Can economic theory and methods help us learn which mechanisms work best in scaling up and spreading evidence-based health protections and prevention strategies to the population level? Economic analysis has become an essential part of the scientific process of identifying which prevention strategies are effective and cost-effective. Two decades of research from CDC’s Prevention Effectiveness program clearly demonstrate this fact. But what does economics offer to the rapidly developing field of implementation science, particularly when applied to the task of preventing disease and injury on a population-wide basis?
I had the chance to examine this issue with some brilliant colleagues this week as more than 700 scholars convened outside Washington DC for the 7th Annual Conference on the Science of Dissemination and Implementation hosted by AcademyHealth and NIH. The field of implementation science attracts a lot of attention these days, bolstered by NIH’s focus on translational research and more recently by PCORI’s game-changing research approach and its heavy emphasis on patient-centered mechanisms for disseminating and implementing effective health interventions. Although a relatively young field of inquiry, D&I research has made impressive strides in less than a decade. A consolidated conceptual framework of D&I processes and mechanisms now exists that integrates constructs from multiple theoretical traditions. Valid and reliable measures of D&I processes are now in use. And researchers are deploying a broad array of experimental, quasi-experimental, and descriptive research designs to study D&I mechanisms in health and medicine, many of which utilize mixed-method approaches.
Even so, economic theory and economic methods are surprisingly hard to find within the current D&I research landscape. This is surprising because, after all, many of the barriers encountered in disseminating and implementing evidence-based health interventions necessarily involve resource constraints, misaligned or under-powered incentives, and asymmetric information. Economics has a lot to say about these problems and their possible solutions. As just one example, we can look to the work of Nobel prize-winning economist Eric Maskin and his game-theoretic approach to implementation theory for solutions to implementation problems that involve social decision-making in the presence of decentralized and asymmetric information – situations that characterize many complex community-level health interventions.
Economic issues are lurking in the shadows of many of the D&I studies presented at this week’s conference, and two particularly prevalent issues are worth calling out. Some D&I studies involve interventions for which no explicit financing mechanism or payment model exists, so the implementation challenge implicitly involves convincing implementation settings to reallocate resources from existing activities in order to support new interventions. For example, RAND’s randomized trials of strategies to help Boys and Girls Clubs implement evidence-based programs for pregnancy and STI prevention fall into this bucket. From an economic implementation perspective, it would seem important to study the population health trade-offs entailed in scaling back staffing for, say, physical activity programs in order to accommodate the new prevention programs.
Other D&I studies focus on interventions that do have explicit financing mechanisms – such as colorectal cancer screenings that are covered by most health insurance plans – but the implementation challenge implicitly involves uncertainties about whether available funding streams are sufficient to fully meet the resource requirements of the intervention and its associated D&I mechanisms. The Emory University/Cancer Prevention and Control Research Network study of community health centers’ use of evidence-based practices for increasing colorectal cancer screenings falls into this bucket. While centers receive insurance payments for eligible insured patients who are screened, the resources expended to implement evidence-based supports like patient outreach and education, reminders, media communication, and provider assessments and feedback may not be commensurate with screening revenue, thereby necessitating some form of cross-subsidization. The extent to which these resource flows and uncertainties influence the spread and sustainability of the intervention appear to be worthy topics for investigation as part of implementation science.
So how can we address these compelling economic research opportunities? I had the good fortune of leading a roundtable session during the second day of the conference devoted to the economics of implementing population health strategies. The goal was to raise awareness among D&I researchers about the potential utility of incorporating economic theory and methods into their implementation science studies, particularly those studies focusing on prevention and population health strategies. Our premise was fairly straightforward:
“Successful strategies to scale up and spread complex community-level interventions require an understanding of the resources required for implementation, how best to distribute them among supporting institutions, and how resource consumption and distribution varies across settings.”
To make the case, I highlighted some of the studies we now have underway through our PHSSR Center and Public Health PBRN program that explicitly examine the economics of implementation, including work involving our National Longitudinal Survey of Public Health Systems (teaser slide below), the Multi-Network Practice and Outcome Variation (MPROVE) study, the Public Health Delivery and Cost Studies (DACS), and our Costing Study of Foundational Public Health Capabilities.
The rich discussion stimulated by this roundtable session has convinced me that there is much to be gained from incorporating economic theory and methods into D&I research studies – particularly those that use a population health lens and public health orientation. The dismal science is poised to play a more active role in this solution-focused scientific endeavor to scale and spread population health.