Getting SMART About Adaptive Implementation Interventions
Presenter: Daniel Almirall & Amy Kilbourne
University of Michigan
The effective treatment and management of a wide variety of health disorders often requires individualized, sequential decision-making. To do this, each patient’s treatment is dynamically tailored over time based on the patient’s history and changing disease state. Adaptive interventions (also known as dynamic treatment regimens) operationalize such individualized decision making using a sequence of decision rules that specify which intervention option to offer, for whom, and when. Intervention options in this case correspond to varying doses, types or delivery modes of pharmacological, behavioral and/or psychosocial treatments. Recently, there has been a surge of clinical and methodological interest in developing and evaluating adaptive interventions via clinical trials. Specifically, there is great interest in the use of sequential multiple assignment randomized trials (SMART), a type of multi-stage randomized trial design, to build high-quality adaptive interventions. The primary aim of this workshop is to provide a brief, conceptual introduction to adaptive interventions and SMART designs. We will use examples of SMART studies in child and adolescent mental health to explain and illustrate ideas. A secondary aim of this workshop is to introduce the idea of adaptive implementation interventions and the use of cluster-randomized SMART designs for their development. In an adaptive implementation intervention, the intervention options correspond to different types and intensities of implementation strategies; these are tailored to site-specific contextual factors. Implementation strategies are highly-specified, theory-based approaches that are used to improve the uptake of effective clinical practices in routine care. For example, not all sites require more intensive (and costly) implementation strategies (e.g., provider coaching, or Facilitation approaches), and may adopt a clinical practice via less costly approaches such as provider training and clinical reminders. As an example, we will present the design and rationale of the ADEPT Study, a NIMH-funded cluster-randomized SMART which aims to develop a high-quality adaptive implementation intervention to improve the uptake/adoption of an evidence-based intervention, known as Life Goals, in community mental health settings.