Viewpoint | Published 14 September 2020 | doi:10.4414/smw.2020.
20323
Cite this as: Swiss Med Wkly. 2020;150:w20323
Powering Swiss health care for the future:
implementation science to bridge “the valley of
death”
De Geest Sabinaab, Zúñiga Franziskaa, Brunkert Theklaac, Deschodt Miekead, Zullig Leah L.e, Wyss Kasparfg, Utzinger Jürgfg
a
Institute of Nursing Science, Department of Public Health, University of Basel, Switzerland
b
Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Belgium
c
Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
d
Gerontology and Geriatrics, Department of Public Health and Primary Care, KU Leuven, Belgium; and Healthcare and Ethics, Faculty of Medicine and Life
Sciences, UHasselt, Belgium
e
Department of Population Health Sciences, Duke University and Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans
Affairs Health Care System, Durham, USA
f
Swiss Tropical and Public Health Institute, Basel, Switzerland
g
University of Basel, Switzerland
A 2019 Swiss Academy of Medical Science (SAMS) bul- both. This type of waste results in a low proportion of the
letin addressed the challenge of translational research: the research initiated eventually resulting in high-quality sci-
enormous rift between basic scientific discoveries and their entific evidence.
use in clinical therapies [1]. The report termed this distance “Research waste 2” refers to the lack of effective and sus-
“the valley of death”. tainable translation and implementation of evidence-based
The same rift also applies to clinical research and the im- innovations from the trial world into daily clinical practice.
plementation of related health policies or innovations into The underperformance of the so-called “research pipeline”
routine health services. Achieving the Swiss Federal Coun- (fig. 1) is simply staggering.
cil’s health policy strategy 2020–2030 [2] and the United Various measures to reduce research waste 1 have been
Nations 2030 Agenda for Sustainable Development, com- implemented, with some success. Prominent examples in-
prising the 17 sustainable development goals (SDGs) [3], clude the obligation to register studies, widespread invest-
will mean embracing new approaches and following paths ment in clinical research infrastructures such as clinical tri-
that will speed up the translation and take-up of evidence al units, and guidelines supporting the quality of scientific
into real-world settings. Also in 2019, a report on im- reporting. While these and related measures have helped
proving patient safety and the quality of care in the Swiss raise the quality of randomised controlled trials [8], more
healthcare system called for investment in implementation are needed.
science as a critical path forward [4].
After all, even well-conducted, well-reported studies still
The valley of death is littered with well-researched, evi- need to cross that wasteland between the trial world and
dence-based programmes, practices, procedures, products real-world settings to guarantee the successful implemen-
and policies developed by health scientists and now desic- tation and sustainability of evidence-based innovations.
cating on bookshelves, waiting to be translated into real- To guide their translation into real-world settings, an in-
world settings. Meanwhile, an estimated 30–40% of pa- creased focus on “implementation science” – a combina-
tients do not receive treatments of proven efficacy, and tion of methodological approaches that focus primarily on
20–25% receive unnecessary or potentially harmful treat- research waste 2 – should be added early in the research
ments [5]. process.
Balas and Boren showed that as little as 14% of published Implementation science is “the scientific study of methods
evidence is translated into clinical practice. The mean wait to promote the systematic uptake of research findings and
between innovation and application is 17 years [6]. Imple- other evidence-based practices into routine practice, and,
mentation deficits contribute to excess research waste. hence, to improve the quality and effectiveness of health
Correspondence: We differentiate between two types of research waste (fig. services and care” [9]. First, though, it is a science, and
Sabina De Geest, PhD, RN,
Institute of Nursing Science,
1): “research waste 1” refers to what an influential Lancet therefore needs to be differentiated from quality improve-
Department Public Health, paper [7] described as research designed without reference ment. Conducting an implementation science study implies
Faculty of Medicine, Uni- to systematic reviews of the existing evidence, research not only a scientific evaluation of the effectiveness of an
versity of Basel, CH-4031 not published in full, studies with avoidable research flaws intervention in a real-world setting (i.e., pragmatic trials),
Basel, sabi-
[Link][at][Link]
and/or studies that are unusable, incompletely reported, or
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Figure 1: The leaky research pipeline: positioning research waste 1 and research waste 2.
but also an evaluation of how and why it either works or are measured concurrently. (6) “Implementation science-
fails in the specific context in which it was tried. specific designs”, such as hybrid designs, combine the
Evidence generated on effectiveness outcomes and from evaluation of an intervention’s effectiveness and the out-
the evaluation of the implementation pathway, including comes of implementation efforts (with the implementation
an assessment of implementation outcomes, can subse- pathway typically analysed using a mixed-methods ap-
quently be transferred to other contexts (whether similar or proach). (7) As diverse competencies are needed, imple-
different) to support a more efficient implementation and/ mentation research is typically conducted by “transdisci-
or scaling up of an intervention. Early attention to imple- plinary research teams”, where the complementary skill
mentation aspects relating to the research pipeline – opti- sets of implementation scientists are aligned with the
mally proof-of-concept and efficacy trials – has the poten- knowledge and skills of other team members, including
tial to shorten the time from discovery to implementation. policy- and decision-makers.
While implementation science builds on existing research Over the past decade, implementation science has gained
principles and methods, its focus is on external validity. traction worldwide as a valuable scientific approach. How-
Therefore, it is attentive to the additional complexities that ever, it has not yet been broadly embraced in Swiss health
characterise real-world contexts. Starting with the strength sciences research. While implementation science has been
of the evidence, implementation science requires the inte- used for some time by Swiss public health researchers for
gration of seven specific considerations (fig. 2) [10]. (1) health system-strengthening projects in the south and the
“Patient and public involvement” requires involving all east (e.g., within the Swiss Programme for Research on
relevant stakeholders in all stages of the project. (2) “Con- Global Issues and Development), the Swiss National Sci-
textual analysis” allows researchers to better understand ence Foundation (SNSF) has only recently funded its first
and map the relevant characteristics of the setting in which implementation science programmes under the umbrella of
the intervention will be implemented. Contextual informa- its National Research Programme 74.
tion contributes to effective intervention co-design and in- Also, to strengthen and foster recognition of implementa-
forms the choice of contextually relevant implementation tion science in Switzerland, the Swiss Implementation Sci-
strategies. (3) Implementation science-specific “theoretical ence Network (IMPACT) was recently launched. IMPACT
frameworks” guide either parts or all of an implementation pursues four major aims: (1) to showcase implementation
science study. (4) “Implementation strategies” facilitate the science healthcare projects conducted by Swiss healthcare
adoption, implementation, sustainability and scaling up of researchers and institutions; (2) to provide networking op-
specific interventions, programmes or practices. (5) “Ef- portunities for implementation science researchers and oth-
fectiveness” (e.g., healthcare utilisation, survival and med- er interested stakeholders in Switzerland; (3) to provide
ication adherence) and “implementation outcomes” (e.g., implementation science training opportunities; and (4) to
feasibility, acceptability reach and implementation cost) leverage funding options for implementation science in
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Switzerland. It is hoped that IMPACT will function as a more cost-effective – particularly by shortening the time to
catalyst to advance the effective translation and implemen- routine use of results – the complexities of implementation
tation of evidence-based interventions, programmes and science studies (e.g., use of contextual analysis, stakehold-
policies, both in Switzerland and beyond. IMPACT is also er involvement, implementation strategies) need to be re-
expected to stimulate approaches to integrating implemen- flected in the funding mechanisms.
tation science expertise into the early stages of clinical tri- Finally, strategies to apply implementation science meth-
als as part of research infrastructures. ods to Swiss health research offer an excellent return on
In our view, boosting the performance of the Swiss health- investment. Designing studies specifically to overcome
care system requires bridging the “valley of death”, which translation barriers promises to remove years from the cur-
will involve increasing the research capacity for imple- rent research process. This, in turn, will maximise the en-
mentation science. First, implementation science needs to tire Swiss research enterprise’s value for patients and pop-
be recognised as an essential part of a high-performing re- ulations. In effect, it will bridge the valley of death.
search enterprise, with high societal returns on investment.
Second, as implementation science projects require com- Disclosure statement
No financial support and no other potential conflict of interest relevant
petencies beyond the traditional clinical research methods,
to this article was reported.
researchers need opportunities both to develop these com-
petencies and to learn the principles of implementation sci- References
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2 Health2030 – the Federal Council’s health policy strategy for the period
evidence-based interventions, but also enhance their sus- 2020–2030. Available from: [Link]
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Figure 2: Key components of implementation science.
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Viewpoint Swiss Med Wkly. 2020;150:w20323
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