From evidence to practice: Dr. Makarov discusses implementation science in urology

In this interview, Danil V. Makarov, MD, MHS, discusses 2 sessions on implementation science that were presented at the 2024 American Urological Association Annual Meeting in San Antonio, Texas. Makarov is a urologist, a health services researcher, and an associate professor of urology and population health, and health policy at New York University School of Medicine in New York, New York.

Danil V. Makarov, MD, MHS

This transcription has been edited for clarity.

Could you highlight the key points from the AUA session, “Implementation Determinants: What gets in the way of evidence-based practice?”

My talk was part of a session called "Implementation Science 101." It was introducing implementation science to the average urologist who might not necessarily be a researcher or an implementation scientist. There was a group of talks on how this type of research is done, what it's used for, etc. My talk was focused on the things that make an intervention work or fail. Some of the things that I discussed is that it's important for us to have our own sense of whether something will work, why it will work, or why it won't work. But also, when you're working in the implementation science space, there's a more formal process of eliciting those implementation determinants, involving collecting mixed methods data, meaning collecting quantitative data, which I think a lot of urologists are very familiar with, but also collecting qualitative data. [This includes] semi-structured, open-ended interviews where you interview stakeholders in the process and ask them, in an open-ended way, what they think about it. The reason that we do this is that we have to approach things in a humble way, where we may not know all the reasons why something worked or why something had failed.

Then, helping to guide that, there are many approaches. This type of inquiry comes out of medical anthropology. You can use a perspective called grounded theory methodology, where you presuppose nothing about the situation. As you might imagine, there's been a lot of work in medical anthropology, a lot of work in the quality improvement space and implementation science, and there are certain theoretical frameworks that that can be applied. The one that I mentioned and that I discussed a lot in my talk was the theoretical domains framework, which is a set of 14 domains, and they don't presuppose an interaction between the domains. It's a good list of things that you should be touching on, or at least considering, in your evaluation of implementation determinants. When you arrive at these implementation determinants, these barriers and facilitators, then there are other theoretical frameworks that allow you to translate that into interventions that you can then roll out in specific situations.

What are you hoping that urologists take away from that session?

I think the main thing that urologists should take away is the importance of Implementation science, and the [ways] that clinicians, in a lot of different roles, participate in Implementation science in its various forms. There are a lot of applications of findings from implementation science, which are really useful in quality improvement. For urologists who are interested in an academic career, I think implementation science is a great space for folks who have medical training. Sometimes it's difficult for us as researchers to say, compete in the laboratory against PhDs who are there all the time, or compete for funding against health care economists or biostatisticians who spend all their time developing these methods. But within implementation science, it's very much a team sport. What our major contribution is, I think as urologists doing implementation science, is determining the important questions, which we are particularly well-suited to do because we're taking care of the patients. We know where the bottlenecks and the problems are in clinical practice. And then also, many physicians are really good at working in teams, because that's what we do all throughout our training and throughout our practice. This is another application of that. It's a lot of fun. It's a great career. We have a really great group of formally trained implementation scientists in urology who are doing a lot of great work. Most of us know one another, and it's a very collegial group of folks.

You also participated in another session titled, “Implementation Strategies on the Front Lines: Practice Panel Discussion of A&F in Urology.” Could you highlight key takeaways from that discussion?

The panel session was really useful. It was led by Shellie Ellis, and she asked practical questions about different projects that we were working on. There were questions about trial designs, [such as] when is it appropriate to do a randomized trial? How should those types of trials be done? Spoiler alert: they usually are cluster randomized trials, and the ideal is a stepped wedge design. However, that's not always possible to do. You sometimes have to rely on quasi-experimental designs. So, I think it was a really good session.

A lot of people came up afterwards. There was a group of folks who stayed through the entire time and had an informal discussion afterwards. I think there's a really strong community in this space. There are a lot of acknowledgements of the importance of the methods and the tools of implementation science and how they can be very useful for urology. There appears to be a lot of a lot of enthusiasm for that.

Is there anything else you want to add?

There was a lot of discussion about how "the time is now" with implementation science, and what things we should be working on and how we should be collaborating. I want to give my full support towards that sentiment. This is a great lens and a great set of tools for approaching important questions in a rigorous way that will both help specific individual patients, but also generate knowledge for these types of efforts in the future.