Implementation of the Diabetes Prevention Program in Georgia Cooperative Extension According to RE-AIM and the Consolidated Framework for Implementation Research

Healthcare workers' perspectives on barriers and facilitators to referral to type 2 diabetes prevention programmes: a systematic review

OBJECTIVES

Diabetes is a growing global health concern. International guidelines recommend referral to diabetes prevention programmes (DPPs) for those at high risk of type 2 diabetes. However, many of those eligible to participate in DPPs are not referred. Healthcare workers (HCWs) are pivotal to the referral processes. This study aimed to identify, appraise and synthesise barriers and facilitators to referral to DPPs from the perspective of HCWs.

DESIGN

Systematic review using the best-fit framework synthesis.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsychINFO, Web of Science and Scopus were searched from January 1997 to July 2023.

ELIGIBILITY CRITERIA

Qualitative, quantitative and mixed methods primary studies exploring HCWs' perspectives of barriers and facilitators to referral to DPPs.

DATA EXTRACTION AND SYNTHESIS

One author screened, extracted and appraised the literature while a second author independently verified at least a 20% sample at each stage. Quality was assessed using the Mixed Methods Appraisal Tool. The best-fit framework approach was used to synthesise the evidence with the Theoretical Domains Framework as the a priori framework.

RESULTS

Of 9998 studies identified, 31 met the inclusion criteria, with a further six identified from reference and citation searching. Barriers and facilitators were coded to 11 of the 14 TDF domains and to another category 'Expectation of Patient Barriers'. The most frequently occurring domains for both barriers and facilitators were Environmental Context and Resources, Expectation of Patient Barriers and Knowledge. HCWs felt that clear easy referral pathways to the programmes and additional staff or resources were essential to improve referral. HCWs' were concerned that attending the DPP would place a (time and/or financial) burden on their patients which left them conflicted about referral. HCWs lacked knowledge of the effectiveness, availability and accessibility of DPPs.

CONCLUSIONS

Future strategies to improve referral to DPPs should include clear referral pathways and the resourcing of referral. Strategies are also needed to build awareness of DPPs and to address concerns among HCWs about their patients.

Implementation lessons learned from the University of California's Diabetes Prevention Program Initiative

BACKGROUND

The University of California's Diabetes Prevention Program (UC DPP) Initiative was implemented systemwide to address diabetes and obesity risk on all 10 campuses. As little is known about implementing lifestyle change programs in university settings, we examined implementation partners' (i.e., UC DPP leaders and campus leads) perceptions of factors influencing program success on UC campuses.

METHODS

We conducted qualitative interviews with UC DPP leaders and campus leads to examine challenges and opportunities with university-based DPP delivery models. Interviews were recorded, professionally transcribed, and reviewed in detail by the research team. Transcripts were analyzed using rapid qualitative analysis (RQA). The study was approved by the UCLA Institutional Review Board. All implementation partners provided verbal informed consent.

RESULTS

Twenty-six implementation partners (8 UC DPP leaders and 18 campus leads) completed interviews in 2021. Seven themes were identified as critical for implementation, including (1) marketing and recruitment (i.e., market and recruit broadly through established channels as well as target at-risk populations); (2) enrollment (i.e., offer the program during convenient times and let participants know what to expect); (3) use an adaptable, evidence-based program; (4) secure funding for the program, participants, lifestyle coaches, and space; (5) hire experienced and dedicated staff and lifestyle coaches; (6) ensure leadership support; and (7) utilize campus linkages and resources. Perceptions of challenges faced with respect to these themes are also described.

CONCLUSIONS

This is one of the first studies to examine the challenges and opportunities of delivering an intensive lifestyle change program across 10 university sites. Understanding factors that enhance success of university-based diabetes prevention programs can facilitate UC DPP efforts and help inform delivery strategies of health and wellness programs across other university settings more broadly.

Identifying Facilitators and Barriers to Implementation of AI-Assisted Clinical Decision Support in an Electronic Health Record System

Recent advancements in computing have led to the development of artificial intelligence (AI) enabled healthcare technologies. AI-assisted clinical decision support (CDS) integrated into electronic health records (EHR) was demonstrated to have a significant potential to improve clinical care. With the rapid proliferation of AI-assisted CDS, came the realization that a lack of careful consideration of socio-technical issues surrounding the implementation and maintenance of these tools can result in unanticipated consequences, missed opportunities, and suboptimal uptake of these potentially useful technologies. The 48-h Discharge Prediction Tool (48DPT) is a new AI-assisted EHR CDS to facilitate discharge planning. This study aimed to methodologically assess the implementation of 48DPT and identify the barriers and facilitators of adoption and maintenance using the validated implementation science frameworks. The major dimensions of RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) and the constructs of the Consolidated Framework for Implementation Research (CFIR) frameworks have been used to analyze interviews of 24 key stakeholders using 48DPT. The systematic assessment of the 48DPT implementation allowed us to describe facilitators and barriers to implementation such as lack of awareness, lack of accuracy and trust, limited accessibility, and transparency. Based on our evaluation, the factors that are crucial for the successful implementation of AI-assisted EHR CDS were identified. Future implementation efforts of AI-assisted EHR CDS should engage the key clinical stakeholders in the AI tool development from the very inception of the project, support transparency and explainability of the AI models, provide ongoing education and onboarding of the clinical users, and obtain continuous input from clinical staff on the CDS performance.

Sustaining the collaborative chronic care model in outpatient mental health: a matrixed multiple case study

BACKGROUND

Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3-4 years after implementation support had concluded.

METHODS

We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends.

RESULTS

CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): "Collaborativeness/Teamwork [Recipients]," "Staff/Leadership turnover [Recipients]," and "Having a consistent/strong internal facilitator [Facilitation]" during and after active implementation. At most high-sustainability sites only, (i) "Having a knowledgeable/helpful external facilitator [Facilitation]" was variably present and enabled sustainability when present, while (ii) "Clarity about what CCM comprises [Innovation]," "Interdisciplinary coordination [Recipients]," and "Adequate clinic space for CCM team members [Context]" were somewhat or less present with mixed influences on sustainability.

CONCLUSIONS

MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.

A structural equation model of CFIR inner and outer setting constructs, organization characteristics, and national DPP enrollment

BACKGROUND

The National Diabetes Prevention Program (DPP) has made great strides in increasing accessibility to its year-long, evidence-based lifestyle change program, with around 3000 organizations having delivered the program. This large dissemination effort offers a unique opportunity to identify organization-level factors associated with program implementation and reach (enrollment) across diverse settings. The purpose of this study was to quantitatively examine the relationships among Consolidated Framework for Implementation Research (CFIR) Inner Setting and Outer Setting constructs and the implementation outcome of reach.

METHODS

This study analyzed data from a 2021 cross-sectional online survey with 586 National DPP Staff (lifestyle coaches, master trainers, program coordinators) with information about their organization, implementation outcomes, and responses to quantitative CFIR Inner Setting and Outer Setting construct items. Structural equation modeling was used to test a hypothesized path model with Inner and Outer Setting variables to explore direct and indirect pathways to enrollment.

RESULTS

The CFIR items had good internal consistency and indicated areas of implementation strength and weakness. Eight variables included as part of the CFIR structural characteristics and one organization characteristic variable had significant direct relationships with enrollment. The length of delivery, number of lifestyle coaches, number of full-time staff, large organization size, and organizations delivering in rural, suburban, and/or urban settings all had positive significant direct relationships with enrollment, while academic organizations and organizations with only non-White participants enrolled in their National DPP lifestyle change programs had a negative association with enrollment.

CONCLUSIONS

Participant reach is an important implementation outcome for the National DPP and vital to making population-level decreases in diabetes incidence in the USA. Our findings suggest that to facilitate enrollment, program implementers should focus on organizational structural characteristics such as staffing. Strengths of this study include the use of adapted and newly developed quantitative CFIR measures and structural equation modeling. Health prevention programs can use the methods and findings from this study to further understand and inform the impact of organization factors on implementation outcomes.