What strategies are used by clinician champions to reduce low-value care?

Facilitation in evidence implementation - experiences, challenges, and determinants of perceived effectiveness: a qualitative systematic review

INTRODUCTION

Facilitation is a key element of evidence implementation. Although quantitative systematic reviews have been undertaken to examine its components and effectiveness, no attempt has been made to synthesize qualitative evidence examining the experiences of facilitators on how facilitation is operationalized, the challenges associated with it, and the factors that can influence its perceived effectiveness.

METHODS

A systematic review of qualitative studies was conducted using the JBI methodology.

RESULTS

A total of 36 qualitative studies was included in the systematic review, with the majority being assessed as high quality following critical appraisal. The findings were extracted and further synthesized, highlighting that facilitation involves providing technical and non-technical support to health professionals, as well as high-intensity collaborations and relationship building. Determinants of perceived effectiveness of facilitation include facilitators' access to resources and learning support; their skills, traits/attitudes, and approach to facilitation; and the context of the organization where the implementation occurs. Work demands, emotional stress, and lack of clarity in roles and career development can pose challenges for facilitators.

CONCLUSION

To maximize the outcomes of facilitation in evidence implementation, the team of facilitators should be carefully selected to ensure they have the right skills, traits/attitudes, and approach to facilitation. They should also be provided with dedicated time to conduct the facilitation and have access to resources, training, and mentoring support. Future research should aim to examine the perspectives of the "implementers" who received support from facilitators to gain a better understanding of which facilitation strategies have an impact on clinical practice behavior.

REVIEW REGISTRATION NUMBER

PROSPERO CRD42023402496.

Can clinician champions reduce potentially inappropriate medications in people living with dementia? Study protocol for a cluster randomized trial

Background

For people living with dementia (PLWD) the overuse of potentially inappropriate medications (PIMs) remains a persistent problem. De-prescribing trials in the elderly have mixed results. Clinician champions may be uniquely suited to lead efforts to address this challenge. Here we describe the study protocol for a 24-month embedded pragmatic cluster-randomized clinical trial within two accountable care organizations (ACOs) of such a clinician champion intervention. The specific aims are to (1) assess the effectiveness of a clinician champion on de-implementing PIMs in PLWD, (2) determine if the intervention is associated with a reduction in emergency department (ED) visits and hospitalizations attributed to a fall, and (3) examine five implementation outcomes: appropriateness, feasibility, fidelity, penetration, and equity.

Methods/design

Two ACOs agreed to participate: United States Medical Management (USMM) and Oschner Health System. The unit of randomization will be the primary care clinic. A clinician champion will be recruited from each of the intervention clinics to participate in a 6-month training program and then work with clinicians and staff in their clinic for 12 months to reduce the use of PIMs in their PLWD population. For aims 1 and 2, Medicare claims data will be used to assess outcomes. The outcome for aim #1 will be medication possession rates per quarter, for the three therapeutic classes of PIMs among patients with dementia in intervention clinics versus control clinics. For aim #2, we will assess the incidence of falls using a previously validated algorithm. For both aims 1 and 2, we will construct hierarchical models with time period observations nested within patient using generalized estimating equations (GEE) with robust standard errors. The key variable of interest will be the treatment indicator assigned based on practice. For aim #3, we will conduct qualitative thematic analysis of documentation by the clinician champions in their project workbooks to evaluate the five implementation outcomes.

Discussion

This embedded pragmatic trial will add to our existing knowledge regarding the effectiveness of a clinician champion strategy to de-prescribe potentially inappropriate medication among patients with dementia as well as its appropriateness, feasibility, fidelity, penetration, and equity.

Trial registration

Clinicaltrials.govNCT05359679, Registered May 4, 2022