From 17 years to 17 months (or maybe 14)

Most papers and presentations about improving the quality of health care begin by lamenting the apocryphal 17-year delay from research to implementation.   The original evidence for that much-repeated 17-year statistic is pretty thin: a single table published in a relatively obscure journal.  But the 17-year statistic is frequently cited because it quantifies a widely recognized problem.  Long delays in the implementation of research evidence are the norm throughout health care.

Given that history, I’ve been especially proud of our MHRN health systems for their rapid and energetic implementation of suicide prevention programs.  This month, Kaiser Permanente Washington started implementing MHRN-developed suicide risk prediction models.  Therapists and psychiatrists at our Capitol Hill Mental Health clinic in Seattle now see pre-visit alerts in the electronic health record for patients who are at high risk of a suicide attempt over the next 90 days.  Implementation started only 17 months ─ not 17 years ─ after we published evidence that those models accurately predict short-term risk of suicide attempt or suicide death.

I certainly have experience developing other evidence-based interventions that are still waiting for wide implementation – some for longer than 17 years.  For those interventions, our published papers, PowerPoint presentations, and impressive p-values never prompted much action.  Our experience with suicide risk prediction models has been almost the opposite: health system leaders are pushing for faster implementation.  For months we’ve received frequent queries from regional and national Kaiser Permanente leaders: “When are you rolling out those risk prediction scores in our clinics?” 

In the middle of celebrating Kaiser Permanente’s rapid implementation of risk prediction models, I learned that our colleagues at HealthPartners were three months ahead of us.  I hadn’t realized that health plan care managers at HealthPartners have been using MHRN risk prediction scores to identify people at high risk for suicidal behavior since July.  In true Minnesota fashion, they just did the right thing with no boasting or fanfare.  Reducing the publication-to-implementation gap from 17 years to 14 months doesn’t have quite the same poetic symmetry as reducing it to 17 months.  But I’ll take faster progress over poetic symmetry.

Why did we see so little delay in our health systems’ implementation of suicide risk prediction models and other suicide prevention programs?  We didn’t need to do any marketing to create demand for better suicide prevention.  Health system leaders were clear about priorities and problems needing solutions.  The specific demand regarding risk prediction models was clear:  The questionnaires providers were using to identify suicide risk were better than nothing, but far short of satisfactory.  Knowing the limitations of the tools they were using, clinicians and health system leaders asked:  Can you build us something better?  We weren’t telling health system leaders what we thought they needed.  We were trying to build what they told us they needed.

When I now hear researchers or intervention developers lament the 17-year delay, I ask myself how that complaint might sound in some other industry.  I imagine giving this report to a board of directors: “We developed and tested an innovative product that our customers really should want.  We’ve spent 17 years telling them about it, but our market share is still trivial.  What’s wrong with our customers?”  I doubt the board of directors would say, “Let’s keep doing the same thing!”  Instead, they’d probably ask, “What are our customers trying to tell us about what they need?”

Greg Simon

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