO THE WEEDS OF THIS AGAIN BUT SOMETIMES HOW THE THEORY FRAMEWORK OR MODEL IS NOT REALLY INTEGRATED INTO THEIR WORK. IT'S MENTIONED ON THE SURFACE LEVEL. FINALLY I WANT TO HIT ON THE RANGE OF IMPLEMENTATION STRATEGIES THAT ARE OUT THERE. NOTING THAT WE CAN ADAPT AND TAYLOR HEM TO THE NEEDS OF THE SITES AS NEEDED. I FELT LIKE THOSE TALKS HINTED AT THIS AS WELL AS OTHER THINGS I'M MENTIONING, BOTH TALKS. FINALLY I DO NOT HAVE THE TIME, I WANT TO HIGHLIGHT THIS IN ADVANCE TO TALK ABOUT THE IMPORTANCE OF EVALUATING COST IMPLEMENTATION. I KEPT HIMMING AND LAWING ABOUT WHETHER TO INCLUDE IT, SEEMED LIKE NOT QUITE ABLE TO INC. IT IN THERE. SO I JUST WANT TO NOTE THERE ARE GROWING NUMBER OF PAPERS RELATED TO ASSESSING COST AND IMPLEMENTATION WHICH IS KEY DEPENDING ON FUNDERS WANT TO KNOW THIS, PARTNERS WANT TO KNOW THIS. IT'S REALLY BURGEONING. MANY GRANT PROPOSALS WILL START TO REQUIRE THAT. SO LET'S GO AHEAD AND TALK A LITTLE BIT ABOUT STUDY DESIGN POSSIBILITIES THAT ARE OUT THERE. I'M GOING TO ENCOURAGE YOU THE READ WHEN YOU GO TO THE END OF MY SLIDE THERE IS A REFERENCE LIST, FIRST ARTICLE IS A REALLY NICE ONE. BUT I ALSO WANT TO ENCOURAGE FOLKS TO READ PROTOCOL PAPERS THAT ARE OUT THERE. ANOTHER THING OVER THE LAST FIVE YEARS THAT HAS ESCALATED IN TERMS OF WHAT'S OUT THERE, I HAVE A PROTOCOL PAPER OUT THERE, NOT THAT MY STUDY ENDED UP GOING EXACTLY AS DESCRIBED MANY THE PROTOCOL PAPER. BUT PROTOCOL PAPERS ARE SUCH A FABULOUS RESOURCE FOR FIGURING WHO U YOU MIGHT WANT TO DO YOUR OWN TRIAL. I DID LOOK FOR ANY PROTOCOL PAPERS QUICKLY FOR CIH INTERVENTIONS ANT I DIDN'T FIND ANY THAT FIT THAT EXACTLY WHICH IS AGAIN SPEAKING TO NEED OF THIS SET OF PRESENTATIONS. BUT I WANTED TO NOTE THAT BEFORE I DIVE INTO THIS NEXT FIGURE. THIS FIGURE RALEIGH ADDS TO WHAT DAVE WAS PRESENTING WHICH HIGHLIGHTS THE IMPORTANCE OF UNDERSTANDING WHERE YOU ARE IN YOUR WORK. BEFORE YOU GET -- YOU PICK WHICH RAF YOU APPLY FOR OR FUNDING ANNOUNCEMENT THINK WHERE IS THIS WORK SOMEWHERE IS THE EVIDENCE BASED PRACTICE? IN TERMS OF EVIDENCE, OR THE INTERVENTION IN TERMS OF EVIDENCE AND READINESS FOR IMPLEMENTATION. THAT'S THE FIRST MAIN QUESTION. NOTE THE Y AXIS IS THE REAL WORLD RELEVANCE AND X AXIS IS TIME. ARE YOU IN THE BOTTOM LEFT HAND CORNER OF UNDERSTANDING IF A PROGRAM OR INTERVENTION MIGHT WORK? THEN PROBABLY NOT READY YET FOR IMPLEMENTATION SCIENCE. DO YOU HAVE A NOVEL IDEA FOR WHICH THERE'S BEEN EFFICACY WORK? MOST LIKELY IN THE PRE-INTERVENTION STAGE. HOPEFULLY WE WILL GET TO TESTING EFFICACY OF THE INTERVENTION AND TESTING EFFECTIVENESS STUDIES. EFFECT CHASSI STUDY NOT TOO REDUNDANT WITH DAVE'S PRESENTATION BUT THERE'S NOT ENOUGH REMINDERS OF THIS, FOCUSED ON INTERVENTION WORK IN VERY CONTROLLED CONDITIONS AN EFFECT ACTIVENESS INTERVENTIONS ARE TESTED IN COMMUNITIES, ORGANIZATIONS WHERE IS THEY WOULD IDEALLY BE DELIVERED GIVING SOME INSIGHT TO WHETHER THIS WILL WORK IN REAL WORLD CONDITIONS. THE IMPLEMENTATION WORK IS REALLY AROUND WHAT WILL ACTUALLY HAPPEN IN COMPLEX PATIENT POPULATIONS AND IT CAN BE VERY DIFFERENT THAN THOSE TWO PREVIOUS STAGE. IS VERY DIFFERENT IN FACT. SO YOU SEE THAT YELLOW BOX UP THERE IN THE TOP CORNER, I FEEL LIKE IT'S MORE A BLACK BOX SOMETIMES WHEN TRYING TO IMPLEMENT BUT IT IS FOCUSED HOW TO MAKE A PROGRAM OR INTERVENTION WORK. WHAT IMPLEMENTATION STRATEGIES GET THE PRACTICE OR INTERVENTION IN PLACE AN MORE IMPORTANTLY, HOW CAN WE SUSTAIN IT? HOW CAN IT BE SUSTAINED AT THE SITE. THE LATTER IS ACTUALLY JUST A QUICK NOTE OFTEN LEFT OUT OF TRADITIONAL GRANT PROPOSALS BUT THIS IS CHANGING. I DO HIGH LIE RECOMMEND THIS PAPER PUBLISHED IN THE END REVIEW OF PUBLIC HEALTH BY BROWN AND COLLEAGUES. AS I NOTED AT THE BEGINNING THIS IS NOT EVEN CLOSE TO A COMPREHENSIVE SUMMARY OF THE POSSIBLE DESIGNS OUT THERE AND IF YOU DON'T GO TO THE ARTICLE YOU WILL SEE MORE. IT ONLY REPRESENTS MINORITY BUT I WANT TO HIT ON HYBRID FACTORIAL DESIGN FOR THE GROUP BECAUSE FORMER IS LIKELY IN CIH PROPOSAL AS DR. WAYNE NOTED HE DIDN'T REALIZE HE HAD BEEN MORE HYBRID WORLD, NOTICED THAT WITH PRAGMATIC TRIALS, IS THERE ACCORDING TO HYBRID WORLD OR PART OF THE HYBRID WORLD. HYBRID TYPE ONE TYPICALLY. THEN I WANT THE HIGHLIGHT FACTORIAL DESIGNS SO YOU CAN HIT ON THE FACT THAT WHILE THERE'S A LOT OF FEELS LIKE THE WILD WEST IN MANY WAYS BURGEONING FIELD AND RELATIVELY NEW FIELD OF IMPLEMENTATION SCIENCE, THERE ARE VERY PRAGMATIC AND RIGOROUS WAYS TO CONDUCT IMPLEMENTATION TRIALS. LET'S FOCUS ON HYBRID DESIGNS BRIEFLY BECAUSE I ONLY HAVE TEN MINUTES. JEFF AND COLLEAGUES WROTE THIS GROUND BREAKING PAPER THAT DAVE REFERENCED BACK IN 2012, IT WAS REALLY AN ANSWER TO THE PUSH PULL OF WHEN IS THERE ENOUGH EVIDENCE TO IMPLEMENT PRACTICE, DOESN'T MEAN THERE'S NOT A LOT OF DEBATE. THERE'S STILL DEBATE WHICH TRIAL YOU ARE INTERVENTION MIGHT FIT FOR BUT JUST KEEP IN MIND THAT'S WHY YOU WRITE A COMPELLING RATIONALE ON YOUR GRANT PROPOSAL, SHOWING THAT YOU HAVE CONSIDERED WHICH HYBRID TYPE BEST SUITED FOR THE INTERVENTION, ET CETERA. AND INCLUDING IF YOU ARE IMPLEMENTING IN A NEW SETTING SO SOMETIMES WITH EVIDENCE BASE PRACTICE OR INTERVENTION YOU THINK IT MUST BE A TYPE THREE BUT SOMETIMES WHEN DOING A NEW SETTING OR NEW PATIENT POPULATION THAT HASN'T BEEN AS HEAVILY STUDIED IT MIGHT BE A TYPE ONE OR TYPE TWO YOU ARE BLENDING MORE EFFECTIVENESS TESTING. IT JUST DEPENDS ON THE DIVERSION COMMUNITY SETTING. SO FOR EXAMPLE TAKING SOMETHING THAT'S ONLY BEEN TESTED IN ADULTS AND TARGETING CHILDREN IN SCHOOLS, IT MAYBE VERY EFFECTIVE IN ADULTS, YOU NEED TO PROBABLY DO MORE HYBRID TYPE ONE. T THEN I WANT TO -- ENOUGH ABOUT HYBRID TRIALS OR HYBRID DESIGNS, I WANT TO HIGHLIGHT FACTORIAL DESIGNS OUT THERE, INCLUDING MULTI-PHASE OPTIMIZATION STRATEGY FOR OR MOST. IT IS ONE I SEE A LITTLE LESS IN PRACTICE THAN BELOW IT BUT IT RECOGNIZES THAT IMPLEMENTATION STRATEGIES CAN VARY IN NUMBER OF STRATEGIES USE AS WELL AS INTENSITY MAKING IT HARD TO TEST THAT IN A SINGLE DESIGN. SO MOST DESIGN ATTEMPTS TO REFIND IMPLEMENTATION STRATEGY APPROACH TO BE FURTHER REFINE SECOND STAGE AND THEN EVALUATED IN RANDOMIZE IMPLEMENTATION TRIAL. THAT'S AN INTENSIVE PROCESS. HAPPY TO MAKE TALK MORE LATER BUT NICE WAY TO OPTIMIZE WHAT YOU ARE TRYING TO DO IN TERMS OF IMPLEMENTATION WORK AND RIGOROUSLY EVALUATE IT. THE SMART TRIAL OR SEQUENTIAL MULTIPLE ASSIGNMENT RANDOMIZE TRIAL IS UNIQUE CASE FACTORIAL EXPERIMENT WITH MULTI-STAGE RANDOMIZATIONS WHERE IMPLEMENTATION STRATEGIES OR PROCESS CAN BE MODIFIED IF UNSUCCESSFUL. SORT FOR EXAMPLE YOU CAN ASSIGN SITES LARGE NUMBER BECAUSE YOU WANT TO BE POWERED APPROPRIATELY TO INITIAL LOW INTENSITY OR STREAMLINED IMPLEMENTATION STRATEGY AND FOR NON-RESPONDERS AFTER A CERTAIN PERIOD OF TIME SOMETIMES SIX TO NINE MONTHS YOU CAN RANDOMIZE TO RECEIVE ORIGINAL IMPLEMENTATION OR ONE THAT ADDS MORE STRATEGIES OFTEN TIMES WHAT YOU SEE IS INTRODUCTION OF FA I WILL IS DAY TORR WHO GETS WITH THE SITES IN INTENSIVE WAY TO PROBLEM BARRIERS COMING UP. THIS ALLOWS YOU TO ADDRESS PASSAGE OF TIME THAT MAKES IT EVENTUALLY EFFECTIVE, IMPLEMENTATION OF THE INTERVENTION OR NEW STRATEGY EMPLOYED. YOU CAN POTENTIALLY HAVE SUBSEQUENT ADAPTATIONS AND STAGE DEPENDING ON YOUR POWER. SO THIS CAN GO FOR A WHILE. SO LET'S TALK ABOUT METHODS. THERE ARE VARIETY OF QUALITATIVE AND QUANTITATIVE METHODS AND ALSO MAKE SURE YOUR TEAM HAS SAVVY IN BOTH IF DOING LARGE IMPLEMENTATION TRIAL. THEY ARE FROM MY EXPERIENCE ONES I SEE MOST OFTEN IN IMPLEMENTATION TRIALS, DOESN'T MEAN YOU HAVE TO USE MIX METHODS BUT THERE'S RESOURCES INCLUDING A COUPLE SITED IN MY REFERENCES THAT YOU CAN REFER TO TO FIGURE OUT WHAT MIGHT WORK BEST FOR YOU. YOU OFTEN HAVE SEMISTRUCTURE INTERVIEWS, I HAVE LISTED THIS IN WHAT I HAVE SEEN MOST FREQUENTLY TO LEAST FREAKILY. BUT YOU OFTEN HAVE SEMISTRUCTURE INTERVIEW GUIDES STRUCTURED ACCORDING TO THEORY OR FRAMEWORK AND/OR ANALYTIC STRATEGY FOR INTERVIEWS IN TEXT, ALSO USUALLY USING A THEORY INFORMED APPROACH AND MANY TIME ALSO INFORMAL INTERVIEWS WHICH ARE RECORDED OR ANALYZED. WHICH ARE NOT OFTEN RECORDED OR ANALYZED BUT PROVIDE RICH INFORMATION. USUALLY THEY ARE NOT PART OF THE PROPOSAL BUT PROVIDE RICH INFORMATION TO HELP UNDERSTAND KEY ORGANIZATIONAL OR PERSONNEL FACTORS THAT OCCUR T A SITE. FOCUS GROUPS MAYBE SITUATIONS WHERE YOU HAVE COMMON STAKEHOLDERS REQUIRED THE COMPLETE A GIVEN INTERVENTION AND IT CAN BE THE MOST EFFICIENT WAY TO GET KEY STAKEHOLDERS TO ADDRESS BARRIERS AN DISCOVER FACILITATORS THAT YOU MAYBE ABLE TO LEVERAGE FOR IMPLEMENTATION BUT HARD TO GET EVERYONE RELEVANT TO MEET AT GIVEN TIME POINT. AS YOU OFTEN GATHER INFORMATION YOU OFTEN DISCOVER RELEVANT FOLKS LEADERS, ET CETERA, SO YOU END UP DOING MORE SEMISTRUCTURE INTERVIEWS AFTER THE FOCUS GROUP. ETHNO GRAPHIC OBSERVATION METHODS ARE ALSO USED SOMETIME PARTICULARLY IF YOU HAVE A COMPLICATED INTERVENTION. YOU ARE PARTICULAR I WILL CONCERNED HOW TO INCORPORATE TO WORK FLOW. THAT IS MORE INTENSIVE, RESOURCE INTENSIVE BUT ANOTHER ONE USED. THEN THERE ARE A VARIETY OF QUANTITATIVE MEASURES, I AM IN THE VA SO WE HAVE HAD OVER 230 YEARS ELECTRONIC MEDICAL RECORDS SO WE ARE LOUD WITH IRB APPROVAL TO PULL THE APPROPRIATE ELECTRONIC MEDICAL RECORD DATA PATIENT DATA WHICH IS WONDERFUL. LESS BURDENSOME TO PATIENT TYPICALLY AND LOOK AT DIFFERENT OUTCOMES BUT WE ARE OFTEN COLLECTING DATA THROUGH SURVEY OR QUESTIONNAIRES. I ONLY HAVE FIVE MINUTES SO I WANT TO MAKE SURE HIT ON EVERYTHING SO STAGES OF IMPLEMENTATION. THE MOST BROAD SENSE IF I CAN HAVE FOLKS THINK ABOUT THESE, YOU HAVE THREE PHASES. I WOULD SAY PROBABLY THE ONE THAT GETS FORGOTTEN THE MOST WRITING GRANT PROPOSALS SUSTAINMENT PHASE, PEOPLE ARE SO EXCITED TO GET EVIDENCE BASE PRACTICE IN THERE. THE LAST THING THEY ARE THINKING IS HOW IS IT GOING TO STAY THERE. BUT BASICALLY YOU ARE IN THE BROADEST SENSE YOU HAVE PREIMPLEMENTATION, IMPLEMENTATION AND SUSTAINMENT. AND IF I CAN GET FOLKS WHEN THEY WRITE PROPOSALS TO THINK IN THOSE TERMS, THAT IS FANTASTIC. THERE IS ANOTHER ONE CALLED EPIS WHICH INCLUDES FORCE PHASES OF EXPLORATION, PREPARATION, IMPLEMENTATION AND SUSTAINMENT SO BREAKING UP THAT FIRST PRE-IMPLEMENTATION STAGE. PREPARATION MEANS YOU ARE STARTING TO PUT IN PLACE COLLABORATION, SUPPORT AND OTHER PROCESSES GOING AT THE SITE THEN TRAINING THE LOCAL PERSONNEL AND DELIVERY OF THE INTERVENTION AND PUTTING IN PLACE WHATEVER SUPPORT PROCESSES ARE NEEDED TO EXECUTE THE INTERVENTION INCLUDING REFERRALS, NOTE THEM PLACE, ET CETERA. SUSTAINMENT IS WHAT HAPPENS WHEN YOU ARE NOT THERE TO HELP THE SITE AND YOU HAVE DONE THE WORK TO HOPEFULLY GET FUNCTIONING ON THEIR OWN WITH INTERVENTION IN PLACE. I WILL QUICKLY REFERENCE THIS INTERESTING STAGES OF IMPLEMENTATION COMPLETION BY LISA AND COLLEAGUES. IT BREAKS DOWN INTO EVEN MORE FINE GRAIN SET OF STAGE AND WHEN DR. WAYNE WAS TALKING I WAS THINKING ABOUT HOW I FEEL LIKE I WOULD BE INTERESTED LOOKING AT YOGA OR TAI CHI AND PLURALISM ISSUE, ONE OBVIOUSLY THINK ABOUT THAT A LOT AHEAD OF YOUR TRIAL AND WHAT'S THE MOST EFFECTIVE APPROACH, BUT IF YOU ARE NOT ABLE TO DO COMMUNITY BASED INTERVENTION LEVERAGING PEOPLE WHO ARE CERTIFIED ET CETERA, SPEND A LOT OF TIME ON STAGES FOUR. AND WHEN YOU WANT TO THINK FIDELITY YOU WANT TO THINK ABOUT FIDELITY NOT JUST TO THE INTERVENTION OF YOGA TAI CHI FOR EXAMPLE BUT ALSO IMPLEMENTATION STRATEGIES. BUT THAT IS LESS WHAT WE ARE TRYING TO COVER NUMBER FIVE, THAT IS A TEASER FOR SOMETHING TO TALK ABOUT LATER. SO REALLY QUICKLY I'M ALSO GOING TO HIT ON VAIRIUS MODELS AND FRAME WORKS. AND I JUST WENT AHEAD ON ONES I SEE OFTEN, LIKE WE HAVE HEARD OF FOR SURE CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH ORIGINALLY ACCOMPLISHED BY LAURA AND COLLEAGUES BACK IN 2009 HAS BECOME POSSIBLY MORE WIDELY CITED THAN REAIM FRAME WORK BY RUSS GLASCOW AND COLLEAGUES. NECK AND NECK FOR CITATIONS. SOME FOLKS ALSO HEARD OF PARIS OR iPARIS, THE ONE I WILL SEE USED MOST THIRD MOST FREQUENTLY IN THINGS I HAVE REVIEWED. BUT I WANT TO HIGHLIGHT A REALLY INTERESTING PAPER THAT CAME OUT IN 2015 BUT KNEELSON AND IT ADDRESSED A REALLY IMPORTANT GAP IN UNDERSTANDING HOW MAKE SENSE OF THEORETICAL APPROACHES AN IMPLEMENTATION SCIENCE. SO PROCESS MODELS YOU CAN SEE FIGURE FOR GUIDING TROUGH PROCESS OF TRANSLATING RESEARCH INTO PRACTICE. CLASSIC THEORY DETERMINANT FRAME WORKS AND IMPLEMENTATION THEORIES ARE GOOD FOR EXPLAINING INFLUENCES IMPLEMENTATION OUTCOMES. SOMEWHERE IN THAT GROUPING WITH THE FRAMEWORK THAT'S WHERE I SEE MOST OFTEN. AND IF YOU WANT TO EVALUATE YOUR IMPLEMENTATION YOU CAN CHOOSE EVALUATION FRAMEWORK. I'M GOING TO HEAD TO THE NEXT SLIDE WHICH IS THE TABLE AND THIS IS A LITTLE DENSE AND I'M NOT GOING TO READ EVERYTHING. AS YOU CAN SEE THIS BREAKS IT DOWN VERY NICELY INTO WHAT ARE THE DIFFERENCES THAT IT'S NOT THAT SOMETIMES THEY CAN'T BLEED INTO ONE ANOTHER BECAUSE THEY DO FOR EXAMPLE, SOMETIMES I RELY ON CLASSIC THEORIES INCLUDING SOCIAL COGNITIVE THEORY TO HELP ME THINK ABOUT WHAT I HAVE BEEN DOING WITH MY DETERMINANT FRAMEWORK. A NICE HANDY REFERENCE FOR THOSE WHO ARE REALLY FEELING LIKE THEIR HEAD SPINNING FROM NUMBER OF LITERATURE IN TERMS OF LOOK AT THEORETICAL APPROACHES AND THE NUMBER OF THEORETICAL APPROACHES. THERE'S QUITE A FEW ON THIS SIDE. ON THE RIGHT SIDE AND IT IS A LOT TO TAKE IN. IMPLEMENTATION STRATEGIES. DAVE ALSO HIGHLIGHTED THAT APTLY IN HIS PRESENTATION. I I LIKE THE TARGET ON THE PIN. I WOULD SAY THAT THAT IS VERY COMMON THAT PEOPLE HAVE NOT THOUGHT THROUGH WHAT THEY WILL USE AS IMPLEMENTATION STRATEGIES WHICH IS WHY INCLUDED TWO KEY ARTICLE HERE. I DIDN'T WANT TO INCLUDE A LOT HERE. BECAUSE THERE ARE A LOT OF IMPLEMENTATION STRATEGIES. FIRST ON THE LEFT, KEY IN EVERY GRANT PROPOSAL ANYTHING YOU WRITE IS REALLY SPECIFYING WHAT YOUR DISCRETE IMPLEMENTATION STRATEGIES ARE. SO DON'T SAY YOU ARE USING FACILITATION. WHAT ARE USING STRATEGIES WITHIN THE FACILITATION YOU ARE USING. THE ARTICLE ON THE LEFT REALLY SET THE GROUND WORK FOR THE EVENTUAL ERIC PROJECT. THAT USED A MODIFY DELPHI PROCESS TO IDENTIFY 75 IMPLEMENTATION STRATEGIES. ONE OF THE MANY PARTICIPANTS IN THIS PROCESS. IT WAS CHALLENGING. WHAT I'M WOULD LIKE TO DO IS RECOMMEND YOU REVIEW THE ARTICL IF AVENUES AND REVIEW LITERATURE ON IMPLEMENTATION STRATEGIES INCLUDING A GROWING BODY OF STUDIES THAT HAVE USED THIS LIST OF 73. TO IDENTIFY WHAT IS BEING USED IN SETTINGS WITH THAT SAID, WE DON'T MOVE FORWARD IN PLANNING IMPLEMENTATION TRIALS BY EXTRACTING EXACTLY WHICH OF THE 73 STRATEGIES MOST RELEVANT FROM THIS LIST, IT WOULD BE EXHAUSTIVE AND UNPRODUCTIVE. KEY THINGS TO THINK ABOUT ARE WHAT ARE IMPLEMENTATION STRATEGIES WHAT EVIDENCE IS THERE FOR THEM AND HOW YOU USE THEM? WHAT EVIDENCE IS NOT JUST THERE FOR YOUR INTERVENTION, BUT ALSO YOUR IMPLEMENTATION STRATEGIES. IS THERE EVIDENCE THAT THIS IS USED IN ANY OF THE STUDIES IN THE SETTINGS WHERE YOU ARE INTERESTED IN IMPLEMENTING IN FOR SIMILAR TYPE OF INTERVENTION I KNOW I'M STARTING TO GO OVER ON TIME SO GOING TO TRY TO WRAP UP QUICKLY. I'M ALSO HIGHLIGHTING A VA RESOURCE, I DON'T KNOW OF AN EQUIVALENT RESOURCE IN THE COMMUNITY BUT NATIONAL QUALITY ENHANCEMENT RESEARCH INITIATIVE PROGRAM WHICH FUNDS OUR IMPLEMENTATION SCIENCE WORK IN THE VA ALSO FUNDED IMPLEMENTATION STRATEGY TRAINING HUBS. I'M MOST FAMILIAR WITH THE IMPLEMENTATION FACILITATION. I KNOW THE COLLEAGUES WELL BECAUSE I USE IMPLEMENTATION FACILITATION OFTEN. I KNOW THESE FOLKS ARE VERY FRIENDLY AND HAPPY TO SHARE THEIR RESOURCES. SO IF ANYONE IS INTERESTED IN ANY OF THESE TYPES OF IMPLEMENTATION STRATEGIES OUT THERE WHICH AGAIN ARE USUALLY BUNDLED, PACKAGES OF IMPLEMENTATION STRATEGIES THERE'S SOME EVIDENCE FOR, I'M SURE THEY ARE HAPPY TO PROVIDE INFORMATION ABOUT THESE STRATEGIES. WE WILL GET INTO TALKING ABOUT OPPORTUNITIES AND CHALLENGES IN THE CASE I WAS GOING TO HIGHLIGHT YOGA BECAUSE I HAPPENED TO KNOW MORE ABOUT IT AND I DO MORE PAIN WORK SO I OPT NOT TO HIGHLIGHT THE TAI CHI NOT BECAUSE ONE IS BEAR THAN OTHER. BUT THESE ARE INITIAL QUESTIONS START TO DEGREE FOLKS THINKING THROUGH QUESTIONS NEED TO BE ANSWERED IF YOU ARE DOING IMPLEMENTATION TRIALS. AND THEN I'M GETTING CLOSER TO WRAPPING UP. SOP BACKWARDS. BECAUSE MORE YOU KNOW THE BETTER IT WILL BE TO MOVE FORWARD IN YOUR PROPOSALS. I HIGHLIGHTED A VARIETY OF OF RESOURCES IN THE VA WE HAVE IMPLEMENTATION RESEARCH GROUPS THAT MEET USUALLY MONTHLY. AND WONDERFUL RESOURCES OF EXPERT MS. THE FIELD. A LOT OF NON-VA FOLKS PRESENT ON THESE TO BE CLEAR. IN A VARIETY OF AREAS. NON-VA MANY OF YOU MAY BE AWARE OF SOME OF THE NCI ONES AS WELL AS CENTER FOR PREVENTION IMPLEMENTATION METHODOLOGY FOR DRUG ABUSE AND HIV. THEY DO NOT HAVE IMPLEMENTATION WEBINAR, BUT VERY GOOD. TALKS AND THEN THERE'S NUMBER OF TRAINING OPPORTUNITIES AS WELL AS DAVE HAD MENTIONED IMPLEMENTATION SCIENCE JOURNALS THAT YOU MAY PERUSE WHEN THINKING ABOUT STUDY, THIS IS A COMPREHENSIVE LIST SO YOU CAN LOOK FOR YOUR GO TO FAVORITE. THEN BECAUSE THIS IS A VERY TIMELY SPECIAL ISSUE IN MEDICAL CARE THAT CAME OUT, INCLUDING ARTICLE BY ONE OF MY COLLEAGUES I WANT TO HIGHLIGHT THIS JOURNAL. WHILE I IT DOESN'T FOCUS ON IMPLEMENTATION TRIALS IN THE VA BUT THE STUDIES IN THERE WILL HAVE A LOT OF FINDINGS RELEVANT FOR IMPLEMENTATION TRIALS FOR CIH, ESPECIALLY LARGE SCALE HEALTHCARE SYSTEM. SO THE LINK ON THE BOTTOM WILL TAKE YOU TO THE ACTUAL SPECIAL ISSUE. THEN I KNOW WE HAVE Q&A COMING UP EVENTUALLY AND I WILL HIGHLIGHT THESE REFERENCES. ONE REFERENCE I WANTED TO HIGHLIGHT MORE IN THE METHODS BUT DID NOT GET INTO WHICH IS I WAS SENIOR AUTHOR ON THIS PAPER COMPARING RAPID QUALITATIVE ANALYTIC METHODS TO MORE IN DEPTH SHOWING THEY WERE EQUIVALENT. SO SOMETIMES THAT'S ISSUE WITH IMPLEMENTATION SCIENCE IF YOU NEED MORE QUICKLY BUT YOU NEED DEVELOPMENTAL FORMATIVE EVALUATION DATA FROM QUALITATIVE STUDIES AND IT WAS EQUIVALENT BUT THESE ARTICLES SHOULD BE FOUNDATIONAL AND HELPFUL IN WRITING GRANT PROPOSALS. I THINK THAT IS ENING MY PRESENTATION FOR NOW. >> AWESOME, AMANDA. THANK YOU BOTH OF YOU FOR FANTASTIC PRESENTATIONS. SO AS WE GET THE NEXT SLIDE SET UP, FOR NEXT GROUP OF PRESENTER, I'M SO HAPPY TO INTRODUCE MY NIH COLLEAGUES WHO WORK IN THE DNI SPACE. CURRENT NCCIH IMPLEMENTATION SCIENCE PORTFOLIO IS SMALL AND ENTHUSIASTIC AND AS NCCI PREPARES TO BUILD VIBRANT PORTFOLIO WE THOUGHT IT WOULD BE NICE TO DESCRIBE WHAT A HEALTHY PORTFOLIO LOOKS LIKE AT SOME OTHER SISTER INSTITUTES AND CENTERS. JOINING FROM ACROSS THE NIH IS DR. GILA NETA FROM DIVISION OF CANCER CONTROL AND POPULATION SCIENCES AT THE NATIONAL CANCER INSTITUTE. FOLLOWING HER WILL BE DR. PINTELLO, CHIEF OF DISSEMINATION IMPLEMENTATION RESEARCH PROGRAM, NATIONAL INSTITUTE OF MENTAL HEALTH SORRY FOR LISTING YOU AS ACTING DANNY. IT'S ONLY NOT ACTING FOR FIVE YEARS SO AI'M A LITTLE SLOW. SORRY FORNA. NEXT AFTER THAT WILL BE DR. DUCHARME, HEALTH SCIENCE ADMINISTRATOR AT THE NATIONAL INSTITUTE ON DRUG ABUSE AND FINALLY TO BRING UP THE REAR IS DR. KATE STONY DEPUTY DIRECTOR OF THE TRANSLATIONAL RESEARCH BRANCH AT NATIONAL HEART LUNG AND BLOOD INSTITUTE. GILA, IF YOU ARE THERE, I'LL TURN IT TO YOU. >> GOOD AFTERNOON, EVERYONE. THIS IS BEEN A GREAT WEBINAR. I HAVE LEARNED A LOT. THANK YOU DAVE FOR INVITING ME TO SHARE A LITTLE BIT ABOUT NCI HEALTHY DNI PORTFOLIO. SO WHAT I WANTED TO DO IN JUST A FEW SLIDES FOR THE FIRST SLIDE IS JUST HIGHLIGHT FUNDING OPPORTUNITIES NCI FUNDED IMPLEMENTATION SCIENCE AWARDS THROUGH THESE. THE FIRST LISTED HERE IS TRANS-NIH DISSEMINATION AND IMPLEMENTATION RESEARCH AND HEALTH PROGRAM ANNOUNCEMENT WHICH AS DAVE MENTIONED EARLIER IS A TRANS-NIH INITIATIVE WITH 21 INSTITUTES CENTERS ABOUT OFFICES SIGNED ON TO IT. NCI IS CURRENTLY AND HAS BEEN FOR A BIT OF TIME THE LEAD ON THAT, IT USED TO BE AT NIMH BUT DAVID CHAMBERS WAS THE INSTIGATOR FOR THIS PROJECT ALONG WITH COLLEAGUES ON THE -- ON THIS PANEL. FOR NCI WE AWARDED 44 RO1, 26 R21 AND SIX R THREEs THROUGH THESE MECHANISMS. ABOUT THE TWO R 37s. I DON'T KNOW IF EVERYBODY ON THIS CALL IS NIH OR NOT BUT HOPEFULLY I DON'T HAVE TO EXPLAIN WHAT THOSE MECHANISMS ARE. THIS IS A BROAD FUNDING OPPORTUNITY WITH THREE PRIMARY MECHANISMS SOME INSTITUTES HAVE ADDITIONAL TRAINING MECHANISMS THROUGH IT. IT DOESN'T CALL ATTENTION TO PARTICULAR TOPIC AREAS. IN ADDITION TO FUNDING 78 AWARDS THROUGH THESE, I SHOULD MENTION THESE PROGRAM ANNOUNCEMENTS STARTED IN 2005 SO THAT'S 78 IS FROM 2005 TO NOW. IN ADDITION TO THOSE, WE HAD THE MOON SHOT INITIATIVES. THAT IN RESPONSE TO CANCER MOON SHOT BLUE RIBBON PANEL IDENTIFYING KEY AREAS IN CANCER CONTROL THAT WE NEED TO TARGET. SO WE DEVELOPED A SERIES OF MOON SHOT INITIATIVES, THESE ARE ONES THAT INCLUDE IMPLEMENTATION SCIENCE. WE FUNNED SEVEN IMPLEMENTATION SCIENCE CENTERS AND ADDITIONAL ONES LISTED HERE ARE TARGET AREAS IN TERMS OF INCREASING COLORECTAL CANCER SCREENING AND FOLLOW-UP. IMPROVING TOBACCO CESSATION IN CANCER PATIENTS. MANAGEMENT OF SYMPTOMS IN CANCER PATIENTS AND SURVIVORS. AND ALSO APPROACHES TO IDENTIFYING CARE FOR INDIVIDUALS WITH INHERITED CANCER SYNDROME. SO THESE Ns YOU SEE AFTER NUMBER OF AWARDS FUNDED AS OF SEVERAL MONTHS AGO IN THE MOON SHOT INITIATIVE WEBSITE IS STILL PENDING AND UPDATE BUT THESE ARE LARGELY COLLABORATIVE AGREEMENTS AND IN THE CASE OF CANCER CENTER INITIATIVE, THOSE ARE SUPPLEMENT AWARDS TO CANCER CENTERS. NEXT SLIDE I WILL TALK BRIEFLY HOW DO WE BUILD A HEALTHY DNI FUNDED RESEARCH PORTFOLIO? YOU NEED TO MAKE SURE YOU YOUR INVESTIGATORS ARE TRAINED AND TRAINED IN THE METHODS THAT AMANDA DID A FABULOUS JOB OF HIGHLIGHTING AND DESCRIBING BRIEFLY. AND TRAIN IN GRANTSMANSHIP AND REVIEW AND UNDERSTANDING WHAT IS THIS FEEL LOOKING FORND HOW DO YOU WRITE SUCCESSFUL APPLICATION. ON THIS SLIDE I HIGHLIGHT THREE THINGS ONE WHICH AMANDA DESCRIBEDD BY IS IMPLEMENTATION SCIENCE WEBINAR SERIES THERE ARE TWO SERIES CONTAINED WITHIN THOSE. THOSE ARE LISTED ON OUR WEBSITE. WE ALSO HAVE TRAINING INSTITUTE FOR DISSEMINATION IMPLEMENTATION IN RESEARCH CANCER WE HOSTED THE LAST THREE YEARS. THIS WAS OFFSHOOT OF BROODER TRAINING INSTITUTE FOR DISSEMINATION IMPLEMENTATION IN RESEARCH AND HEALTH. BETWEEN THOSE TWO INSTITUTES, WHICH HAVE GONE ON FOR THE LAST NINE -- THE BROAD ONE HAS BEEN THE LAST NINE YEARS. THE CANCER ONE FOR THE LAST THREE, WE HAVE TRAINED NEARLY 500 INVESTIGATORS. THROUGH THAT TRAINING INSTITUTE. THE OTHER THING I WANTED TO MENTION ON THE RIGHT SIDE, WE HAVE PROVIDED SAMPLE GRANTS SAMPLE GRANT APPLICATIONS. THESE ARE EXAMPLES OF GRANT APPLICATIONS THAT WERE AWASHINGTON, D. CXFCC. CXFCKED. THROUGH THROUGH DISSEMINATION RESEARCH FUNDING AND HEALTH FUNDING OPPORTUNITIES. DEPENDING HOW BIG YOUR MONITOR IS, YOU PROBABLY CAN'T MAKE OUT DETAILS. BUT ESSENTIALLY THESE ARE A RANGE OF TOPICS INCLUDE RO1 AND R21 APPLICATIONS AND YOU CAN INVESTIGATORS ANYONE CAN GO TO THE WEBSITE AND SEE AN EXAMPLE OF NOT JUST SPECIFIC AIMS PAGE BUT RESEARCH STRATEGY AND OTHER INFORMATION THAT IS NOT TYPICALLY PUBLICLY AVAILABLE. SO WE ARE EXTREMELY GRATEFUL TO THE INVESTIGATORS FOR ALLOWING US TO SHARE THIS MATERIAL WITH. THIS IS PART OF THE WEBSITE MOST VISITED SO CLEARLY USEFUL RESOURCE. THE LAST SLIDE -- AND AMANDA IS AIRTIGHT EVERY ALUM. IN THE CHAT WE CAN SEE THAT. HURRAY. SO I WANTED TO CLOSE AND PASS THE TORCH AND SAVE TIME FOR MY OTHER COLLEAGUES SO THEY DON'T HAVE TO TALK ABOUT THIS AND CAN FOCUS ON ROBUST PORTFOLIOS. BUT KATE STONY, LORI DUCHARME, DENNY PENT PINTELLO AND MYSELF ORGANIZED CROSS THE NIH DISSEMINATION AND IMPLEMENTATION AN HEALTH. THIS IS AN NIH AND ACADEMY HEALTH CONFERENCE THAT STARTED INITIALLY AS AN NIH EXCLUSIVELY NIH AND VA CONFERENCE AND I SHOULD MENTION VA IS ALSO A CO-HOST OF THIS CONFERENCE. BUT THE FIRST FIVE YEARS IT WAS A CONFERENCE OF SEVERAL HUNDRED PEOPLE THAT WOULD MEET ANNUALLY HOSTED BY THE NIH AND THE VA AND HAS GROWN TO BE WELL OVER A THOUSAND AND LAST YEAR IT WAS OVER 1400 IMPLEMENTATION SCIENCE EXPERTS ACROSS THE WORLD. MEETING TO CONVENE. FINALLY NCI LAUNCHED A SMALLER VERSION OF THIS FOCUSED ON IMPLEMENTATION SCIENCE AN CANCER CONSORTIUM OF IMPLEMENTATION SCIENTISTS TO EXPLORE KEY AREAS MANY THE FEEL APPROXIMATE GENERATE PUBLIC GOODS INCLUDING AS AMANDA REFERENCED, GUIDANCE TO FIELD ON HOW TO MEASURE COSTS. SO I'LL END THERE. I'M SURE I WENT OVER. >> THANKS SO MUCH. SO DENNY YOU ARE UP, CAN WE GET THE SLIDE UP? >> THANK YOU VERY MUCH FOR INVITING ME. I'M DENNY PINTELLO FROM NIMH, I RECEIVED THE DNI RESEARCH PORTFOLIO, WE WERE CHALLENGED TO PUT EVERYONE ON ONE SLIDE SO YOU'LL SEE VISUAL STUFF BECAUSE WE HAVE A LOT GOING ON, VERY EXCITED TO SHARE WITH YOU. WE HAVE A LONG HISTORY AS GILA MENTIONED AT NIMH SUPPORTING DNI RESEARCH. WHEN THINK ABOUT WHEN YOU LOOK AT HOW DO YOU FIGURE OUT WHO IS REALLY COMMITTED TO THIS AREA, I'M ONE OF THOSE FOLKS WHO FOLLOW THE MONEY. IF YOU LOOK AT THE PIE CHART, THIS REPRESENTS THE NIH FISCAL COMMITMENT ACROSS THE INSTITUTES. ONLY FIVE INSTITUTES ARE HIGHLIGHTED NOW BUT IT'S $20 MILLION OF JUST THE RO1 ONLY PROJECTS. AND THIS WAS -- THESE DATA CAME FROM NHLBI REVIEW COMMISSIONED BY CHERYL BOYS WITH KATE SEWNY BACK IN 2017 BUT EVEN THOUGH IT WAS THREE YEARS AGO GIVE YOU A SNAP SHOT OF NIMH HAS ABOUT A THIRD, NCI HAS A THIRD AND NHLBI HAS 20% AND AT THE TIME NIDA HAD SEVEN%. THESE THINGS HAVE CHANGED OVER THE LAST THREE YEARS. BUT GIVES YOU A REALLY GOODS SENSE OF THE FISCAL COMMITMENT AND PERHAPS IN THE FUTURE NCCIH WILL BE PART OF THIS AS WELL. I LIKE TO GO NEXT TOO GIVE A SNAP SHOT OF NIHMH FUNNED RESEARCH PROJECT IT IS LAST 15 YEARS. AS YOU HEARD GILA MENTION, THERE'S TWO PIPELINES. THE PIPELINE FROM THE THREE REVIEWED BY THE DIRH REVIEW COMMITTEE COMING FROM THE TRANS-NIH FOA. THIS RED WHEEL REPRESENTS WHAT WE CALL RESEARCH TOPIC CIRCLES. THESE ARE GENERATED BY NIH REPORTER BUT GIVES YOU A SENSE OF THE 67 PROJECTS THAT CAME THROUGH THIS PATHWAY. HERE ARE TOPICS BEING FUNDED. HIV, CHILD WELFARE, BEHAVIORAL PHARMACOLOGICAL CLINICAL TRIALS. SO THAT'S VISUAL OF THAT ONE PATHWAY. NEXT FUNDED HYBRID DESIGN, THE WE CLICK THAT. THIS IS THE LAST SIX YEARS SINCE 2014 WE FUNDED OVER 80 HYBRID DESIGNS. THIS COMES THROUGH OUR NIMH FOA SPECIALIZED NIMH FOA REVIEWED BY OUR OWN COMMITTEE AT OUR INSTITUTE. YOU CAN SEE SIMILAR TYPE TOPICS AS FAR AS HIV BUT WE OWE -- HAVE A LOT OF AUTISM SPECTRUM DISORDERS PROJECTS AS WELL AS PRIMARY CARE AND OTHER ARENAS. THAT GIVES YOU AN OVERVIEW OF WHAT THE PORTFOLIO AT NIMH LOOKS LIKE. SO I WANTED TO GIVE YOU THAT. I WANT TO SHARE SUCCESSOR STORIES WE HAVE HAD OVER THE YEARS. I USED A COUPLE OF CATEGORIES HERE OF STATEWIDE IMPLEMENTATION. WE HAVE A LOT OF GREAT RESEARCHERS DOING FANTASTIC THINGS. I WAS ONLY ABLE TO PICK A FEW BECAUSE I DIDN'T WANT THE OVERWHELM TOO MUCH BUT GREG HAS DONE GREAT WORK WITH SAFE CARE WHICH IS IMPLEMENTED OFFER BASED RESEARCH PACKAGE IMPLEMENTED ACROSS CHILD PROTECTIVE SERVICES ACROSS THE STATES, MANY STATES IN THE UNITED STATES AND EVEN INTERNATIONALLY. PATTY CHAMBERLAIN'S WORK WE FUND, THE CASCADING DISSEMINATION TRAINING BASED ON TRAIN THE TRAINERS. AND WORK IN SUSTAINMENT WE FUND MEASUREMENT DEVELOPMENT, CAROL LOUIS, AND LISA SALDANA AS AMANDA MENTIONED WE FUNDED DEVELOPMENT AT STAGE OF IMPLEMENTATION COMPLETION TOOL. SO HA IS EXCITING WORK. A SCHOOL BASED MENTAL HEALTH SERVICES, A BUNCH OF GREAT RESEARCHERS. AND AMY IS TESTING A SMART ADAPTIVE DESIGN WITH ADOLESCENT DEPRESSION IN HIGH SCHOOL, THAT WE ARE TESTING DOING GREAT WORK ON THAT. AUTISM, WE ARE GROWING THAT PORTFOLIO QUITE A BIT. WE HAVE GREAT RESEARCHERS INCLUDING DAVID MANNDEL TESTING PRINCIPLES OF BEHAVIORAL ECONOMICS AND DEIMPLEENTATION. BUT WAIT THERE IS MORE, WE HAVE NIH INITIATIVE SO HE CLICKED THE NEXT PIECE. I CAN'T GO THROUGH ALL BECAUSE I WANT TO KEEP US ON TIME. BUT WE HAVE THE RACE INITIATIVE, RECOVERY AFTER THE INITIAL SCHIZOPHRENIC EPISODE. THAT'S OUR PARTNERSHIP WITH SAMSA WHICH EMBEDS SPECIALTY CARE TEAMS IN MENTAL HEALTH BLOCK GRANT MONEY TO GO OUT AND WORK WITH KIDS FOR EARLY PSYCHOSIS. P 50 GRANTS ACCELERATING. TABS FORMING MENTAL HEALTH CARE. EPINET PRACTICE BASE RESEARCH. NET WORK SHARING DATA REAL TIME TO ENHANCE TREATMENT OF MENTAL HEALTH AND MENTAL HEALTH RESEARCH NETWORK WHICH IS A HUGE RESEARCH CONSORTIUM. THEN TWO MORE PIECES, OUR TRAINING PIECE. WE HAVE K GRANTS AND T GRANTS. IMPLEMENTATION RESEARCH INSTITUTE, SOME MAY HAVE HEARD THIS HIGHLY COMPETITIVE GROUP OF FOLKS, TWO YEAR PROGRAM AND WE HAVE A CHILD TRAINING WHICH IS CHILD RESEARCH IN INTERVENTION PREVENTION AND SERVICES RESEARCH THAT JUST FINISHED LAST WEEK. AND EACH OF THESE WORK WITH MENTEES AND MENTOR PAIRINGS TO DEVELOP GREAT RESEARCH APPLICATIONS AND PUBLICATIONS SO THEY CAN LEARN HOW TO MAKE A DIFFERENCE IN THE FIELD REDUCING SYMPTOMS OF MENTAL HEALTH ISSUES. LASTLY I WANT TO ECHO, WANT TO CLICK THE LAST PIECE HERE, SIMILAR TO AMANDA'S YELLOW BOX, THESE ARE THREE AREAS OF INTEREST THAT WE HAVE FOR OUR FUTURE RESEARCH STUDIES IN THE PRE-IMPLEMENTATION ARENA, LOOKING AT WAYS TO OPTIMIZE READINESS AND ALIGNMENT AT THE SYSTEMIC OBJECTIONAL AND PROVIDER LEVEL. IMPLEMENTATION WE ARE DEVELOPING AN TESTING NEW IMPLEMENTATION STRATEGIES AND SUSTAINMENT POST IMPLEMENTATION, WE ARE TRYING TO INVITE RESEARCH THAT'S DESIGNED TO EMBED INTO PROCEDURES ELECTRONIC HEALTHCARE RECORDS IN SYSTEMS OF CARE. FROM THANK YOU FOR YOUR TIME INTEREST IN OUR PORTFOLIO AND LET MY COLLEAGUE FROM NIDA SHARE HER THOUGHTS. >> THANKS SO MUCH. THAT WAS FANTASTIC. LORI SLIDE UP, YOU ARE OFF AND RUNNING. >> OKAY. SO YOU WILL SEE SHORTLY I DID NOT BRING A FANCY SLIDE. BUT I THOUGHT I WOULD SHARE A FEW EXAMPLES AND HIGHLIGHTS FROM THE ANY NIDA IMPLEMENTATION SCIENCE PORTFOLIO. WE HAVE BUILT THIS PORTFOLIO SLOWLY BUT STEADILY OVER LAST 12 YEARS FUNDED NORTH OF 150 IMPLEMENTATION GRANTS OF VARIOUS SIZES IN THAT TIME. WHILE WE HAVE CERTAINLY FORTUNATE IN TERMS OF RACEHORSES WE HAVE DONE IT WITHOUT A LOT OF DEDICATED INFRASTRUCTURE AND BY THAT I MEAN WE DON'T HAVE ANYTHING IN THE WAY OF FORMAL TRAINING PROGRAM LIKE COLLEAGUE AT NCI AND NIMH MENTIONED. FOR NEW INVESTIGATORS WHO ARE PROPOSING K AWARDS OR EXPERIENCED INVESTIGATORS WHO WANT TO ADD IMPLEMENTATION SCIENCE TO THEIR TOOL KIT, WE DEFINITELY POINT THEM TO THE PUBLIC FACING RESOURCES THAT ARE AVAILABLE THROUGH THE ARCHIVES FROM TITER AND TO IT -- TRAINING PROGRAMS GILA MENTIONED AND TO THE BIG NATIONAL CONFERENCE AND WE SHOULD ALSO MENTION THERE IS AN ANNUAL GRANTSMANSHIP PROGRAM AVAILABLE AS PART OF THAT EVENT. WE HAVE ALSO PARTNERED WITH NIMH TO BUY A COUPLE OF SLOTS IN THEIR IRI TRAINING PROGRAM FOR NIDA RESEARCHERS WHICH HAS HELPED US TO SEE THE FIELD WITH SOLID IMPLEMENTATION SCIENCE TRAINING SO ANOTHER PLUG FOR SOME TRAINING INFRASTRUCTURE WHEREVER YOU CAN GET IT. THOSE THINGS THAT I JUST MENTIONED ARE PART OF LARGER STRATEGY TO BORROW FROM LARGER FIELDS WHERE WE CAN. SO FIRST ITEM ON THIS SLIDE IS AN EXAMPLE OF THAT. SO FOR SEVERAL YEARS WE HAVE BEEN SUPPORTINGLY SAW'S WORK EXTENDING STAGE OF IMPLEMENTATION COMPLETION MODEL WHICH AMANDA SHOWED YOU WHICH DENNY MENTIONED BECAUSE IT WAS INITIALLY FUNDED BY NIMH SO WITH MYTA FUNDING SHE'S INCORPORATING A COACHING ELEMENT AND ON GOING FIDELITY INTO THAT MODEL INTO SUSTAINABILITY OUTCOMES. THAT'S AN EXAMPLE OF A WIN WIN, WE GET THE OF ADAPTING HER MODEL FOR PECULIARITIES OF THE DRUG ABUSE PREVENTION SPACE AND LISA TESTS HER MODEL IN BROADER RANGE OF CLINICAL SETTINGS. ANOTHER EXAMPLE, NEXT ONE HERE IS EARLY ON WE WENT AND RECRUITED SOME ENGINEERS TO HELP US THINK THROUGH SOME OF THE PAIN POINTS IN THE ADDICTION TREATMENT SYSTEM AND THERE ARE MANY. AND LIKE GOOD ENGINEERS DO, THEY CAME IN AND TOOK ONE LOOK AT THE SYSTEM AND SAID THERE IS YOUR PROBLEM. THEY THEN DESIGNED A SERE IS OF RESEARCH STUDIES TO TEST THE USE OF THINGS LIKE LOCAL CHANGE TEAMS AND RAPID CYCLE TESTING AND PROCESS IMPROVEMENT PRINCIPLES. TO MAKE NOTICEABLE IMPROVEMENTS THAT PROGRAMS GET EXCITED ABOUT AND SUSTAIN ON THEIR OWN. THOSE STRATEGIES BECAME KNOWN ASONIA TECHS IN ADVANCE RECOVERY AND THEY HELPED GAIN TRACTION IN THE FIELD. WHILE WE BORROW OTHER FIELDS NOT TO SAY WE DON'T HAVE SPECIALTIES OF OUR OWN. NIDA'S LARGEST IMPLEMENTATION SCIENCE INVESTMENT TO DATE HAVE BEEN SERIES OF COOPERATIVES FOCUSED ON THE JUSTICE SYSTEM. AS YOU MIGHT IMAGINE A LARGE PROPORTION OF THE POPULATION HAS OR IS AT RISK FOR SUBSTANCE USE DISORDER. AND WE USED A COUPLE OF STRATEGIES IN EACH OF THESE COOPERATIVES, THE FIRST I LISTED HERE JJ TRIALS WAS FOCUSED ON ADDRESSING DRUG ABUSE PREVENTION AN TREATMENT IN THE JUVENILE JUSTICE SYSTEM AND WE FUNDED SIX UO ONE TO COOPERATIVE AGREEMENT BUT WE HAD THEM WORK TOGETHER TO FIELD A COMMON BUT VERY AMBITIOUS IMPLEMENTATION STUDY PROTOCOL WHICH WAS HEAD TO HEAD CLUSTER RANDOMIZE TRIAL WITH PHASED ROLL OUT ACROSS 36 AGENCIES AND SOMEHOW MANAGED A DOUBLE BLIND PARTS OF IMPLEMENTATION TRIAL. JAKE COIN THE NEXT ONE IS OUR HEEL FUNDED INITIATIVE, THAT IS USING IMPLEMENTATION STRATEGIES TO ADDRESS THE OPIOID CRISIS BY IMPROVING SERVICES FOR PERSONS INVOLVED MANY THE CRIMINAL JUSTICE SYSTEM. AND THERE WE DID THE OPPOSITE. WE FUNDED 11 LARGE COOPERATIVE GRANTS BUT WE WANT TO EMBRACE THE DIVERSITY OF THEIR PROJECTS. SO THEY WILL EACH FIELD THEIR OWN TRIALS BUT WE WORKED TOGETHER TO DEVELOP A ROBUST SET OF COMMON MEASURES THAT WILL LET US POOL DATA FROM THOUSANDS OF CLIENTS AND AGENCIES ACROSS THE STUDIES FOR SHARED ANALYSES. A HYBRID APPROACH WHICH IS LESS RESOURCE INTENSIVE ON OUR END BUT STILL REQUIRES COOPERATION ACROSS PROJECTS ARE COLLABORATORIES AND EXAMPLE OF THAT, IS A GROUP OF SIX RO1s WE FUNDED UNDER AN RFA DESIGNED TO LOOK AT STRATEGIES FOR INTEGRATING SUBSTANCE USE DISODE TREATMENT INTO PRIMARY CARE SETTINGS AND THOSE GRANTS THEY EACH FIELDED THEIR OWN INDEPENDENT PROJECTS BUT THEY VOLUNTARILY CHOSE TO ALL USE THE SAME IMPLEMENTATION CON SIP ACTUAL FRAMEWORK TO MEASURE THE SAME IMPLEMENTATION OUTCOMES SO OBVIOUSLY WHAT YOU ARE SEEING HERE IS WE HAVE A STRONG RECURRING THEME WE LIKE TO ENCOURAGE COLLABORATION SO THE HOLE IS GREATER THAN SUM OF THE PARTS WHEN WHEN HE DO WIG COOPERATIVES. FINALLY I WILL MENTION ONE LARGE NIDA FUNDED CENTER OF EXCELLENCE WHICH AMANDA MENTIONED THANK YOU FOR THE SHOUT OUT WHICH IS CENTER FOR PREVENTION IMPLEMENTATION METHODOLOGY. LED BY HENDRIX BROWN THAT LED US TO FOCUS ON ISSUES TOLL SPECIFIC TO IMPLEMENTING EVIDENCE BASE PREVENTION INTERVENTIONS FOR DRUG USE AN HIV AND DEVELOP METHOD SPECIFICALLY TAYLORED TO THAT AREA OF RESEARCH. THOSE ARE HIGHLIGHTS FROM NIDA AND TO SUMMARIZE THEN HOW WE BUILT THIS IMPLEMENTATION PORTFOLIO OVER TIME IN HIND SITE I WOULD SAY THERE'S THREE PART STRATEGY SO WE LEVERAGED EXISTING INFRASTRUCTURE WHEREVER WE COULD. WE BORROWED FROM OTHER FIELDS BUT WE MADE SURE WHEN WE CREATED MUTUAL WINS FOR THE INVESTIGATORS AND DOING THOSE TWO THINGS ALLOWED US TO FOCUS INVESTMENT OF RESOURCES ON THE PROBLEMS THAT FALL UNIQUELY WITHIN NIDA MISSION AND FOR WHICH RESOURCES DEVELOPED IN OTHER PARTS OF THE HEALTHCARE SYSTEM DON'T NEATLY OR ADEQUATELY TRANSLATE TO ADDICTION SCIENCE. SO THANK YOU FOR INCLUDING US IN THE THIS SESSION. I HOPE THAT WAS HELPFUL. I NEED TO JUMP ON ANOTHER CALL BUT IF NCCIH TEAM HAS ANY QUESTIONS I'M HAPPY TO RESPOND OFFLINE. >> THANK YOU SO MUCH. AS WE BRING UP KATE SLIDE LAURA WAS MICE ENOUGH TO JOIN US AS SHE IS HOSTING A TWO DAY MEETING FOR HEEL SO HUE FOR JUMPING OFF AND JOINING US. KATE GET YOUR SLIDE UP AND GIVES GIVE IT TO YOU. >> YOU CAN SKIP THIS ONE GO TO NEXT ONE THANK YOU. HAPPY TO BE HERE. THANKS FOR THE INVITATION DAVE AND IT IS GREAT TO HEAR MY COLLEAGUES THAT CAME BEFORE ME TALK ABOUT THEIR PROGRAMS. I HAVE LEARNED THINGS IN LISTENING TO THOSE WONDERFUL PROGRAMS. WHAT I WANTED TO DO IS GIVE A BROAD OVERVIEW HOW CITRUS CENTER FOR TRANSLATION RESEARCH AND IMPLEMENTATION SCIENCE IS STRUCTURED. CITRUS IS A DIVISION WITHIN NHLBI. IT WAS CEATED IN IN 2014. SO WE ARE KIND OF NEW. AND THE PURPOSE OF THE PROGRAM TO SERVE AS STRATEGIC FOCAL POINT SPECIFICALLY FOR T-FOUR TRANSLATION RESEARCH IMPLEMENTATION SCIENCE AS WELL AS RESEARCH AGENDA THAT ADDRESSES BOTH DOMESTIC AND GLOBAL HEALTH INEQUITIES AND TRAINING FOR WORK FORCE TO ACHIEVE THESE GOALS. WE SEE THIS TRAINING ELEMENT BEING CRITICAL FOR THE WORK THAT WE ARE DOING. SO CITRUS IS ORGANIZED AROUND THREE BRANCHES BUT IT HAS -- WE REALLY TAKE A ONE CITRUS VIEW SO FOR EXAMPLE WE HAVE A GLOBAL HEALTH AND HEALTH INEQUITIES BRANCH. IMPLEMENTATION SCIENCE BRANCH AND TRANSLATION RESEARCH BRANCH BUT WE FOCUS ON LATE STAGE T FOUR IMPLEMENTATION SCIENC ACROSS ALL THE BRANCHES AND WORK VERY CLOSELY WITHIN OUR OTHER DIVISIONS ACROSS NHLBI TO ENSURE WE ARE ALSO FUNDING EARLIER STAGE IMPLEMENTATION READY RESEARCH. THAT'S CRITICAL FOR OUR MISSION. WE WANT TO ENSURE EARLY STAGE RESEARCH ISSUES TOWARD EARLY STAGE RESEARCH OFTEN TIMES WE FIND AFTER SOME VERY EARLY IMPLEMENTATION SCIENCE RESEARCH CURVES THAT IT NEVER GETS O THE T-FOUR STAGE SO OUR JOB IS TO MAKE SURE THAT WE ARE WORKING ACROSS THE TRANSLATIONAL SPECTRUM AND NOT JUST WITHIN EARLY STAGE IMPLEMENTATION SCIENCE. WE ALSO OF COURSE REALIZE AS EVERYONE CALLS IT HIGHLIGHTED THE -- TRAINING NEW GENERATION OF LEADERS IN IMPLEMENTATION SCIENCE AND TAKE THAT RESPONSIBILITY QUITE SERIOUSLY. NEXT SLIDE PLEASE. THEN WE TALK CITRUS BEING SMALL BUT MIGHTY. WHAT WE MEAN IS THAT IT'S SMALL BUT BUSY. A FEW IMPORTANT INITIATIVES ARE LISTED HERE AND I THOUGHT I WOULD JUST GO THROUGH EACH ONE TO GIVE YOU AN IDEA OF THE SCOPE OF WHAT WE DO. FIRST UP HERE IS THE DECIPHER INITIATIVE, DECIPHER STANDS FOR DISPARITIES ELIMINATION THROUGH COORDINATED INTERVENTION. TO PREVENT AND CONTROL HEART AND LUNG DISEASE RISK. SO THAT'S A LONG TITLE WHICH IS WHY WE USE THE ACRONYM DECIPHER. DEZYCIPHER IS A BIPHASE I CAN COOPERATIVE INITIATIVE THAT OPERATES OFF THE UG FOUR UH THREE FUNDING MECHANISM. WE ARE VERY EXCITED ABOUT THIS SUBSTANTIAL PROGRAM, ABOUT TO BE LAUNCHED. AWARDEES TEST LATE STAGE IMPLEMENTATION STRATEGIES FOR DELIVERING EVIDENCE BASED MULTI-LEVEL INTERVENTIONS TO REDUCE OR ELIMINATE CARDIOVASCULAR AND PULL MANYNARY HEALTH DISPARITIES. AND PROMOTE AND IMPROVE POPULATION HEALTH AND HYBRID COMMUNITIES. THIS IS A SUBSTANTIAL PROGRAM AND WE HAVE A ADDITIONAL COORDINATING CENTER TO HELP COORDINATE THIS PROGRAM SO THAT THEY OPERATE IN CONCERT WITH EACH OTHER AN LEVERAGE EACH OTHER STRENGTHS. THE NEXT INITIATIVE IS THE TRAIN INITIATIVE. AGAIN, ANOTHER ACRONYM BUZZ WE HAVE A LONG TITLE. IT STANDS FOR TRAIN STANDS FOR T-H TRANSLATION RESEARCH CAPACITY BUILDING INITIATIVE IN LOW INCOME COUNTRIES. SO ONE OF OUR BRANCHES IS A GLOBAL HEALTH BRANCH CONDUCTING IMPLEMENTATION SCIENCE ON THE GLOBAL STAGE. TRAIN IS THIS GLOBAL INITIATIVE TO BUILD CAPACITY IN LOW INCOME COUNTRIES AND IT WORKS BY CREATING TRANSDISCIPLINARY TEAMS TO CONDUCT THE LATE STAGE T-H RESEARCH IN LOW INCOME COUNTRIES. THE STUDIES ARE REALLY REQUIRED TO ADDRESS CHRONIC NON-COMMUNICABLE HEART LUNG BLOOD AND SLEEP DISEASE AND DISORDERS. THE NEXT INITIATIVE I WANT TO HIGHLIGHT IS THE HIGH TRACK INITIATIVE WHICH STANDS FOR HYPERTENSION OUTCOMES FOR T-FOUR RESEARCH WITHIN LOWER AND MIDDLE INCOME COUNTRIES. THIS IS A COOPERATIVE AGREEMENT. NOTICE THAT MANY OF OUR INITIATIVES ARE BASED ON COOPERATIVE AGREEMENTS IN PART BECAUSE WE REALLY LIKE THEM TO WORK TOGETHER AS A COLLECTIVE SO WE FEEL THAT THE BEST WAY TO ENHANCE THAT IS TO FUND THESE AS COOPERATIVE AGREEMENTS. SO THE PURPOSE OF THE HIGH TREK PROGRAM IS TO TEST IMPLEMENTATION STRATEGIES TO IMPROVE DELIVERY OF EVIDENCE BASED INTERVENTIONS WITHIN PARTICULAR REGION OF LOW OR MIDDLE INCOME COUNTRIES OR NATIONAL LEVELS AMONG SEVERAL COUNTRIES FOR THE PREVENTION TREATMENT AND CONTROL SPECIFICALLY HYPERTENSION. HYPERTENSION IS THE NUMBER ONE KILLER ACROSS THE WORLD. AND THERE'S A TERRIFIC NEED TO UNDERSTAND HOW WE CAN BETTER IMPLEMENT AND DISSEMINATE STRATEGIES FOR CONTROLLING HYPERTENSION WHICH WE KNOW ARE EFFECTIVE. IN HIGH TREK WE REQUIRE THE UTILIZATION OF A THEORETICAL OR CONCEPTUAL IMPLEMENTATION FRAMEWORK. IN FACT THAT'S CASE ACROSS ALL OUR INITIATIVES. WE HAVE AN RO1 INITIATIVE THAT'S AVAILABLE ON IMPLEMENTATION OF SHARED DECISION MAKING. THIS IS SPECIFICALLY FOCUSED ON HEART LUNG BLOOD AND SLEEP DISEASE AND CONDITIONS, THAT'S WHAT HLBS IS. THIS IS A RO1 CLINICAL TRIAL OPTIONAL AND THIS PROGRAM SUPPORTS RESEARCH ON INCREASING THE UPTAKE OF SHARE DECISION MAKING INTO ROUTINE CLINICAL PRACTICE. WE ARE REALLY STRIVING HERE TO IMPROVE PATIENT CENTERED CARE FOR HEART LUNG BLOOD AND SLEEP DISEASE AND CONDITIONS. TO SPECIFICALLY UNCOVER AND UNDERSTAND THE BARRIERS AND FACILITATORS THAT ARE RELATED TO SDM STRATEGIES AND ULTIMATELY TO REDUCE HEALTH DISPARITIES AND DELIVER TREATMENTS THAT ARE REALLY THE BEST FIT, BEST SUITED FOR INDIVIDUAL PATIENTS. WE OF COURSE ALSO SIGN ON TO THE -- SEVERAL IMPORTANT TRANS-NIH INITIATIVES WHICH ARE TRAINING RELATED AND WE HAVE WE ALSO SIGN UP TO RESEARCH SUPPLEMENTS TO PROMOTE DIVERSITY AND HEALTH RELATED RESEARCH WHICH INCLUDES SUPPLEMENTS FOR INVESTIGATORS WHO ARE -- BECOME DISABLED AND TO PROMOTE REENTRY INTO THE BIOMEDICAL AND BEHAVIORAL RESEARCH CAREERS. WITHIN THE DISSEMINATION IMPLEMENTATION RESEARCH IN HEALTHY RO1 THAT GILA MENTIONED, WE HAVE A VERY ACTIVE PORTFOLIO AND IMPORTANT PORTFOLIO FOR US AND IN FACT WHEN CITRUS WAS INITIALLY FORMED IN 2014 THIS IS WHAT WE HAD AT NHLBI FOR THE MOST PART TO DO DISSEMINATION AND IMPLEMENTATION RESEARCH. SO OUR JOB AT CITRUS HAS BEEN TO SUSTAIN THAT INITIATIVE SO THAT OUR INVESTIGATORS CAN USE IT FOR INVESTIGATOR INITIATED WORK AND TO PROMOTE SPECIFIC NEEDS IN HEART LUNG BLOOD AND SLEEP DISEASE WITHIN CONTEXT OF IMPLEMENTATION SCIENCE. SO WITH THAT I'M GOING TO TURN IT BACK TO DAVE. THANK YOU ALL FOR YOUR ATTENTION. >> THANK YOU SO MUCH, KATE. THAT WAS FANTASTIC AND REALLY THANKS TO ALL THE PRESENTERS, I KNOW WE ARE RUNNING A BIT LATE AND SO I'M GOING TO TURN THINGS OVER TO EMMELINE EDWARDS, DR. EDWARDS, DIRECTOR OF THE DIVISION OF EXTRAMURAL RESEARCH AT NCCIH. EMMELINE. >> THANK YOU, DAVE. I WANT TO THANK ALL THE PRESENTERS FOR THE EXCELLENT TALKS. WE DO HAVE A LITTLE EXTRA TIME IF WE NEED IT. HOWEVER, WE HAVE A NUMBER OF QUESTIONS THAT HAVE POPPED OUT INTO THE CHAT BOX. SO THE FIRST QUESTION IS FOR PETER WAYNE. QUESTIONS GOES LIKE THIS. REGARDING YOGA, TAI CHI AND OTHER ASIAN EASTERN BASE PRACTICES HOW MUCH OF THE SUCCESS OR FAILURE/DROP OUT IN AMERICA COULD BE CONTRIBUTED TO BELIEF INTO PRACTICE? SECOND PART OF THE QUESTION IS, COULD THE STEREOTYPES AND PREFERENCE FOR BIOMEDICINE BIOMEDICINE/WESTERN MEDICINE OVER EASTERN MEDICINE HAVE SIGNIFICANT IMPACT ON OUTCOME? AND HOW WOULD YOU OVERCOME THIS BIAS AS MUCH PETER? >> THOSE ARE VERY RICH QUESTIONS. I THINK WE NEED ANTHROPOLL GISTS ON BOARD AS WELL. THERE'S GOOD RESEARCH AND MY COLLEAGUES HERE TED AND OTHERS HAVE SHOWN A BELIEF IN ANY INTERVENTIONS IS IMPORTANT. EXPECTATION. WHETHER THERE ARE DIFFERENCES IN CULTURE FOR EXAMPLE, IN CHINA DOING TAI CHI VERSUS IN THE U.S., I THINK IS AN INTERESTING QUESTION AND I THINK SOME COMPARATIVE EXPERIMENTS ACROSS CULTURES WITH SIMILAR INTERVENTIONS MIGHT BE INTERESTING. IT GETS INTHE TEACHERS AS WELL, MOTIVATION CONTEXT ALL SORTS OF THINGS. THE QUESTION OF BIOMEDICINE IS A REALLY INTERESTING ONE. IT FEEDS INTO BELIEF. I THINK WE HAVE A SPECIAL NICHE HERE IN OUR ACADEMIC ENVIRONMENT AT HARVARD WHERE WE TEACH TAI CHI AND MANY WAYS PHYSICIAN OR THE HEALTHCARE SYSTEM REPLACED THE SHAWMAN WITH THE RATTLE IN TRADITIONAL HEALING. IT'S A REALLY INTERESTING QUESTION BECAUSE WHEN WE TEACH WE ASK PEOPLE WE EDUCATE THEM ABOUT THEIR HEALTH. WE TELL AS THEY ARE DOING THIS, CAPILLARIES ARE DILATING AND BLOOD IS PROFUSING AND THAT WE MIGHT THROW IN SOMETHING LIKE CHIEF FOLLOWS BLOOD ACCORDING TO CHINESE MEDICINE, WE TALK ABOUT FASCIA AND LANGEVIN WORK AS STRETCHING. I THINK BIOMEDICAL FRAMEWORKS HELP AS METHOD FORS BUT ALSO ADD CREDIBILITY. SO THAT WOULD BE AN INTERESTING INGREDIENT TO STUDY. WHAT IF YOU TAUGHT THE SAME THING WITH AND WITHOUT SCIENCE. AND WILL THAT HAVE A DIFFERENT EFFECT ON EFFECTIVENESS. THOSE ARE JUST FASCINATING QUESTIONS I WOULD LOVE TO ASK BUT I DON'T THINK THERE'S ANY DATA FOR THAT. >> THANK YOU, PETER. I WILL JUST GO TO THE NEXT QUESTION. ORECU THERAPY MAYBE EFFECTIVE FOR TREATMENT OF POST-OPERATIVE PAIN AND WE USE FRAMEWORK OF RESEARCH TO IMPLEMENT PERIOPERATIVE THERAPY AT THE VA MEDICAL CENTER. WE HAVE MODERATE PENETRATION OF EVIDENCE BASE INTERVENTION INTO ROUTINE PRACTICE. HOWEVER AT LARGE ACADEMIC MEDICAL CENTER ACROSS THE STREET THIS EVIDENCE BASE INTERVENTION IS NOT IN USE AT ALL. A MAJOR BARRIER IS THE JURISDICTION OF STATE REGULATORY AGENTS STATE BOARD OF ACUPUNCTURE IN NURSING HAVE RULES ABOUT THE SCOPE OF PRACTICE THAT APPLY OUTSIDE THE VA BUT DO NOT APPLY ON FEDERAL PROPERTY. ALL THIS TO ASK WHETHER NIH INSTITUTES HAVE SEEN DISSEMINATION AND IMPLEMENTATION PAROLES ADDRESSING THESE SORT OF ISSUES. IF NOT SEARCH PROPOSAL ENTERTAIN SO I THINK THIS COULD BE ANSWERED BY ANYBODY FROM THE NIH. IN OTHER WORDS DO WE ACTUALLY DEAL WITH ISSUES THAT ARE RELATED TO STATE REGULATIONS, STATE REGULATORY AGENCIES AND HOW DO WE -- HAVE WE SEEN THAT PROPOSAL AND IS THAT SOMETHING -- IF NOT ARE WE INTERESTED IN SUCH PROPOSAL? I'M GOING TO LEAVE IT OPEN TO OUR -- ANY OF OUR NIH COLLEAGUES THAT ARE ON THE CALL. >> I WILL START AND INVITE MY NIH COLLEAGUES TO JUMP IN IF THEY LIKE. IN GENERAL, I DO THINK THAT THIS AREA IS OF INTEREST. I THINK MANY -- MOST PEOPLE THAT I WORK WITH IN IMPLEMENTATION SCIENCE PORTFOLIO ARE GRANT IDEAS TEND TO NEGLECT A LEGISLATIVE ANGLE IN TERMS OF IS THAT ONE OF THE LEVERRINGS OR MORE IMPORTANT BARRIER TO IMPLEMENTING SOMETHING, AS ONE OF THE STRATEGY YOU CAN USE TO IMPLEMENT AN INTERVENTION. THIS IS REALLY IMPORTANT ESPECIALLY WHEN WE TALK ABOUT THINGS LIKE METHADONE PROGRAMS WHICH HAVE STRICT LICENSING. SO I THINK THAT IN GENERAL THIS -- IF YOU HAVE A STRATEGY BY WHICH YOU WISH TO TEST YOUR LEGISLATIVE INTERVENTION STRATEGIES, I THINK THAT'S SOMETHING I WOULD VERY MUCH BE INTERESTED IN HEARING MORE ABOUT. DO KATE DENNY OR GILA WANT TO JUMP IN >> WE HAVE A COUPLE OF STUDIES PARTICULARLY JONATHAN HURDLE'S WORK WITH MENTAL HEALTH LEGISLATURES FINDING OUT WHAT TYPES OF ATTITUDES AND PERCEPTIONS THEY HAVE OF CURRENT MENTAL HEALTH GUIDELINES PROTOCOLS THEY HAVE IN EACH OF THEIR STATES. HE'S COLLECTING DATA TO DO DISSEMINATION RESEARCH. THAT IS SOMETHING HE HAS BEEN DOING. WE HAVE AS MENTIONED THE SAMSA NIMH PARTNERSHIP, WHICH IS UTILIZE MENTAL HEALTH BLOCK TO IMPLEMENT, IMPLEMENTATION STRATEGY OF COORDINATING SPECIALTY CARE TEAMS FOR EARLY STAGE PSYCHOSIS AMONG ADOLESCENT BUT THAT TOOK AN ACT OF CONGRESS TO IMPLEMENT SO THAT WAS AN INTERESTING DRIVER OF IMPLEMENTATION SCIENCE. >> GREAT, THANKS. KATE, ARE YOU ABOUT TO JUMP IN? >> A QUICK ADDITION TO THAT. IT'S NOT EXACTLY LEGISLATIVE BUT WE DO SUPPORT SOME RESEARCH ON POLICY. MANY OF THESE STUDIES TEND TO BE NATURAL EXPERIMENTS WHERE WE LOOK AT IMPACT OF POLICIES AFTER THE FACT COMPARING ACROSS VARIOUS CITIES OR COUNTIES, WHATEVER WE ARE LOOKING AT. SO THAT IS SOMETIMES INFORMATIVE OF LEGISLATIVE POLICIES. BUT IS MOSTLY AN EVALUATION. >> GREAT. GILA, WERE YOU GOING TO JUMP IN? >> BRIEFLY. WE FUNDED A COUPLE AWARDS TO ROSS BROWN PRIMARILY FOCUSED ON DISSEMINATION STRATEGIES TO POLICY MAKERS AND LEGISLATORS. AND HIS WORK WAS ACTUALLY FEATURED IN NCI ANNUAL BUDGET PROPOSAL ANNUAL PLAN BUDGET PROPOSAL TO CONGRESS FOR FISCAL YEAR 21. SO YOU CAN READ ABOUT HA WORK. ALSO FOR THE IMPLEMENTATION SCIENCE CONSORTIUM IN CANCER, FOR THE LAST TWO YEARS, WE HAVE FOCUSED SPECIFICALLY ON THINKING ABOUT RESOURCES TO BOLSTER POLICY IMPLEMENTATION SCIENCE. THERE ARE VARIOUS FOLKS INCLUDING KAREN FROM HARVARD WHO HAVE BEEN HELPING LEAD THAT EFFORT AND JONATHAN AS WELL. >> THIS IS AN OPPORTUNITY FOR ME TO ALSO ADD THAT WHEN IN DOUBT IT'S ALWAYS GREAT IDEA TO ACTUALLY CONTACT PROGRAM STAFF TO GET A SENSE OF PRIORITIES AND ALSO THE OVERALL INTEREST IN A PARTICULAR TOPIC. SO OUR PROGRAM DIRECTORS ARE REALLY GREAT RESOURCE FOR THE COMMUNITY. AS YOU ARE HIKING ABOUT DEVELOPING A PROPOSAL. SO BEFORE YOU SUBMIT ALWAYS GOOD TO ACTUALLY TALK TO PROGRAM STAFF. I HAVE ODE QUESTION. I AD GASTROENTEROLOGIST WHO WORKS WITH AN UNDERSERVED PATIENT POPULATION. WITH WITH A CONDITION CALLED CYCLIC VOMITING SYNDROME. IT'S ALSO INVOLVED IN STUDY EFFECTIVENESS OF MIND BODY INTERVENTION IN THIS CAN BE. I FIND THE NIH HAS LITTLE OR NO FUNDING TO HELP THESE PATIENTS. WHILE CANCER AND OTHER CONDITIONS IS HEALTH PRIORITY, FUNDING IS PARTICULARLY NON-EXISTENT FOR GI DISORDERS LIKE CVS. HOW CAN WE GET THE NIH TO RECOGNIZE THE NEED FOR FUNDING IN THESE AREAS WHICH SIGNIFICANTLY IMPACT PATIENTS FAMILY AND HEALTHCARE SYSTEM IN OPEN QUESTION TO OUR NIH COLLEAGUES. WE DON'T HAVE SOMEBODY FROM NIDDK THERE THAT WOULD BE THE MOST APPROPRIATE BUT IF YOU WANT TO JUMP IN? >> ACTUALLY I WOULD ANSWER WITH YOUR EARLIER COMMENT EMMELINE, IT'S SO IMPORTANT TO REACH OUT TO NIH PROGRAM STAFF, TO HAVE A SENSE OF INSTITUTE OR CENTER INTEREST AND HELP YOU TO FIND THE BEST PATHWAY FOR YOUR RESEARCH QUESTIONS. ESPECIALLY IF YOU ARE JUST STARTING OUT WITH A NEW GRANT APPLICATION TO REALLY GET GOING -- BASICALLY GET THAT GUIDANCE TO MAKE SURE YOU ARE APPLYING TO THE RIGHT IF LOW IT'S THE BEST MATCH FOR YOUR RESEARCH QUESTIONS. I WOULD ANSWER HA WITH YOUR COMMENT. >> OKAY. >> I WOULD JUST ADD IN THAT I HAVE BEEN REALLY IMPRESSED BY THE SUPPORT FROM NCCIH FOR IRRITABLE BOW WE WOULD SYNDROME LOOKING AT BEHAVIORAL COMPONENTS OF BELIEF AND MIND BODY INTERVENTIONS IN THAT AREA. I MAY POINT TO SOME WAYS OF STUDYING THESE GI ISSUES FROM A COMPLIMENTARY INTEGRATIVE MEDICINE PERSPECTIVE. >> GREAT POINT, PETER. WHILE NCCIH IS NOT DISEASE FOCUSED PER SE, AND WE ARE MORE INTERESTED IN THE INTERVENTION, WE DO FUND AWARD THAT IS LOOKING AT THE IMPACT OF MIND AND BODY OR OTHER COMP MEN DAY APPROACHES USED IN DIFFERENT MODEL SYSTEM INCLUDING DISEASE MODEL SYSTEM. SO AGAIN, THE IDEA OF TALKING TO PROGRAM STAFF BEFORE SUBMITTING IS ESSENTIAL. IS SOMEBODY ELSE WANTS TO JUMP IN? >> THE ONLY THING -- >> I WAS JUST GOING TO ADD ALSO SOME INSTITUTES AND CENTERS ARE DISEASEING A NOTTIC AND MORE FOCUSED ON DELIVERY OF THE WHO OR THE IMPLEMENTERS SO IF YOU ARE LOOKING AT NURSES BEING INVOLVED IN IMPLEMENTING, MANAGEMENT FOR THIS DISEASE THEN NINR MAYBE A GOOD OPTION AND DAY ARE SIGNED ON TO PROGRAM ANNOUNCE PES. THIS IS ONE EXAMPLE LOOKING AT AGING POPULATIONS WE HAVE THE NATIONAL INSTITUTE OF AGING, SO YEAH LIKE EMMELINE SAID JUST TALKING TO THE RELEVANT PROGRAM DIRECTORS AT THE RELEVANT INSTITUTES AND BEING CREATIVE AND THINKING ABOUT WHERE THIS APPLICATION MIGHT FIT. >> I COULD ALSO ADD WE ARE VERY INTERESTED ALSO ABOUT THE INTERACTION BETWEEN THE DIFFERENT SYSTEMS OF THE BODY FOR EXAMPLE NERVOUS SYSTEM AN GASTRO INTESTINAL SYSTEM, WE ARE INTERESTED IN PROCESSES LIKE -- SOMETHING LIKE CYCLIC VOMITING COULD INVOLVE SOME KIND OF MAL FUNCTION THAT MAY INVOLVE MULTIPLE SYSTEMS. SO THIS COULD BE ALSO AN AREA THAT MIGHT FIT INTO INTEGRATIVE APPROACH TO UNDERSTANDING MULTI-SYSTEM DISEASES AND THEIR TREATMENT. >> THANKS, ELAINE. SO AT THIS POINT I DON'T SEE ANY OTHER QUESTIONS FROM THE CHAT. BUT I WOULD LIKE TO ASK WHETHER THE PANELISTS THEMSELVES HAVE QUESTIONS FOR EACH OTHER BEFORE WE CON COLLUDE. IF NOT, I'M GOING TO TURN IT OVER TO DAVE TO HAVE CONCLUDING REMARKS. THANK YOU. >> THANK YOU SO MUCH, EMMELINE. I CAN NOT TELL YOU HOW HAPPY I AM THAT THE NCCIH IS EMBRACED IMPLEMENTATION SCIENCE AND RESEARCH COMMUNITY IN COMPLIMENTARY INTEGRATIVE HEALTH CONTINUES TO HAVE A LANDING SPOT TO MOVE RESEARCH PROGRAMS THROUGH IMPLEMENTATION SCIENCE. THE NCCIH IS SIGNED ON TO THE NIH WIDE DNI FUNDING OPPORTUNITY ANNOUNCEMENT SO WE HAVE BEEN AND CONTINUE TO BE OPEN FOR BUSINESS AND ENCOURAGE APPLICATIONS MANY THIS IMPORTANT AREA. ALSO WANT TO POINT OUT TO BE ON THE LOOK OUT FOR A SPECIAL ISSUE ON IMPLEMENTATION SCIENCE FROM THE JOURNAL OF ALTERNATIVE COMPLIMENTARY MEDICINE. THAT WILL BE COMING I'M SURE THAT WILL BE NCCIH WILL TWEET ABOUT OR POST ON THE SOCIALSES THAT WE HAVE COMING OUT. I'LL HAVE A LONG LIST OF THANK YOUS, ALSO I THINK GETTING A PRIVATE MESSAGE FROM DR. SHIRTLEFF SO TURN IT TO HIM IN A MOMENT BUT MY LONG LIST OF THANK YOUS INCLUDES FIRST TO PETER AND AMANDA FOR REALLY OUTSTANDING PRESENTATIONS, IING HOW THEY WERE FANTASTIC. TO MY NIH COLLEAGUES GILA DENNY LORI AND KATE, THANK YOU FOR THE TIME TO BE WITH US TODAY. TO THE LEADERSHIP AND COLLEAGUES AT NCCIH YOUR SUPPORT IS AMAZING IN MOVING THIS AREA OF SCIENCE FORWARD FOR COMPLIMENTARY HEALTH INTERVENTIONS. I ALSO WANT TO MAKE SURE THE SAY THANKS TO PEOPLE BEHIND THE SCENES KATHERINE ROBERT AND PETE IN IT SUPPORT AND FRIENDS AT NIH VIDEO CAST AND PROBABLY MANY, MANY OTHER PEOPLE THAT WILL I SHOULD BE MENTIONING AND FORGETTING TO SAY YOUR NAME. FINALLY THANKS TO THE AUDIENCE FOR LISTENING TO OUR PRESENTATION TODAY. AND FOR THE QUESTIONS YOU POSE. I UNDERSTAND WE HAD ABOUT 300 PEOPLE HERE TODAY LISTENING TO US. SO WITH THAT, I WILL SAY ONE FINAL THANK YOU. DID YOU ALL AND BID YOU ALL A GOOD DAY. >> I WANT TO ADD A SPECIAL THANK YOU TO DAVE CLARK BECAUSE NOT ONLY HAS HE ORGANIZED AND LED THIS WORKSHOP BUT HE'S PLAYED A IMPORTANT LEADER SHIP ROLE AT NIH ABOUT IMPLEMENTATION SCIENCE SO WE LOOK FORWARD TO HEARING MUCH MORE FROM HIM.