Implementation science in pediatric health care: advances and opportunities

ThisissueofJAMAPediatricsrepresentsaspecialfocusonimplementation science inpediatrichealth care. Implementation science refers to the study ofmethods to promote the systematic uptakeofclinical researchfindings intoroutinepractice.1 It isdescribed in a multitude of ways around the world (knowledge translation, transfer,mobilization, exchange, dissemination),2 but ultimately all terms share a similar goal: to close persistent knowledge-to-practicegaps inhealthcareanddecisionmaking inanefforttoimproveoutcomes.Real-worlduptakeofevidencebasedpractices isessential inpediatrichealthcaretoensurechildreneverywherebenefit fromeffective treatments, suchas the useof glucocorticoids for childrenwith croup thathas resulted inasubstantialandimportantdecrease inhospitalizationforthis condition.3 Although the field of implementation science has grown exponentially throughout the late 20th and early 21st centuries, examination of the evidence base for health care practices canbe traced to the 1800s,whenpractices suchasbloodletting were being called into question as medically sound.4 Around this time major advances were also being realized in thefieldofpediatricmedicine, spearheadedbyindividualssuch as Abraham Jacobi, MD, who received the first academic appointment inpediatrics in theUnitedStates (1860)andwasone of the foundingmembers and the first president of theAmerican Pediatric Society (1871).5,6 Jacobi is well known for advocating that children are not small adults in size or disease as well as for how he used data to advocate for changes in practices such as the institutionalization of children and to support andpromotepractices suchasbreastfeedingor theproper preparationofcow’smilkwhenbreastmilkwasnotavailable.5,6 The articles in this issue of JAMAPediatrics bring together the fieldsof implementation scienceandpediatrics, representingawiderangeofhealthissues,researchdesigns,andtherapeutic interventions.For example,Arduraet al7 evaluate theeffect of implementingnewhospital-basedprotocols for reducingcentral catheter–associated infections inhomesettings, illustrating complementarybut at timesoverlappinggoalsof implementation science and quality improvement. The systematic review andmeta-analysis byManja et al8 on target oxygen saturation ranges forpreterm infants is anexcellent exampleofoneof the cornerstonesof implementationscienceanddemonstrates that thereisnotalwaysanevidence-supportedbestpracticeonwhich to informimplementation.Theseapproacheshighlightnotonly theprogress thathasbeenmade inplacingnewresearchwithin thecontextofexistingevidencebutalsotheactivepursuitof tailoredmessagingand interventions tomoveevidence intopractice.So,wheredowegonext in implementationscience?Where dowe go next in pediatric implementation science? We suggest that to further advance pediatric implementation science, there must be a continued and persistent focuson the following: (1) theuseof conceptual frameworks and theories to provide guidance into the relevant factors influencing the implementation process; (2) evaluation of the efficacyof implementation interventions; (3) applicationandadvancement of research designs that are best suited for implementation science; and (4) coordinationof efforts tomobilize and scale up widespread change. Implementation research isoftencomplex, andas suchour recommendationsare in line with the Medical Research Council’s guidance on developingandevaluatingcomplex interventions,9 avaluable resource for implementation researchers. Conceptual frameworks are systems of concepts, assumptions, and theories organized graphically or narratively,10 and theories are defined as a coherent and noncontradictory set of statements, concepts, or ideas thatorganizes, predicts, andexplainsphenomena, events, andbehavior.11 They arepromoted in implementation science toguide the systematic adoptionof evidence inpracticeandarepostulatedtoprovidegeneralizable componentsfordevelopingresearchquestionsandinterventions, allowing for an incremental accumulation of knowledge.1 Severalconceptual frameworksfor implementationandknowledge translationhavebeenpublished,12 andasnonehavebeendemonstrated tobe superior to another, users cancurrently choose which bestmeet their needs. One commonly used framework developed in Canada and adopted internationally is the Knowledge-to-ActionFramework.13,14 It provides step-by-step guidance for implementationandhasbeenused inanumberof healthcontexts.15 It identifies2keyphases tomovefromknowledge production to implementation: the knowledge creation phase and the action cycle (Figure). ApplyingtheKnowledge-to-ActionFrameworktothearticles in thecurrent issue (Table) placeseachof the studiespresented hereinthecontextofthefull implementationprocess.Doingthis highlights theabsenceof studies rigorouslyaddressingbarriers andfacilitators toknowledgeuseandsustainingknowledgeuse in the current issue. The lackof studies examining the sustainmentofevidence-basedpractice isperhapsunsurprising, as incorporatingmechanismsforsustainedimplementationandlongterm tracking often falls outside the traditional research realm and fundingperiods, and this lack is a commoncriticism in the Opinion