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Best S, Long JC, Fehlberg Z, Taylor N, Ellis LA, Boggs K, Braithwaite J. Using a theory informed approach to design, execute, and evaluate implementation strategies to support offering reproductive genetic carrier screening in Australia. BMC Health Serv Res 2023; 23:1276. [PMID: 37981708 PMCID: PMC10658900 DOI: 10.1186/s12913-023-10053-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 09/23/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Health care professionals play a central role in offering reproductive genetic carrier screening but face challenges when integrating the offer into practice. The aim of this study was to design, execute, and evaluate theory-informed implementation strategies to support health care professionals in offering carrier screening. METHODS An exploratory multi-method approach was systematically employed based on the Theoretical Domain Framework (TDF). Implementation strategies were designed by aligning TDF barriers reported by health care professionals involved in a large carrier screening study, to behaviour change techniques combined with study genetic counsellors' experiential knowledge. The strategies were trialled with a subset of health care professionals and evaluated against controls, using findings from questionnaires and interviews with healthcare professionals. The primary outcome measure was the number of couples who initiated enrolment. RESULTS Health care professionals (n = 151) reported barriers in the TDF Domains of skills, e.g., lack of practice in offering screening, and challenges of environmental context and resources, e.g., lack of time, which informed the design of a skills video and a waiting room poster using the TDF-behaviour change technique linking tool. Following implementation, (Skills video n = 29 vs control n = 31 and Poster n = 46 vs control n = 34) TDF barrier scores decreased across all groups and little change was observed in the primary outcome measure. The skills video, though welcomed by health care professionals, was reportedly too long at seven minutes. The waiting room poster was seen as easily implementable. CONCLUSIONS As carrier screening moves towards mainstream healthcare, health care professionals report barriers to offering screening. To meet their needs, developing and testing experiential and theory-informed strategies that acknowledge contextual factors are essential.
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Affiliation(s)
- Stephanie Best
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia.
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, Australia.
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia.
- Victorian Comprehensive Cancer Centre Alliance, Melbourne, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | - Janet C Long
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
| | - Zoe Fehlberg
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, Australia
| | - Natalie Taylor
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Louise A Ellis
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
| | - Kirsten Boggs
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Clinical Genetics, Sydney Children's Hospitals Network-Westmead, Sydney, Australia
- Centre for Clinical Genetics, Sydney Children's Hospitals Network-Randwick, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
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Wright L, Bennett S, Meredith P, Doig E. Planning for Change: Co-Designing Implementation Strategies to Improve the Use of Sensory Approaches in an Acute Psychiatric Unit. Issues Ment Health Nurs 2023; 44:960-973. [PMID: 37643312 DOI: 10.1080/01612840.2023.2236712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Implementing sensory approaches in psychiatric units has proven challenging. This multi-staged study involved qualitative interviews (n = 7) with mental health care staff in an acute psychiatric ward to identify the local factors influencing use of sensory approaches, and co-design implementation strategies with key stakeholders to improve their use. Using framework analysis, results revealed that the use of sensory approaches were hindered by: inadequate access to sensory resources/equipment; lack of time; lack of staff knowledge; and belief that sensory approaches are not effective or part of staff's role. To address identified barriers a systematic theory-informed method was used to co-design implementation strategies to improve the use of sensory approaches.
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Affiliation(s)
- Lisa Wright
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Metro North Mental Health - The Prince Charles Hospital, Metro North Health, Brisbane, Australia
| | - Sally Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Pamela Meredith
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- School of Health and Behavioural Sciences, University of Sunshine Coast, Sunshine Coast, Australia
| | - Emmah Doig
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- STARS Education and Research Alliance, Metro North Health, Brisbane, Australia
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Morrow A, Steinberg J, Chan P, Tiernan G, Kennedy E, Egoroff N, Hilton D, Sankey L, Venchiarutti R, Hayward A, Pearn A, McKay S, Debono D, Hogden E, Taylor N. In person and virtual process mapping experiences to capture and explore variability in clinical practice: application to genetic referral pathways across seven Australian hospital networks. Transl Behav Med 2023; 13:561-570. [PMID: 37036763 PMCID: PMC10415733 DOI: 10.1093/tbm/ibad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Genetic referral for Lynch syndrome (LS) exemplifies complex clinical pathways. Identifying target behaviours (TBs) for change and associated barriers requires structured group consultation activities with busy clinicians - consolidating implementation activities whilst retaining rigour is crucial. This study aimed to: i) use process mapping to gain in-depth understandings of site-specific LS testing and referral practices in Australian hospitals and support identification of TBs for change, ii) explore if barriers to identified TBs could be identified through process mapping focus-group data, and iii) demonstrate pandemic-induced transition from in-person to virtual group interactive process mapping methods. LS clinical stakeholders attended interactive in-person or virtual focus groups to develop site-specific "process maps" visually representing referral pathways. Content analysis of transcriptions informed site-specific process maps, then clinical audit data was compared to highlight TBs for change. TBs were reviewed in follow-up focus groups. Secondary thematic analysis explored barriers to identified TBs, coded against the Theoretical Domains Framework (TDF). The transition from in-person to pandemic-induced virtual group interactive process mapping methods was documented. Process mapping highlighted six key areas of clinical practice variation across sites and site-specific TBs for change were identified. Key barriers to identified TBs emerged, categorised to seven TDF domains. Process mapping revealed variations in clinical practices surrounding LS referral between sites. Incorporating qualitative perspectives enhances process mapping by facilitating identification of TBs for change and barriers, providing a pathway to developing targeted interventions. Virtual process mapping activities produced detailed data and enabled comprehensive map development.
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Affiliation(s)
- April Morrow
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Priscilla Chan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Gabriella Tiernan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Elizabeth Kennedy
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Natasha Egoroff
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Desiree Hilton
- Familial Cancer Service, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | | | - Rebecca Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Anne Hayward
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Amy Pearn
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Skye McKay
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Deborah Debono
- Centre for Health Services Management, School of Public Health, University of Technology Sydney, New South Wales, Australia
| | - Emily Hogden
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Natalie Taylor
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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Steinberg J, Chan P, Hogden E, Tiernan G, Morrow A, Kang YJ, He E, Venchiarutti R, Titterton L, Sankey L, Pearn A, Nichols C, McKay S, Hayward A, Egoroff N, Engel A, Gibbs P, Goodwin A, Harris M, Kench JG, Pachter N, Parkinson B, Pockney P, Ragunathan A, Smyth C, Solomon M, Steffens D, Toh JWT, Wallace M, Canfell K, Gill A, Macrae F, Tucker K, Taylor N. Lynch syndrome testing of colorectal cancer patients in a high-income country with universal healthcare: a retrospective study of current practice and gaps in seven australian hospitals. Hered Cancer Clin Pract 2022; 20:18. [PMID: 35509103 PMCID: PMC9066828 DOI: 10.1186/s13053-022-00225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To inform effective genomic medicine strategies, it is important to examine current approaches and gaps in well-established applications. Lynch syndrome (LS) causes 3-5% of colorectal cancers (CRCs). While guidelines commonly recommend LS tumour testing of all CRC patients, implementation in health systems is known to be highly variable. To provide insights on the heterogeneity in practice and current bottlenecks in a high-income country with universal healthcare, we characterise the approaches and gaps in LS testing and referral in seven Australian hospitals across three states. METHODS We obtained surgery, pathology, and genetics services data for 1,624 patients who underwent CRC resections from 01/01/2017 to 31/12/2018 in the included hospitals. RESULTS Tumour testing approaches differed between hospitals, with 0-19% of patients missing mismatch repair deficiency test results (total 211/1,624 patients). Tumour tests to exclude somatic MLH1 loss were incomplete at five hospitals (42/187 patients). Of 74 patients with tumour tests completed appropriately and indicating high risk of LS, 36 (49%) were missing a record of referral to genetics services for diagnostic testing, with higher missingness for older patients (0% of patients aged ≤ 40 years, 76% of patients aged > 70 years). Of 38 patients with high-risk tumour test results and genetics services referral, diagnostic testing was carried out for 25 (89%) and identified a LS pathogenic/likely pathogenic variant for 11 patients (44% of 25; 0.7% of 1,624 patients). CONCLUSIONS Given the LS testing and referral gaps, further work is needed to identify strategies for successful integration of LS testing into clinical care, and provide a model for hereditary cancers and broader genomic medicine. Standardised reporting may help clinicians interpret tumour test results and initiate further actions.
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Affiliation(s)
- Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia.
| | - Priscilla Chan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Emily Hogden
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Gabriella Tiernan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - April Morrow
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Yoon-Jung Kang
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Emily He
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Rebecca Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Leanna Titterton
- NSW Health, Western Sydney Local Health District, Westmead, NSW, Australia
| | | | - Amy Pearn
- Cancer Council NSW, Sydney, NSW, Australia
| | - Cassandra Nichols
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Skye McKay
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Anne Hayward
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Natasha Egoroff
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Alexander Engel
- The University of Sydney, Northern Clinical School Royal North Shore Hospital, Sydney, NSW, Australia
| | - Peter Gibbs
- Personalised Oncology Division, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
| | - Annabel Goodwin
- Cancer Genetics Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | | | - James G Kench
- Department of Tissue Pathology & Diagnostic Oncology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nicholas Pachter
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western, Australia
| | - Bonny Parkinson
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - Peter Pockney
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Abiramy Ragunathan
- Westmead Familial Cancer Services, The Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW, Australia
| | | | - Michael Solomon
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, The University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - Marina Wallace
- Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, Western Australia, Australia
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Anthony Gill
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Finlay Macrae
- Colorectal Medicine and Genetics, Department of Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kathy Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital, Sydney, NSW, Australia
- Prince of Wales Clinical School, UNSW, Sydney, NSW, Australia
| | - Natalie Taylor
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
- School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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Implementation Strategies to Address Suboptimal Genetic Referral Practices. Am J Med Genet A 2022; 188:1025-1026. [PMID: 35286019 DOI: 10.1002/ajmg.a.62286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Popoola M, Dingle M, MacLaren J, Dyson J. What are the barriers to nurses mobilising adult patients in intensive care units? An integrative review. Aust Crit Care 2021; 35:595-603. [PMID: 34756801 DOI: 10.1016/j.aucc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/08/2021] [Accepted: 09/05/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES There is a need for early mobilisation of patients in intensive care units to prevent acquired weaknesses which can have a long-term impact on health and quality of life. This need is not always fulfilled. We therefore sought to conduct an integrative review of international evidence to answer the question: What are the barriers to nurses mobilising adult patients in intensive care units? REVIEW METHOD USED We conducted a systematic search and thematic analysis. We were able to present a descriptive quantitative synthesis of the survey articles included. DATA SOURCES We searched CINAHL, MEDLINE, and PsycINFO databases between and including 2010 and 2020 using search terms synonymous with "intensive care unit" and "nurse" and "early mobilisation" and "barrier using Boolean operators" and "truncation". We completed backwards and forwards citation searches on included studies. RESULTS We included seven articles which we synthesised into three themes and 13 subthemes as follows: (i) organisational barriers (subthemes were staffing levels, time and workload, resources, and care coordination), (ii) individual barriers (subthemes were self and team safety, knowledge and training, beliefs about the consequences of early mobilisation, stress, and other barriers), and (iii) patient-related barriers (subthemes were medical instability/physical status, patient safety, neurological deficits and sedation, and nonconcordance of patients). CONCLUSION Nurses' barriers were wide ranging, and interventions to improve concordance with early mobilisation need to be tailored to address this group's specific barriers.
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Affiliation(s)
| | - Maria Dingle
- City, University of London, Northampton Square, London, EC1V 0HB, UK.
| | - Julie MacLaren
- City, University of London, Northampton Square, London, EC1V 0HB, UK.
| | - Judith Dyson
- Birmingham City University, Westbourne Road, Edgbaston, Birmingham, B15 3TN, UK.
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Views and experiences of palliative care clinicians in addressing genetics with individuals and families: a qualitative study. Support Care Cancer 2021; 30:1615-1624. [PMID: 34549349 DOI: 10.1007/s00520-021-06569-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/11/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE A proportion of people with palliative care needs unknowingly have a genetic predisposition to their disease, placing relatives at increased risk. As end-of-life nears, the opportunity to address genetics for the benefit of their family narrows. Clinicians face numerous barriers addressing genetic issues, but there is limited evidence from the palliative care clinician perspective. Our aims are to (1) explore the views and experiences of palliative care clinicians in addressing genetics with patients and their families and (2) generate suggested strategies that support integration of genetics into palliative care. METHODS An interpretive descriptive qualitative study using semi-structured interviews with palliative care doctors and nurses (N = 14). RESULTS Three themes were identified: (1) Harms and benefits of raising genetics: a delicate balancing act, (2) Navigating genetic responsibility within the scope of palliative care and (3) Overcoming practice barriers: a multipronged approach. Participants described balancing the benefits of addressing genetics in palliative care against potential harms. Responsibility to address genetic issues depends on perceptions of relevance and the scope of palliative care. Suggestions to overcome practice barriers included building genetic-palliative care relationships and multi-layered genetics education, developing clinical resources and increasing organisational support. CONCLUSIONS Integrating aspects of genetics is feasible, but must be balanced against potential harms and benefits. Palliative care clinicians were uncertain about their responsibility to navigate these complex issues to address genetics. There are opportunities to overcome barriers and tailor support to ensure people nearing end-of-life have a chance to address genetic issues for the benefit of their families.
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Morrow A, Chan P, Tucker KM, Taylor N. The design, implementation, and effectiveness of intervention strategies aimed at improving genetic referral practices: a systematic review of the literature. Genet Med 2021; 23:2239-2249. [PMID: 34426665 PMCID: PMC8629749 DOI: 10.1038/s41436-021-01272-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Despite rapid advancements in genetics and genomics, referral practices remain suboptimal. This systematic review assesses the extent to which approaches from implementation science have been applied to address suboptimal genetic referral practices. Methods A search of MEDLINE, EMBASE, and PsycINFO generated 7,794 articles, of which 28 were included. Lay barriers were mapped to the Theoretical Domains Framework (TDF) and interventions mapped to behavior change techniques. Use of implementation and behavior change frameworks was assessed, and the Theory and Techniques Tool used to determine theoretical alignment. Results Knowledge was the most frequent retrospectively TDF-coded barrier, followed by environmental context and resources, and skills. Significant referral improvements occurred in 56% of studies. Among these, the most frequent interventions were clinical data review systems, family history collection and referral tools, and embedding genetics staff into nongenetic specialties. Few studies used implementation frameworks or reported implementation outcomes, though some deployed intuitive strategies that aligned with theory. Conclusion Genetic referral interventions are rarely informed by implementation and/or behavior change theories, limiting opportunities for learning across contexts. Retrospective coding has provided a suite of theoretically linked strategies, which may be useful for informing future efforts. Incorporating these strategies into clinical guidelines may facilitate operationalization within the system.
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Affiliation(s)
- April Morrow
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia. .,Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.
| | - Priscilla Chan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Katherine M Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital and Community Health Services, Randwick, NSW, Australia.,UNSW Prince of Wales Clinical School, Randwick, NSW, Australia
| | - Natalie Taylor
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
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Dyson J, Cowdell F. How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review. Int J Qual Health Care 2021; 33:6324052. [PMID: 34279637 DOI: 10.1093/intqhc/mzab106] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/21/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The use of theory is recommended to support interventions to promote implementation of evidence-based practices. However, there are multiple models of behaviour change which can be complex and lack comprehensiveness and are therefore difficult to understand and operationalize. The Theoretical Domains Framework sought to address these problems by synthesizing 33 models of behaviour or behaviour change. Given that it is 15 years since the first publication of the Theoretical Domains Framework (TDF), it is timely to reflect on how the framework has been applied in practice. OBJECTIVE The objective of this review is to identify and narratively synthesize papers in which the TDF, (including frameworks that incorporate the TDF) have been used have been used to develop implementation interventions. METHODS We searched MEDLINE, PsychINFO, CINAHL and the Cochrane databases using the terms: 'theoretical domains framework*' or TDF or Capability, Opportunity, Motivation to Behaviour (COM-B) or 'behav* change wheel' or 'BCW' AND implement* or improv* or quality or guideline* or intervention* or practice* or EBP or 'evidence based practice' and conducted citation and key author searches. The included papers were those that used any version of the TDF published from 2005 onwards. The included papers were subject to narrative synthesis. RESULTS A total of 3540 papers were identified and 60 were included. Thirty-two papers reported intervention design only and 28 reported intervention design and testing. Despite over 3000 citations there has been limited application to the point of designing interventions to support the best practice. In particular use of the framework has not been tried or tested in non-western countries and barely used in non-primary or acute care settings. Authors have applied the framework to assess barriers and facilitators successfully but reporting of the process of selection of behaviour change techniques and intervention design thereafter was variable. CONCLUSION Despite over three thousand citations of the framework there has been limited application to the point of designing interventions to support best practice. The framework is barely used in non-western countries or beyond primary or acute care settings. A stated purpose of the framework was to make psychological theory accessible to researchers and practitioners alike; if this is to be fully achieved, further guidance is needed on the application of the framework beyond the point of assessment of barriers and facilitators.
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Affiliation(s)
- Judith Dyson
- Healthcare Research and Implementation Science, Faculty of Health, Education and Life Sciences, Birmingham City University, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK
| | - Fiona Cowdell
- Faculty of Health, Education and Life Sciences, Nursing and Healthcare Research, Birmingham City University, Westbourne Road, Birmingham B15 3TN, UK
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O’Shea R, Taylor N, Crook A, Jacobs C, Jung Kang Y, Lewis S, Rankin NM. Health system interventions to integrate genetic testing in routine oncology services: A systematic review. PLoS One 2021; 16:e0250379. [PMID: 34010335 PMCID: PMC8133413 DOI: 10.1371/journal.pone.0250379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Integration of genetic testing into routine oncology care could improve access to testing. This systematic review investigated interventions and the tailored implementation strategies aimed at increasing access to genetic counselling and testing and identifying hereditary cancer in oncology. METHODS The search strategy results were reported using the PRISMA statement and four electronic databases were searched. Eligible studies included routine genetic testing for breast and ovarian cancer or uptake after universal tumour screening for colorectal or endometrial cancer. The titles and abstracts were reviewed and the full text articles screened for eligibility. Data extraction was preformed using a designed template and study appraisal was assessed using an adapted Newcastle Ottawa Scale. Extracted data were mapped to Proctor's et al outcomes and the Consolidated Framework for Implementation Research and qualitatively synthesised. RESULTS Twenty-seven studies, published up to May 2020, met the inclusion criteria. Twenty-five studies ranged from poor (72%), fair to good (28%) quality. Most interventions identified were complex (multiple components) such as; patient or health professional education, interdisciplinary practice and a documentation or system change. Forty-eight percent of studies with complex interventions demonstrated on average a 35% increase in access to genetic counselling and a 15% increase in testing completion. Mapping of study outcomes showed that 70% and 32% of the studies aligned with either the service and client or the implementation level outcome and 96% to the process or inner setting domains of the Consolidated Framework for Implementation Research. CONCLUSION Existing evidence suggests that complex interventions have a potentially positive effect towards genetic counselling and testing completion rates in oncology services. Studies of sound methodological quality that explore a greater breadth of pre and post implementation outcomes and informed by theory are needed. Such research could inform future service delivery models for the integration of genetics into oncology services.
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Affiliation(s)
- Rosie O’Shea
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Natalie Taylor
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Ashley Crook
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Chris Jacobs
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Yoon Jung Kang
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Sarah Lewis
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole M. Rankin
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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12
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Gudgeon JM, Varner MW, Hao J, Williams MS. Model-Based Re-Examination of the Effectiveness of Tumor/Immunohistochemistry and Direct-to-Sequencing Protocols for Lynch Syndrome Case Finding in Endometrial Cancer. JCO Oncol Pract 2021; 17:e1785-e1793. [PMID: 33886346 DOI: 10.1200/op.20.00988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Despite widespread provision of Lynch syndrome (LS) screening programs, questions remain about the most effective and efficient protocol for LS case finding. The purpose of this study was to explore the performance of the two protocols widely shown to be the most efficient and effective, respectively: immunohistochemical (IHC) staining of tumor and direct-to-sequencing (DtS) in endometrial cancer populations. METHODS Simulation models were developed to explore performance of the IHC and DtS protocols, updated to reflect current evidence. Analyses explicitly account for protocol complexity and failure points, as well as decreased sequencing costs. Key outcomes are percent of LS cases identified, total protocol costs and efficiency, and break-even analyses of sequencing costs. All costs are in 2020 US dollars (USD). RESULTS Under plausible conditions, the IHC protocol is expected to identify 40%-78% of LS cases and DtS protocol from 49% to 97%. When the key variable success in proceeding to sequencing is fixed for both protocols at 50%, 75%, and 100%, the DtS protocol is 9%, 12%, and 16% better at case finding, respectively, than the IHC protocol. The break-even cost of sequencing is about $488 USD when the outcome is total direct testing protocol costs; it is about $670 USD when the outcome is cost per LS case detected. CONCLUSION This study quantifies the plausible differences in the clinical effectiveness and cost-effectiveness of the two LS case-finding protocols. We demonstrate the large influence of success in proceeding to sequencing and potential impact of decreasing sequencing prices.
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Affiliation(s)
| | | | - Jing Hao
- Department of Population Health Sciences, Geisinger, Danville, PA
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13
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Morrow A, Parkinson B, Kang YJ, Hogden E, Canfell K, Taylor N. The health and economic impact of implementation strategies for improving detection of hereditary cancer patients—protocol for an in-depth cost-effectiveness evaluation with microsimulation modelling. Implement Sci Commun 2020. [DOI: 10.1186/s43058-020-00058-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patients with Lynch syndrome (an inherited cancer predisposition syndrome) remain largely underdiagnosed despite clinically and cost-effective testing strategies to detect patients. This is largely due to poor referral rates for high-risk patients for consideration of genetic testing. Targeted approaches to improve the implementation of guidelines and thus uptake rates of genetic testing require the use of limited and valuable healthcare resources. Decision makers must carefully balance the potential health impacts of implementation approaches against the associated costs, similar to when assessing the direct impact of health interventions. This protocol outlines the methods used to conduct an economic evaluation of different implementation approaches aimed at improving referral rates of high-risk patients, including estimating implementation approach costs.
Methods
A cluster randomised controlled trial (the Hide and Seek Project, HaSP) is underway to compare two different implementation approaches aimed at improving referral rates, and thus detection, of Lynch syndrome among colorectal cancer patients across eight Australian hospital networks. An in-depth process evaluation is being conducted alongside the trial and includes measures to collect comprehensive data on both implementation and intervention costs. These costs, in addition to HaSP outcome data, will be incorporated as inputs into an existing microsimulation model—Policy1-Lynch—to project the downstream economic and health impacts and determine the more cost-effective implementation approach from the Australian healthcare perspective.
Discussion
The ability to model the impact of different implementation approaches will enable the most efficient way of improving Lynch syndrome detection. The approach used in this study could also be applied to assess other implementation approaches aimed at increasing the uptake of cost-effective health interventions.
Trial registration
ANZCTR, ACTRN12618001072202. Registered on 27 June 2018.
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14
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Pomare C, Ellis LA, Long JC, Churruca K, Tran Y, Braithwaite J. "Are you ready?" Validation of the Hospital Change Readiness (HCR) Questionnaire. BMJ Open 2020; 10:e037611. [PMID: 32847914 PMCID: PMC7451484 DOI: 10.1136/bmjopen-2020-037611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Organisational change in hospitals is a frequent, seemingly inevitable occurrence. A critical precursor to successful organisational change is change readiness. This paper presents the adaptation of a self-report measure of change readiness for hospital staff, examines its reliability and validity, and evaluates the relationship between hospital change readiness (HCR) and staff well-being. METHODS The questionnaire was piloted among 153 staff from a large metropolitan, public hospital in Sydney, Australia. The hospital was undergoing a major change involving a multimillion-dollar development project that included a new building and new models of care. Construct validity was evaluated by confirmatory factor analysis (CFA) and reliability was assessed by internal consistency. Differences between professional groups were examined using regression analyses and structural equation modelling (SEM) was used to test the relationship between change readiness and staff well-being (job satisfaction and burnout). RESULTS The HCR Questionnaire was found to reflect theoretically derived and empirically observed domains and have high internal reliability. CFA identified that a two-factor structure demonstrated excellent fit. Cronbach's alpha for the two subscales (appropriateness and change efficacy) was 0.85 and 0.75, respectively. No statistically significant differences of HCR were identified between professional groups. SEM revealed that perceiving change as appropriate was significantly positively related to job satisfaction (0.33) and significantly negatively related to burnout (-0.30), and feeling capable in implementing the change was significantly negatively related to burnout (-0.40). CONCLUSIONS The HCR Questionnaire provides reliable information on how prepared hospital staff felt for organisational change and showed significant relationships with staff well-being. This questionnaire is validated for the Australian hospital context, particularly in the case of hospital redevelopment. It can be used to help manage times of hospital organisational change with minimal disruption to the quality and safety of patient care.
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Affiliation(s)
- Chiara Pomare
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kate Churruca
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Yvonne Tran
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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15
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Carland JE, Elhage T, Baysari MT, Stocker SL, Marriott DJE, Taylor N, Day RO. Would they trust it? An exploration of psychosocial and environmental factors affecting prescriber acceptance of computerised dose-recommendation software. Br J Clin Pharmacol 2020; 87:1215-1233. [PMID: 32691902 DOI: 10.1111/bcp.14496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/14/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Dose-prediction software can optimise vancomycin therapy, improving therapeutic drug monitoring processes and reducing drug toxicity. Success of software in hospitals may be dependent on prescriber uptake of software recommendations. This study aimed to identify the perceived psychosocial and environmental barriers and facilitators to prescriber acceptance of dose-prediction software. METHODS Semi-structured interviews, incorporating prescribing scenarios, were undertaken with 17 prescribers. Participants were asked to prescribe the next maintenance dose of vancomycin for a scenario(s) and then asked if they would accept a recommendation provided by a dose-prediction software. Interviews further explored opinions of dose-prediction software. Interview transcripts were analysed using an inductive approach to identify themes and the Theoretical Domains Framework was used to synthesise barriers and facilitators to software acceptance. RESULTS When presented with software recommendations, half of the participants were comfortable with accepting the recommendation. Key barriers to acceptance of software recommendations aligned with 2 Theoretical Domains Framework domains: Knowledge (uncertainty of software capability) and Beliefs about Consequences (perceived impact of software on clinical outcomes and workload). Key facilitators aligned with 2 domains: Beliefs about Consequences (improved efficiency) and Social Influences (influence of peers). A novel domain, Trust, was identified as influential. CONCLUSION Prescribers reported barriers to acceptance of dose-prediction software aligned with limited understanding of, and scepticism about, software capabilities, as well as concerns about clinical outcomes. Identification of key barriers and facilitators to acceptance provides essential information to design of implementation strategies to support the introduction of this intervention into the workplace.
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Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Tania Elhage
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Melissa T Baysari
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Natalie Taylor
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.,Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
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16
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Morrow A, Tucker KM, Shaw TJ, Parkinson B, Abraham C, Wolfenden L, Taylor N. Understanding implementation success: protocol for an in-depth, mixed-methods process evaluation of a cluster randomised controlled trial testing methods to improve detection of Lynch syndrome in Australian hospitals. BMJ Open 2020; 10:e033552. [PMID: 32540886 PMCID: PMC7299044 DOI: 10.1136/bmjopen-2019-033552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION In multisite intervention trials, implementation success often varies widely across settings. Process evaluations are crucial to interpreting trial outcomes and understanding contextual factors and causal chains necessary for successful implementation. Lynch syndrome is a hereditary cancer predisposition conferring an increased risk of colorectal, endometrial and other cancer types. Despite systematic screening protocols to identify Lynch syndrome, the condition remains largely underdiagnosed. The Hide and Seek Project ('HaSP') is a cluster randomised controlled trial determining the effectiveness of two approaches to improving Lynch syndrome detection at eight Australian hospital networks. To enhance widespread implementation of optimal Lynch syndrome identification, there is a need to understand not only what works, but also why, in what contexts, and at what costs. Here we describe an in-depth investigation of factors influencing successful implementation of procedures evaluated in the HaSP trial. METHODS AND ANALYSIS A mixed-methods, theory-driven process evaluation will be undertaken in parallel to the HaSP trial. Data will include: interviews of Implementation Leads and Lynch syndrome stakeholders, pre-post implementation questionnaires, audio analysis of meetings and focus groups, observation of multidisciplinary team meetings, fidelity checklists and project log analysis. Results will be triangulated and coded, drawing on the Theoretical Domains Framework, Consolidated Framework for Implementation Research and Proctor's implementation outcomes. ETHICS AND DISSEMINATION Use of a theory-based process evaluation will enhance interpretation and generalisability of HaSP trial findings, and contribute to the implementation research field by furthering understanding of the conditions necessary for implementation success. Ethical approval has been granted and results will be disseminated via publications in peer-reviewed journals and conference presentations. At trial completion, key findings will be fed back to sites to enable refinement of intervention strategies, both in the context of Lynch syndrome and for the possible generalisability of intervention components in other genetic and broader clinical specialties. HASP TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (Identifier: ACTRN12618001072202). Registered 27 June 2018. http://www.ANZCTR.org.au/ACTRN12618001072202.aspx.
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Affiliation(s)
- April Morrow
- Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Katherine M Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
- UNSW Prince of Wales Clinical School, Randwick, New South Wales, Australia
| | - Tim J Shaw
- Research in Implementation Science and eHealth (RISe), Faculty of Health Sciences, University of Sydney, Camperdown, New South Wales, Australia
| | - Bonny Parkinson
- The Macquarie University Centre for the Health Economy, Macquarie University, Macquarie, New South Wales, Australia
| | - Charles Abraham
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Natalie Taylor
- Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
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17
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Morrow A, Hogden E, Kang YJ, Steinberg J, Canfell K, Solomon MJ, Kench JG, Gill AJ, Shaw T, Pachter N, Parkinson B, Wolfenden L, Mitchell G, Macrae F, Tucker K, Taylor N. Comparing theory and non-theory based implementation approaches to improving referral practices in cancer genetics: a cluster randomised trial protocol. Trials 2019; 20:373. [PMID: 31221211 PMCID: PMC6585019 DOI: 10.1186/s13063-019-3457-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/20/2019] [Indexed: 02/02/2023] Open
Abstract
Background Lynch syndrome (LS) is an inherited, cancer predisposition syndrome associated with an increased risk of colorectal, endometrial and other cancer types. Identifying individuals with LS allows access to cancer risk management strategies proven to reduce cancer incidence and improve survival. However, LS is underdiagnosed and genetic referral rates are poor. Improving LS referral is complex, and requires multisystem behaviour change. Although barriers have been identified, evidence-based strategies to facilitate behaviour change are lacking. The aim of this study is to compare the effectiveness of a theory-based implementation approach against a non-theory based approach for improving detection of LS amongst Australian patients with colorectal cancer (CRC). Methods A two-arm parallel cluster randomised trial design will be used to compare two identical, structured implementation approaches, distinguished only by the use of theory to identify barriers and design targeted intervention strategies, to improve LS referral practices in eight large Australian hospital networks. Each hospital network will be randomly allocated to a trial arm, with stratification by state. A trained healthcare professional will lead the following phases at each site: (1) undertake baseline clinical practice audits, (2) form multidisciplinary Implementation Teams, (3) identify target behaviours for practice change, (4) identify barriers to change, (5) generate intervention strategies, (6) support staff to implement interventions and (7) evaluate the effectiveness of the intervention using post-implementation clinical data. The theoretical and non-theoretical components of each trial arm will be distinguished in phases 4–5. Study outcomes include a LS referral process map for each hospital network, with evaluation of the proportion of patients with risk-appropriate completion of the LS referral pathway within 2 months of CRC resection pre and post implementation. Discussion This trial will determine the more effective approach for improving the detection of LS amongst patients with CRC, whilst also advancing understanding of the impact of theory-based implementation approaches in complex health systems and the feasibility of training healthcare professionals to use them. Insights gained will guide the development of future interventions to improve LS identification on a larger scale and across different contexts, as well as efforts to address the gap between evidence and practice in the rapidly evolving field of genomic research. Trial registration ANZCTR, ACTRN12618001072202. Registered on 27 June 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3457-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- April Morrow
- Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Emily Hogden
- Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Yoon-Jung Kang
- Cancer Council NSW, Woolloomooloo, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | | | - Karen Canfell
- Cancer Council NSW, Woolloomooloo, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | - Michael J Solomon
- University of Sydney, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - James G Kench
- University of Sydney, Sydney, NSW, Australia.,Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Anthony J Gill
- University of Sydney, Sydney, NSW, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital St Leonards, St Leonards, NSW, Australia.,NSW Health Pathology Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Tim Shaw
- University of Sydney, Sydney, NSW, Australia
| | - Nicholas Pachter
- Genetic Services of Western Australia, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Bonny Parkinson
- Macquarie University Centre for the Health Economy, Macquarie University, Macquarie Park, NSW, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Gillian Mitchell
- Familial Cancer Research Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Finlay Macrae
- Colorectal Medicine and Genetics, and Department of Medicine, University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Kathy Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital, Syndey, NSW, Australia.,Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Natalie Taylor
- Cancer Council NSW, Woolloomooloo, NSW, Australia. .,University of Sydney, Sydney, NSW, Australia.
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18
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Churruca K, Ludlow K, Taylor N, Long JC, Best S, Braithwaite J. The time has come: Embedded implementation research for health care improvement. J Eval Clin Pract 2019; 25:373-380. [PMID: 30632246 DOI: 10.1111/jep.13100] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/19/2018] [Accepted: 12/22/2018] [Indexed: 12/23/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The field of implementation science has developed in response to slow and inconsistent translation of evidence into practice. Despite utilizing increasingly sophisticated approaches to implementation, including applying a complexity science lens and conducting realist evaluations, challenges remain to getting the kinds of outcomes hoped for by implementation efforts. These include gaining access and buy-in from those implementing the change and accounting for the influence of local context. One emerging approach to address these challenges is embedded implementation research-a collaborative, adaptive approach to improvement. It involves researchers and implementers working together in situ from the outset of, and throughout, an implementation project. Both groups can benefit from the collaboration: it increases the rigor of evaluation, provides opportunities to improve the intervention through direct feedback, and promotes better on-the-ground understanding of the change process. We aimed to examine the potential benefits, and some of the challenges, of increased embeddedness. METHOD We performed a multi-case analysis of implementation research projects that varied by degree of embeddedness. RESULTS Embedded implementation research may offer a range of advantages over dichotomized research-practice designs, including better understanding of local context and direct feedback to improve the implementation along the way. We present a model that spans four approaches: dichotomized research-practice, collaborative linking-up, partially-embedded, and deep immersion. CONCLUSION Embedded implementation research approaches hold promise in comparison to traditional dichotomized-research practice designs, where the research is external to the implementation and conducts a summative evaluation. We are only beginning to understand how such partnerships operate in practice and what makes them successful. Our analysis suggests the time has come to consider such approaches.
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Affiliation(s)
- Kate Churruca
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Kristiana Ludlow
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | - Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Stephanie Best
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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19
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Gudgeon JM, Varner MW, Hashibe M, Williams MS. Is immunohistochemistry-based screening for Lynch syndrome in endometrial cancer effective? The consent's the thing. Gynecol Oncol 2019; 154:131-137. [PMID: 31130287 DOI: 10.1016/j.ygyno.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE To investigate the plausible failure rate of the immunohistochemistry (IHC)-based screening protocol to identify Lynch syndrome (LS) index cases among endometrial cancer (EC) patients. METHODS We developed a simulation model of the IHC protocol in this context. The model was populated from systematic and focused reviews, augmented with local data and expert opinion. The virtual cohort represents the number of women expected to be diagnosed with EC in the U.S. in 2018. The outcomes include protocol failure rates and LS cases missed in a variety of hypothetical scenarios. RESULTS The best estimate of failure rate of the IHC protocol is 58%; minimum and maximum estimates are 33% and 80%, respectively. These failure rates are driven primarily by the high rates of failure to obtain consent from patients for sequencing (25% to 80%). The multiple imperfect tests and potential failure points in this protocol, collectively, make up 7% to 20% of the total failure rate. When consent for sequencing was fixed in the model at 25%, 50%, and 80%; the expected ranges for index case identification failure are 78%-82%, 57%-64%, and 29%-42%, respectively. CONCLUSION The primary driver of failure to identify index cases remains consent for sequencing. Consent rates have shown little improvement since LS screening programs were instituted in the U.S., leaving us to conclude these high failure rates are resistant to substantial improvement. These missed opportunities will be magnified because cascade screening for carrier status among family members will not be pursued.
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Affiliation(s)
- James M Gudgeon
- Intermountain Healthcare, Salt Lake City, UT, United States of America.
| | - Michael W Varner
- University of Utah School of Medicine, Salt Lake City, UT, United States of America; Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT, 30 North 1900 East, Salt Lake City, Utah, 84132.
| | - Mia Hashibe
- Huntsman Cancer Institute, Salt Lake City, UT, United States of America; Division of Public Health, Department of Family & Preventive Medicine, University of Utah School of Medicine, Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City, UT, 84112.
| | - Marc S Williams
- Geisinger Health System, Danville, PA, United States of America; Genomic Medicine Institute, Geisinger Health System, 100 N Academy Dr., Mail Stop 26-20, Danville, PA 17822-2620.
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20
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Long JC, Winata T, Debono D, Phan-Thien KC, Zhu C, Taylor N. Process evaluation of a behaviour change approach to improving clinical practice for detecting hereditary cancer. BMC Health Serv Res 2019; 19:180. [PMID: 30894169 PMCID: PMC6425681 DOI: 10.1186/s12913-019-3985-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND This retrospective process evaluation reports on the application of a 1-year implementation program to increase identification and management of patients at high risk of a hereditary cancer syndrome. The project used the Theoretical Domains Framework Implementation (TDFI) approach, a promising implementation methodology, used successfully in the United Kingdom to address patient safety issues. This Australian project run at two large public hospitals aimed to increase referrals of patients flagged as being at risk of Lynch syndrome on the basis of a screening test to genetic services. At the end of the project, the pathologists' processes had changed, but the referral rate remained inconsistent and low. METHODS Semi-structured interviews explored participants' perceptions of the TDFI approach and Health services researchers wrote structured reflections. Interview transcripts and reflections were coded initially against implementation outcomes for the various TDFI approach activities: acceptability, appropriateness, feasibility, value for time cost, and adoption. On a second pass, themes were coded around challenges to the approach. RESULTS Interviews were held with nine key project participants including pathologists, oncologists, surgeons, genetic counsellors and an administrative officer. Two health services researchers wrote structured reflections. The first of two major themes was 'Theory-related challenges', with subthemes of accessibility of theory underpinning the TDFI, commitment to that theory-based approach, and the problem of complexity. The second theme was 'Practical challenges' with subthemes of stakeholder management, navigating the system, and perceptions of the problem. Health services researchers reflected on the benefits of bridging professional divides and facilitating collective learning and problem solving, but noted frustrations around clinicians' time constraints that led to sparse interactions with the team, and lack of authority to effect change themselves. CONCLUSIONS Mixed success of adoption as an outcome was attributed to the complexity and highly nuanced nature of the setting. This made identifying the target behaviour, a key step in the TDFI approach, challenging. Introduced changes in the screening process led to new, unexpected issues yet to be addressed. Strategies to address challenges are presented, including using an internal facilitator with a focus on applying a theory-based implementation approach.
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Affiliation(s)
- Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Teresa Winata
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Deborah Debono
- Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, NSW, 2007, Australia
| | - Kim-Chi Phan-Thien
- St George and Sutherland Clinical School, University of New South Wales, Kensington, Sydney, NSW, 2052, Australia
| | - Christine Zhu
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Natalie Taylor
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia. .,Cancer Research Division, Cancer Council NSW, 153 Dowling St, Woolloomooloo, NSW, 2011, Australia. .,Faculty of Health Sciences, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia.
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