The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management?
Introduction
Care of patients with chronic illnesses is arguably the major health care challenge for the next century [1], [2]. Chronic illness management modalities include face-to-face counseling, community outreach programs, and computer-mediated interventions. Often choices regarding which type of intervention to adopt are based on organizational precedence, convenience for providers, or results in randomized efficacy trials rather than impact in practice settings. More comprehensive evaluation of the strengths and weaknesses of different delivery modalities should lead to greater public health impact and more cost-effective health care.
This article illustrates how many commonly used interventions can result in inequitable and limited patient participation, and poor implementation, impact, and maintenance. Our purpose is to stimulate a more comprehensive and systematic comparison of the strengths and weaknesses of different intervention modalities so that resources are allocated in the most efficient and equitable manner. To accomplish this, we use the “RE-AIM” framework [3], [4], [5], [6] to help refocus priorities on public health issues and give balanced emphasis to internal and external validity. Like previous work by Green et al. [7], Rogers [8], and Abrams et al. [9], upon which it draws, RE-AIM is concerned with issues related to impact in real-world settings and the translation of research to practice. RE-AIM integrates and extends this previous work by incorporating both individual and organizational setting level variables, and by including long-term maintenance issues at both levels. A major feature of RE-AIM is that it shifts the focus from short-term efficacy among restricted samples of participants in randomized efficacy trials to longer-term effectiveness in real-world settings.
We illustrate the use of RE-AIM for comparing chronic disease intervention modalities. The RE-AIM model consists of five evaluative dimensions that describe the overall population-based impact of an intervention: Reach, Efficacy, Adoption, Implementation, and Maintenance (see Table 1).
Reach refers to the participation rate within the target population and the characteristics of participants versus non-participants. Factors determining reach are the size and characteristics of the potential audience and patients’ barriers (e.g. cost, necessary referrals, scheduling, transportation, and inconvenience) to participation. Efficacy pertains to the impact of an intervention on specified outcome criteria, when it is implemented as intended [10], [11]. Adoption operates at the system level and concerns the percentage and representativeness of organizations that will adopt a given program. Factors associated with adoption include cost, level of resources and expertise required, and how similar a proposed service is to current practices of the organization. Implementation refers to intervention integrity, or the quality and consistency of delivery when the intervention is replicated in real-world settings. Finally, Maintenance operates at both the individual and the system level. At the individual level, maintenance refers to how well behavior change efforts hold up in the long term. At the organization level, it refers to the extent to which a treatment or practice becomes institutionalized [12] as a routine part of usual care within an organization.
Section snippets
Intervention modalities
To illustrate the application of RE-AIM, we compared 13 common chronic illness intervention modalities (Columns 1–3 in Table 2) using the five RE-AIM dimensions. Of course, different interventions can be used in combination or simultaneously. Nevertheless, each of the interventions we considered is conceptually distinct, and comparisons using the various RE-AIM dimensions can be enlightening. In rating different modalities, we have assumed that the content is appropriate for the audience in
Results of consensus ratings
Within the broad categories just described, we considered 13 specific intervention types. The four authors each independently categorized each intervention type as high, medium, or low on each of the five RE-AIM dimensions (Table 3). When there were disagreements, majority ratings were used.
Discussion
This article illustrates use of a new framework for considering the strengths and limitations of chronic illness intervention modalities. The various RE-AIM dimensions provide a comprehensive set of criteria for evaluating interventions that should be of relevance to researchers, funders, and program planners [3], [5]. Two strengths of this approach that make it particularly appropriate for public health and population-based applications are its emphasis on external validity (Reach and
Implications for practice and policy
The purpose of this article was to illustrate the use of the RE-AIM model as a heuristic framework with which chronic disease management strategies can be considered and compared. By providing a common metric for evaluating a wide range of interventions, the RE-AIM framework could be used to set priorities for research funding and reimbursement. By addressing both individual and system level impacts, RE-AIM could form the basis for a more sophisticated consideration of interventions from the
Acknowledgements
This research was supported by NIH grants, RO1 DK 35524-13 (Dr. Glasgow), 5 PO1 CA72085 (Dr. Glasgow), RO1 DK 51581 (Dr. McKay), and the Health Services Research and Development Service and Mental Health Strategic Health Group of the Department of Veterans Affairs, and by the Clinical Research Grants Program of the American Diabetes Association (Dr. Piette). We thank Dr. Tom Vogt for helpful comments on an earlier draft.
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