Implementation of an Innovative Health Service A “Real-World” Diffusion Study Janneke Harting, MPH, Patricia van Assema, PhD, Erik Ruland, MD, Patrick van Limpt, MD, Ton Gorgels, PhD, Jan van Ree, PhD, Frank Vermeer, PhD, Nanne K. de Vries, PhD Background: Although reporting on the healthcare-setting level of continuance or discontinuance of an intervention once a trial is completed has been recommended, such “real-world” diffusion studies are rare. The present example was made possible by funding to explore opportu- nities for post-trial implementation of an innovative health counseling intervention for cardiovascular prevention in The Netherlands. Methods: Between 2001 and 2004, in a longitudinal case study, we compared two healthcare settings: a cardiology outpatient clinic and general practices. Rogers’ diffusion of innovations theory served as the theoretical background. Information was extracted from minutes of meetings and informal conversations with health counselors, and checked by the project manager. Additional data were collected from physicians with a short questionnaire. Results: Implementation of the health counseling intervention was successful in the cardiology outpatient clinic, but was unsuccessful in the general practices. Success was related to a centralized diffusion system, stronger “change agent” efforts, avoidance of post-trial interruption of service delivery, easily achievable “reinventions,” and positive physician perceptions of the service (i.e., not complex and compatible with current practice routines). Support came from changes in the organization of care that created opportu- nities for, instead of competition with, the innovative service. However, coincidental events may also have played a part. Conclusions: Our findings confirm the importance of most theoretically predicted individual and organizational diffusion variables. This implies that the implementation of innovative healthcare services requires attention at both levels. (Am J Prev Med 2005;29(2):113–119) © 2005 American Journal of Preventive Medicine Introduction R eal-world diffusion studies are needed to learn about the exportability of interventions in less- controlled conditions than those accompanied by trials. 1,2 However, diffusion studies constitute 1% of all public health and health promotion research, 3,4 and the continuation of health behavior change pro- grams has rarely been reported at healthcare setting level. 5 This article describes the post-trial implementa- tion of an innovative health counseling service. Counseling by a health advisor about healthy lifestyle changes for patients at high cardiovascular risk was a new, additional service in the Dutch healthcare system. To assess its effectiveness, the service was initially of- fered in a randomized controlled trial (1999 to 2001) in one cardiology outpatient clinic, and in several general practices. As the trial progressed, the question arose as to whether the service could be continued. Although results of the trial were not yet available, based on encouraging outcomes of the accompanying process evaluation, a Dutch health insurance company never- theless provided funding to explore opportunities for further implementation (2001 to 2004). The subsidy comprised payment for the health advisors (2005 US$258,000), indirect costs (accommodation, traveling expenses, materials, and training [US$72,000]), and a small research grant (US$22,000). This course of events created a rather unique oppor- tunity to study the implementation of the innovation “on its way” to conduct a comparative analysis, 6 and thus to report at setting level on the post-trial continu- ance of the intervention. 7 For this purpose, Rogers’ diffusion of innovations theory has proved its value. 1 In From the Department of Health Education and Promotion (Harting, van Assema, de Vries), Care and Public Health Research Institute (Harting, van Assema, van Limpt, van Ree, de Vries), Nutrition and Toxicology Research Institute (van Assema, de Vries), and Depart- ment of General Practice (van Limpt, van Ree), Maastricht Univer- sity, Maastricht, The Netherlands; Regional Public Health Institute (Ruland), Maastricht, The Netherlands; Department of Cardiology, University Hospital Maastricht (Gorgels), Maastricht, The Nether- lands; and Bernhoven Hospital (Vermeer), Oss, The Netherlands Address correspondence and reprint requests to: Janneke Harting, Department of Health Education and Promotion, PO Box 616, NL-6200 MD Maastricht, The Netherlands. E-mail: j.harting@ gvo.unimaas.nl. 113 Am J Prev Med 2005;29(2) 0749-3797/05/$–see front matter © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc. doi:10.1016/j.amepre.2005.04.012