EFFECTIVE DISSEMINATION OF HEALTH AND CLINICAL INFORMATION AND RESEARCHFINDINGS



NIH GUIDE, Volume 21, Number 10, March 13, 1992



PA NUMBER:  PA-92-51



P.T. 16



Keywords:

  Information Science/Systems 

  Health Services Delivery 

  Technology Assessment 

  Technology Planning/Policy 



Agency for Health Care Policy and Research



PURPOSE



The Agency for Health Care Policy and Research (AHCPR) invites

applications to conduct applied research and demonstrations on

effective dissemination of health-related information and clinical

practice guidelines, technology assessments, general health services

research findings, and research findings used in policy decisions and

recommendations.



HEALTHY PEOPLE 2000



The Public Health Service (PHS) is committed to achieving the health

promotion and disease prevention objectives of "Healthy People 2000,"

a PHS-led national activity for setting priority areas.  This Program

Announcement, Effective Dissemination of Health and Clinical

Information and Research Findings, could be related to any priority

area.  Potential applicants may obtain a copy of "Healthy People 2000"

(Full Report:  Stock No. 017-001-00474-0) or "Healthy People 2000"

(Summary Report:  Stock No. 017-001-00473-1) through the Superintendent

of Documents, Government Printing Office, Washington, DC 20402-9325

(telephone 202-783-3238).



ELIGIBILITY REQUIREMENTS



Applications may be submitted by public and private non-profit

institutions, units of State and local government, and individuals.

For-profit institutions are not eligible for AHCPR grants.



MECHANISM OF SUPPORT



This Program Announcement will use the traditional research grant

(R01).  Responsibility for the planning, direction, and execution of

the proposed project will be solely that of the applicant.  It is

anticipated that projects will vary from one to three years in length.

Project lengths could be up to five years in rare cases due to the

complexity or breadth of the subject area, or in areas proposing to

investigate the longer term effects of particular forms of

dissemination.



RESEARCH OBJECTIVES



Background



The purpose of the AHCPR is to enhance the quality, appropriateness,

and effectiveness of health care services and to improve access to that

care.  AHCPR is the Federal Government's focal point for general health

services research, including medical effectiveness research, and has

lead responsibility for the Medical Treatment Effectiveness Program

(MEDTEP).  MEDTEP projects systematically study the relationships

between medical treatments and procedures and the outcomes.  Patient

Outcomes Research Team (PORT) projects focus on variations in clinical

practice and outcomes for a particular medical condition.  The AHCPR

convenes expert non-Federal panels and awards contracts to develop

clinical practice guidelines for specific conditions and treatments.

The AHCPR Office of Technology Assessment evaluates medical devices,

procedures and services and makes coverage recommendations to Federal

health programs.  The AHCPR intramural research program undertakes

health policy research and analysis on National medical expenditures,

hospital cost and utilization data, and long-term care.  Health

services research focuses on a broad range of policy and delivery

system issues in the areas of cost and financing, primary care, and

technology and quality assessment.  In addition, the AHCPR is

responsible for increasing the quality and quantity of data for general

health services research, including medical effectiveness research.



The AHCPR authorizing legislation (the Omnibus Budget Reconciliation

Act of 1989, P.L. 101-239) requires the AHCPR to disseminate as broadly

as possible the products and results of its research.  This Program

Announcement for demonstrations and applied research is part of the

AHCPR dissemination program.  The focus on "effective dissemination" is

based upon a growing recognition that distribution of information does

not guarantee adoption or use.  The definition of effective

dissemination used in this PA goes beyond the traditional concepts of

diffusion and distribution of information and encompasses the process

through which target groups become aware of, receive, accept, and

utilize disseminated information.  The test of effective use is the

extent to which target audiences become more informed, make decisions,

or change behavior patterns as a result of using the disseminated

information.  The goal of effective dissemination is to improve patient

care, patient outcomes and quality of life.



Early studies of innovation diffusion in the health arena examined the

spread of new information, knowledge or technologies, the

characteristics of the diffusion process, and the role that people and

organizations played in the adoption of innovations.  These studies

confirmed that some innovations were not adopted or utilized and that

there was a long lag time between availability and widespread use of

new scientific information.



Underlying many efforts to provide new clinical information or practice

guidelines to practitioners has been the assumption that clinical

practice behavior will change if relevant scientific evidence is

effectively disseminated to health care providers and patients.  The

dissemination-related health literature has focused primarily on the

introduction of medical technology, the flow of new information into

practice, continuing medical education, and more recently on physician

behavior change resulting from the diffusion of new information or

clinical practice guidelines.  Most of this literature has focused on

practitioners and health care settings.  Pertinent research related to

consumers has focused on public health and health education

information, the psychology of mass communications and other work

related to marketing.  Research directed at policy makers has examined

the use of data and evaluation studies in legislative and executive

settings.



Objectives



The objective of this Program Announcement is to stimulate new grant

applications for demonstrations and applied research projects that

examine the most effective means of disseminating a broad range of

products (health and clinical information, research findings, clinical

practice guidelines, technology assessments, policy recommendations) to

a wide variety of target groups (consumers, health care practitioners,

the health care industry, researchers, policy makers, and the press).

Applied research in effective dissemination should be

multi-disciplinary, drawing on the fields of communications and

information theory, commercial marketing, social and behavioral

psychology, education, computer sciences, and policy sciences.  The

eventual goal is for disseminated information to be assimilated and

used in ways that improve the effectiveness and quality of health care

services, utilization of and access to those services, and ultimately

patient outcomes and quality of life.



A.  Audiences, media, and products of dissemination -- The audiences,

media, and products of dissemination that are of interest to the AHCPR

include:



Audiences:  Consumers (individuals or organizations); health care

practitioners of all disciplines (physicians, nurses, allied health

professionals, and professional organizations); the health care

industry (organizations, group practices and managed care

organizations, third-party payers, medical equipment manufacturers,

pharmaceutical manufacturers, Federal health care systems, quality

assurance and utilization review organizations); policy makers

(Federal, State and local, executive and legislative, and private

sector decision makers); researchers (both biomedical and general

health services); and the press (popular media and newspapers, general

health, trade and scientific journals).



Media:  Printed (direct mail, technical and trade journals, popular

magazines and newspapers); and electronic (TV, radio, and electronic

databases).



Products:  General health services research findings; clinical

information; clinical practice guidelines; health technology

assessments; research-based policy recommendations; and general health

information for consumers.



B.  Types of projects supported -- The AHCPR invites applications on

effective dissemination that focus on practical methods to achieve

better informed audiences, improved decision making, and behavioral

change that improve the delivery of health care and patient outcomes.

AHCPR encourages projects that involve dissemination of AHCPR products

or other research and information products similar to AHCPR products so

that findings can contribute to improving the effectiveness of the

dissemination program.  The following types of projects will be

considered responsive to this Program Announcement:



1.  Demonstration projects (with appropriate research hypotheses)

measuring the effectiveness of dissemination mechanisms (e.g.,

continuing professional education, opinion leaders, peer review and

feedback, computerized systems, incentives, organizational approaches)

or combinations of mechanisms in stimulating the use of disseminated

information;



2.  Studies examining the comparative effectiveness of different

dissemination mechanisms using the same information with different

audiences or different information with the same audiences;



3.  Studies examining the effectiveness of different dissemination

mechanisms under conditions in which the target audiences are either

economically advantaged or economically disadvantaged by the behavioral

change;



4.  Studies examining the comparative cost of different methods of

stimulating behavior change (e.g., cost measures may be calculated by

cost per thousand population, magnitude of changes);



5.  Longitudinal studies of sustained change in knowledge, skills,

attitudes, and behavior as a result of dissemination of health and

clinical information;



6.  Projects designed either to improve health services research

methods as applied to effective dissemination or to overcome

dissemination research problems, especially projects that focus on

multi-disciplinary research methods (e.g., the use of behavioral change

models in health information dissemination campaigns); and



7.  Innovative research on unique methods of reaching particular

audiences (e.g., informing consumers to stimulate and effect

practitioner behavioral change and multi-faceted dissemination

campaigns).



C.  Research Questions -- The following questions are illustrative of

the kinds of research questions that grant applications might address

concerning the audiences, products, and dissemination mechanisms

discussed above:



o  What can be learned from dissemination experiences of the past to

help ensure that disseminated information is assimilated and used by

target audiences?  What are the crucial variables in these experiences

(e.g., quality of information, format, endorsements, economic impact,

targeting activities)?



o  How can the experience and knowledge of the commercial marketing and

advertising enterprises be adapted to the dissemination of health and

clinical information in the professional/patient environment to effect

behavior change?



o  How effective are the mass media in transmitting health information

to practitioners and consumers?  What are the determinants of

behavioral change resulting from information presented in the media?



o  What are the needs and preferred sources of different audiences for

health and clinical information and how do these needs affect the

design of dissemination strategies?  What do we know about the needs of

the six major groups of audiences and how do the needs differ?  How do

differences among audiences affect the development of dissemination

strategies?



o  How do the attributes of disseminated products and information

(credibility of source, content tailored to audience need, product

format, timeliness, utility of product, adaptability, validity, ability

to be evaluated) affect dissemination strategies and how are these

attributes associated with acceptance and use or rejection of

disseminated information?



o  When is the best moment in time for dissemination to take place to

maximize the likelihood that it is used by a targeted audience?  Does

this moment differ across audiences?



o  Is the health belief model for disseminating health information to

consumers the most appropriate one to guide dissemination strategies?

What alternative models could be developed or considered?



o  What are the economic, social, educational, and psychological

determinants of consumer and practitioner behavior in accessing and

using health and clinical information?  At what points in that behavior

can dissemination strategies most effectively intervene to stimulate

change in that behavior?



o  How do cultural, socioeconomic, and access factors affect the

assimilation of clinical information by providers and patients within

special populations or target groups and geographic areas (e.g.,

minority and rural)?



o  Who are health practitioner peers and what is the typology for their

constituent groups?  What are the determinants of change produced by

peer influence?



o  How can the principles of "academic detailing" be adapted to

dissemination strategies for consumers and policy makers?



o  What factors are associated with effective use of the professional

education and continuing professional education systems in

disseminating new scientific information and its adoption into clinical

practice?



o  What roles do organizational and/or personal networks play in the

dissemination process?  Do networks speed the dissemination or the

assimilation and use of new information?  What are the implications for

dissemination of the communication patterns within and between

networks?



o  How can communication and computer technologies be designed to

affect assimilation and retention by health care providers?



o  What is the comparative effectiveness of different systems to

computerize medical practice guidelines in disseminating new clinical

information to practitioners?



o  What is the effect of structural and process variables (e.g.,

multifaceted organizational relationships within provider

organizations; work environment; personnel mix; administrative

governance; medical direction; type of medical equipment available

within an institution; degree of compliance with recommended

guidelines; and level of internal communication) within different

provider settings on the relationship between the assimilation of

practice guidelines by providers and patient outcomes?  How do these

variables facilitate or hinder the dissemination and assimilation of

new information and knowledge?



o  How do organizational factors affect the adoption of new information

and innovations and when does that adoption result in decisions that

improve efficiency or patient outcomes?  Do different kinds of health

care organizations or personnel within them (e.g., different management

levels) differ in patterns of assimilation and use of information?



o  What is the appropriate typology for the use of new knowledge or new

information by policy makers?



o  What is the most effective means of translating, synthesizing, or

adapting data and findings from health services research and clinical

trials into useful information for policy makers and decision makers at

the Federal, State and local levels and the private sector?



o  How do economic and regulatory incentives affect the timing and

nature of decisions to adopt and utilize medical practice guidelines?



o  What are the most effective avenues for reaching third party payers

and other decision makers in the private sector with health and

clinical information and research findings?  What formats and products

are associated with the most utility to these audiences?



o  How can dissemination strategies be made most cost-effective?  When

resources are insufficient to disseminate information broadly to all

audiences, what mechanisms exist to select target groups and maximize

the effectiveness of what is disseminated?



STUDY POPULATIONS



SPECIAL INSTRUCTIONS TO APPLICANTS CONCERNING INCLUSION OF WOMEN AND

MINORITIES IN RESEARCH STUDY POPULATIONS



The AHCPR requires all applicants for research grants to include

minorities and women in study populations so that research findings can

be of benefit to all persons at risk of the disease, disorder, or

condition under study.  Special emphasis must be placed on the need to

include minorities and women in studies of diseases, disorders and

conditions which disproportionately affect them.  This policy is

intended to apply to males and females of all ages.  If women or

minorities are excluded or inadequately represented in research, a

clear and compelling rationale should be provided.  AHCPR will not

award grants for applications which do not comply.  If the required

information is not contained in the application, the application will

be returned without review.



The composition of the proposed study population must be described in

terms of gender and racial/ethnic group.  In addition, gender and

racial/ethnic issues should be addressed in developing a research

design and sample size appropriate for the scientific objectives of the

study.  This information should be included in the form PHS 398 in

Section 2, A-D of the Research Plan AND summarized in Section 2, E,

Human Subjects.



Applicants are urged to assess carefully the feasibility of including

the broadest possible representation of minority groups.  However,

AHCPR recognizes that it may not be feasible or appropriate in all

research projects to include representation of the full array of United

States racial/ethnic minority populations (i.e., Native Americans,

Asian/Pacific Islanders, Blacks, Hispanics).  Where appropriate, the

applicant must provide the rationale for studies on single minority

population groups.



For the purpose of this policy, clinical research includes human

biomedical and behavioral studies of etiology, epidemiology, prevention

(and preventive strategies), diagnosis, or treatment of diseases,

disorders or conditions, including but not limited to clinical trials.



The usual NIH policies concerning research on human subjects also

apply.  Basic research or clinical studies in which human tissues

cannot be identified or linked to individuals are excluded.  However,

every effort should be made to include human tissues from women and

racial/ethnic minorities when it is important to apply the results of

the study broadly, and this should be addressed by applicants.



For foreign awards, the policy on inclusion of women applies fully;

since the definition of minority differs in other countries, the

applicant must discuss the relevance of research involving foreign

population groups to the United States' populations, including

minorities.



If the required information is not contained within the application,

the application will be returned.



Peer reviewers will address specifically whether the research plan in

the application conforms to these policies.  If the representation of

women or minorities in a study design is inadequate to answer the

scientific question(s) addressed AND the justification for the selected

study population is inadequate, it will be considered a scientific

weakness or deficiency in the study design and will be reflected in

assigning the priority score to the application.



All applications for clinical research submitted to NIH are required to

address these policies.  NIH funding components will not award grants

or cooperative agreements that do not comply with these policies.



APPLICATION PROCEDURES



Applications are to be submitted on the grant application form PHS 398

(rev. 9/91) and will be accepted at the standard application deadlines

as indicated in the application kit.  State and local governments may

use Form PHS 5161 and submit an original and two copies of the

application.



Application kits are available at most institutional business offices

and may be obtained from the Office of Grants Inquiries, Division of

Research Grants, Westwood Building, Room 449, National Institutes of

Health, Bethesda, MD 20892, telephone 301/496-7441.  They may also be

obtained from the Office of Scientific Review, Agency for Health Care

Policy and Research, Suite 602, 2101 East Jefferson Street, Rockville,

MD 20852, telephone 301/227-8449.  The title and number of the Program

Announcement must be typed in Section 2a on the face page of the

application.



The completed original application and five legible copies (two copies

when using the PHS 5161) must be sent or delivered to:



Division of Research Grants

National Institutes of Health

Westwood Building, Room 240

Bethesda, MD  20892



The Division of Research Grants (DRG) will not accept any application

in response to this announcement that is essentially the same as one

currently pending initial review, unless the applicant withdraws the

pending application.  The DRG will not accept any application that is

essentially the same as one already reviewed.  This does not preclude

the submission of substantial revisions of applications already

reviewed, but such applications must include an introduction addressing

the previous critique.



Applications must be received by the Division of Research Grants, NIH.

The first due date is June 1, 1992.  Thereafter, the due dates for

application are October 1 and February 1 and June 1.  However, an

application received after a deadline may be acceptable if it carries

a legible proof-of-mailing date assigned by the carrier and the

proof-of-mailing date is not later than one week prior to the deadline

date.  If the receipt date falls on a weekend, it will be extended to

Monday; if the date falls on a holiday, it will be extended to the

following work day.  The receipt date will be waived only in

extenuating circumstances. To request such a waiver, an explanatory

letter must be included with the application.  No waiver will be

granted prior to receipt of the application.



REVIEW CONSIDERATIONS



The review criteria for these applications are the considerations of

scientific and technical excellence, which include:  adequacy of the

method to carry out the project; availability of the data or the

proposed plan to collect the data required for the project;

qualifications and experience of the Principal Investigator and

proposed staff; adequacy of the plan for organizing and carrying out

the project; reasonableness of the proposed budget; and adequacy of the

facilities and resources available to the applicant.



Upon receipt, applications will be reviewed for completeness.

Incomplete applications will be returned to the applicant without

further consideration.  Applications will be evaluated in accordance

with the criteria stated above for scientific/technical merit by an

appropriate peer review group.  Applications assigned to the AHCPR and

that request total direct costs in excess of $250,000 will be reviewed

extensively by the National Advisory Council for Health Care Policy,

Research and Evaluation.  Secondary review of applications will be by

the appropriate National Advisory Council.



AWARD CRITERIA



Applications will compete for available funds with all other

applications.  The following will be considered in making funding

decisions:  Quality of the proposed project as determined by peer

review, availability of funds, and program balance among research areas

of the announcement.



INQUIRIES



Those considering applying in response to this PA are strongly

encouraged to discuss the project with AHCPR program administrators in

advance of formal submission.  The opportunity to clarify any issues or

questions from potential applicants is welcome.  Direct inquiries

regarding programmatic issues to:



Margaret VanAmringe, Director

Center for Research Dissemination and Liaison

Agency for Health Care Policy and Research

2101 East Jefferson Drive, Suite 501

Rockville, MD  20892

Telephone:  (301) 227-8362



Direct inquiries regarding fiscal matters to:



Ralph Sloat

Grants Management Officer

Agency for Health Care Policy and Research

2101 East Jefferson Street, Suite 601

Rockville, MD  20857

Telephone:  (301) 227-8447



AUTHORITY AND REGULATIONS



This program is described in the Catalog of Federal Domestic Assistance

No. 93.180 and 93.226. Awards are made under authorization of the

Public Health Service Act, Title IX, as amended (Public Law 101-239)

and administered under PHS grants policies and Federal Regulations 42

CFR 67, Subpart A and 45 CFR Part 74.  This program is not subject to

the intergovernmental review requirements of Executive Order 12372.



.

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