“Vision without execution is just hallucination” – Thomas Edison
Healthcare research with the potential to improve patient outcomes is abundant; however, evidence often fails to be promptly or accurately implemented into practice. Closing the so-called evidence-to-practice gap requires a clear understanding of what drives healthcare behaviour, and how change can be systematically supported and sustained. Evaluating how behaviour and evidence intersect is challenging, requiring the assessment of multiple domains that span psychology, organisational behaviour and education. Implementation science is the study of how these methods can be applied to facilitate and assess the adoption of evidence-based practice into real-world use. Given the complexity of implementation science as a concept, several frameworks have been proposed to help ensure experimental rigour, reproducibility and comparisons across interventions.
“To measure is to know” – Lord Kelvin
A multitude of implementation science frameworks exist, with some of the most widely used in the healthcare field being CFIR (Consolidated Framework for Implementation Research),1 RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance)2 and TDF (Theoretical Domains Framework).3 Each addresses distinct, but interconnected, challenges in translating evidence into practice.
CFIR serves as a diagnostic tool to predict or explain barriers and facilitators to implementation effectiveness. This five-domain approach examines intervention characteristics, outer setting influences, inner organisational dynamics, individual stakeholder attributes and implementation processes.
RE-AIM functions as an evaluation framework, offering quantifiable metrics on reach, effectiveness, adoption, implementation fidelity and maintenance, to demonstrate real-world value. It goes beyond traditional clinical trial endpoints to measure outcomes that matter to healthcare and policy decision-makers: How many patients are being reached? Is the intervention being implemented as intended? Will the benefits persist?
The TDF is a behaviour change framework, providing evidence-based insights into the psychological and social factors that influence health practitioner clinical behaviour change. It builds upon the COM-B (Capability, Opportunity, Motivation – Behaviour)4 model, which shows that behaviour change requires adequate capability, opportunity and motivation, and expands these core components into 14 domains to provide more granular insights. The domains of TDF, which include knowledge, skills, social influences and environmental context, provide an understanding of why practitioners may or may not embrace new healthcare practices. This framework is particularly valuable in medical communications as it can inform the development of education that aims to change clinical behaviour, rather than simply increasing awareness.
“The whole is greater than the sum of its parts” – Aristotle
To maximise impact, these frameworks can be used synergistically across different phases of implementation and clinical adoption, either sequentially or in parallel. For example, consider a pharmaceutical company launching a novel immunotherapy for lung cancer. TDF analysis may reveal that healthcare professionals think that the treatment is effective, but that they are concerned about managing immune-related adverse events. These findings can then inform the development of targeted educational interventions. CFIR could be used to systematically evaluate cancer centres to determine which have the organisational readiness to support successful implementation of the new therapy. RE-AIM assessment would then track uptake of the educational interventions, and how faithfully they are replicated and then maintained over time.
The integrated use of implementation science frameworks can provide pharmaceutical companies and healthcare organisations with concrete advantages: they can predict which interventions may succeed in specific contexts; design targeted strategies that address real-world barriers rather than assumed ones; and demonstrate measurable impact to key stakeholders. Organisations that use implementation science frameworks are better positioned to bridge the gap between evidence and practice, with the ultimate goal of transforming patient care and optimising clinical outcomes.
1. Damschroder LJ, et al. Implement Sci 2022;17:75
2. Glasgow RE, et al. Front Public Health 2019:7:64
3. Cane J, et al. Implement Sci 2012;7:37
4. Michie S, et al. Implement Sci 2011:6:42