Multilevel Interventions in Health Care Conference: Presentation by Kurt Stange, MD, PhD

Multilevel Interventions in Health Care Conference: Presentation by Kurt Stange, MD, PhD


>>>DR. STEVEN CLAUSER: So I’ll
introduce now Kurt Stange. Kurt is a family physician. He
has been practicing for many years. He has done a lot of
work in family oriented system design and primary care. He is
the editor of the Annals of Family Medicine. He and his
team did an incredible amount of work preparing for this
and we are happy to have him and it’s an honor to have him
participating with us today.>>>DR. KURT STANGE: Thanks,
Steve. Erica Bresau, Allen Dietrich, Russ Glasgow
and I contributed equally to this work. We actually
developed a method for the madness of trying to synthesize
this diverse literature. And so the method started
with those of us who were on the team. We tried to develop
a team that would have a multi-disciplinary perspective
to look at the literature from different angles. And we
did multiple iterations of literature searches that were
designed to include the breadth of the field concentrating on
the cancer control continuum, but also trying to inform
the literature search from other fields of
multilevel interventions. And then we developed a matrix
of article types and tried to make sure we had
filled in that matrix. So there were three
dimensions of that. There were cancer and
non-cancer articles; intervention and
observation articles; and then three levels that went
from a theory to methodological work, to empirical research.
And then we spent three and a half days immersed in this
literature, getting it down to about 45 articles that we
thought were worthy of particular input. And we did
this where there were no distractions except for the
overhead noise of airplanes and really bad food at one of
the Chicago O’Hare airports. And our goal there was to
really characterize how multilevel interventions are
currently conceptualized and implemented in the literature,
to describe illustrative examples and to identify
opportunities for multilevel interventions to
advance cancer control. So I’ve got a couple of
slides to characterize this literature, three slides
on these opportunities, and then one closing slide of
the discussion questions we’d like you to consider. So we
identified three threads, three large threads in this
literature. The first are a large series of contextualized
single level studies. So these are studies that
typically intervene on one level, often the individual
or the practice or provider. But they actually consider other
contextually important levels. And in some way this is
not part of the charge of the conference. And yet if we
think of where the literature is now, where mostly we have
intervention studies that just look at one level, this would
be a huge advance if those studies that were targeting
one level, actually just put that level in context. Maybe
gather a little data on some of those other levels, put
that single level in a larger theoretical context, and
interpreted the findings in that. So as we’re thinking
specifically about multilevel interventions here, there’s also
an opportunity to think about single level studies that we
actually put in context. And there were a lot of studies
that started to try to do that. There was a large body of
literature of health system research. And actually the work
that Steve Taplin did when he was at Group Health at Puget
Sound, and that many others here in the HMO were Cancer
Research Network and others have done. These studies
typically include interventions at the individual and the
practice level, often at the system level. And this can be
done because these integrated systems actually really
have access to data, and their business model
fosters them thinking about those levels. And they also
often have sufficient community context that they can
involve that level, or that they consider the
local or regional health policy level. So there was a
large body of literature from these health system
intervention studies. And then finally we saw a
lot of studies that were community-wide studies. And
we’ve heard references to a number of those as well. These
studies actually typically took a public health perspective, but
within that larger frame looked at health care system family and
individual level interventions, practice level interventions.
And because of their public health perspective, when they
looked at individuals sometimes they were thinking of them as
patients, but they also were able to consider that when we’re
thinking about things that affect health it’s not just when
they’re patients in healthcare, but it’s about living the rest
of their lives. And within this we focus primarily on
the cancer control studies. But there really was a
large body of learning that can inform this field from
really four generations of community-based heart studies.
So this is a single slide that characterizes our observations
from this literature. The first observation is that
multilevel interventions are inherently context-dependent,
but context is inadequately reported in most reports. And
this might be because often these multilevel studies are
large studies and they’re published over many
papers over time. But reading this literature you
don’t get enough of a sense of context often to think about
how you might apply these into different settings, or how
you might think about how the levels interact. Often less than
three levels are reported. We found a large body of
literature that were theory articles. But when we got to
the empirical literature, often theory was
briefly mentioned, but it was really hard to see
how it was used to actually guide the intervention, or
to interpret the findings, or how the empirical findings
actually went back to re-inform and reinterpret the theory.
Across the cancer control continuum, the vast majority of
studies we were able to find really focused on the prevention
and early detection end. A few were on the survivorship
end, but very few on the diagnosis treatment end of
life care of the spectrum. And one question, is that
because these multilevels are less important for these
studies or is that because those literatures are blind to
these other levels that might be affecting the phenomena
that they’re studying at those levels. Reporting
of temporal issues. The idea that often there’s a
life course perspective on the people in the study, or
that the different levels of environment to change over
the course of the study, those temporal effects, there
was very limited evidence of reporting of those. And across
this literature there were lots of glimmers of hope, that this
is really an important area, that these multilevel
interventions are where we need to go, as Steve has talked about
in setting up this conference. But it’s mostly a hope. And
when we look at how we publish things and how we fund
things, often those are really at odds with what we need to
do to really advance these multilevel approaches. So
looking at the opportunities that we can draw from this
literature, we organized what we found in the literature in
three areas. One is in design, next is analysis, and
finally dissemination. So in the design of studies
there is a need for multilevel studies to just consider
contextual factors across these levels and across time, how
these things evolve over as they interact over time.
There is a need for designs that really involved rapid
learning over time, that are dynamic and
adaptive, and really open to the emergent phenomena
that happen when you’re looking at the interaction
across multiple levels. There is a need to specify the
interfaces among the levels. Often these were just
alluded to, that they weren’t really specified. And
I think of the papers we’re going to hear at this
conference, Brian Weiner’s paper that really talks about,
gives us a way of explicitly articulating those interactions,
is very important. And then finally, specifying
the levels affecting the phenomena of the understudy,
even when they’re not explicitly focused on. So, just
in the theory and the framing of the question and the
interpreting of the results, to acknowledge that there are
these other levels that are affecting the phenomena
is important. In the analysis across the
literature we saw a greater need to evaluate both
process and outcomes. And some of the exemplary
studies that we did didn’t just treat all those intermediate
steps as a black box and look at an intervention
effect on a distal outcome, but really looked at how these
different levels interacted over time, how that
process evolved over time. In order to do that, there’s
a need to capture measures of central tendency, but
to move beyond that. And one of the ways to do that
is with mixed method designs. So, studies that do
quantitative analyses, quantitative modeling,
at levels where there are sufficient data and
sufficient variability; but then not just
ignoring other levels, those higher up levels where
there might not be sufficient numbers or sufficient
variability for modeling. That’s where a mixed methods
approach that really uses qualitative methods
can be really helpful. And the qualitative methods also
can be helpful in understanding the context for how some
of these levels interact. And then Joe Morrissey is
going to tell us more about an opportunity we saw in the
literature for more complex system and simulation
modeling. And then finally in translation, there is a
need for more transparency in the reporting of
contextual factors. And Elizabeth Yano is going
to talk to us more about this. We saw a need in the literature
for moving beyond our reification of fidelity to
the intervention to ways of thinking about interventions,
the locally adapted, that are reinvented,
that evolve over time, and that include
participatory approaches. Really moving beyond this idea
that we’re trying to discover interventions that can be
sustainable, to discovering principles and approaches in
intervention opportunities that we can articulate into
ways that can evolve over time and in different
situations and settings. And then to report that in
a way that others can use. I’m going to close with
discussion questions that we hope you’ll
consider in your groups. First there’s the question of
how do we develop multilevel interventions that create
synergy across these multiple levels, where the whole is
greater than the sum of the parts, that continually
pay attention to context, and that adapt and
learn over time. And another way of saying this
is “how do we develop designs and analytic techniques that
reflect the complexity of the phenomena we’re trying to
study and trying to influence?” And then how do we
disseminate to foster informed adaptation or
reinvention of local context and continued evolution
and learning. Thank you.>>>[APPLAUSE]

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