Implementation and evaluation of the VA DPP clinical demonstration: protocol for a multi-site non-randomized hybrid effectiveness-implementation type III trial

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

Increased dissemination of the CDC's Diabetes Prevention Program (DPP) is imperative to reduce type 2 diabetes. Due to its nationwide reach and mission to improve health, Cooperative Extension (Extension) is poised to be a sustainable DPP delivery system. However, research evaluating DPP implementation in Extension remains scant. Extension professionals delivered the DPP in a single-arm hybrid type II effectiveness-implementation study. Semi-structured interviews with Extension professionals were conducted at three time points. The Consolidated Framework for Implementation Research (CFIR) guided interview coding and analysis. Constructs were rated for magnitude and valence and evaluated as facilitators or barriers of RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes. The program reached 119 participants, was adopted by 92% (n = 12/13) of trained Extension professionals and was implemented according to CDC standards: all programs exceeded the minimum 22-session requirement (26 ± 2 sessions). The program was effective in achieving weight loss (5.0 ± 5.2%) and physical activity (179 ± 122 min/week) goals. At post-intervention, eight professionals (67%) had begun or planned to maintain the intervention within the next 6 months. Several facilitators were identified, including Extension leadership structure, organizational compatibility, and technical assistance calls. Limited time to recruit participants was the primary barrier. Positive RE-AIM outcomes, facilitated by contextual factors, indicate Extension is an effective and sustainable DPP delivery system. Extension and other DPP implementers should plan strategies that promote communication, the program's evidence-base, recruitment time, and resource access. Researchers should explore DPP implementation in real-world settings to determine overall and setting-specific best practices, promote intervention uptake, and reduce diabetes.

Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation

BACKGROUND

Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns.

METHODS

In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns.

RESULTS

Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice.

CONCLUSIONS

Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Metformin prescription for U.S. veterans with prediabetes, 2010-2019

Affecting an estimated 88 million Americans, prediabetes increases the risk for developing type 2 diabetes mellitus (T2DM), and independently, cardiovascular disease, retinopathy, nephropathy, and neuropathy. Nevertheless, little is known about the use of metformin for diabetes prevention among patients in the Veterans Health Administration, the largest integrated healthcare system in the U.S. This is a retrospective observational cohort study of the proportion of Veterans with incident prediabetes who were prescribed metformin at the Veterans Health Administration from October 2010 to September 2019. Among 1,059,605 Veterans with incident prediabetes, 12,009 (1.1%) were prescribed metformin during an average 3.4 years of observation after diagnosis. Metformin prescribing was marginally higher (1.6%) among those with body mass index (BMI) ≥35 kg/m2, age <60 years, HbA1c≥6.0%, or those with a history of gestational diabetes, all subgroups at a higher risk for progression to T2DM. In a multivariable model, metformin was more likely to be prescribed for those with BMI ≥35 kg/m2 incidence rate ratio [IRR] 2.6 [95% confidence intervals (CI): 2.1-3.3], female sex IRR, 2.4 [95% CI: 1.8-3.3], HbA1c≥6% IRR, 1.93 [95% CI: 1.5-2.4], age <60 years IRR, 1.7 [95% CI: 1.3-2.3], hypertriglyceridemia IRR, 1.5 [95% CI: 1.2-1.9], hypertension IRR, 1.5 [95% CI: 1.1-2.1], Major Depressive Disorder IRR, 1.5 [95% CI: 1.1-2.0], or schizophrenia IRR, 2.1 [95% CI: 1.2-3.8]. Over 20% of Veterans with prediabetes attended a comprehensive structured lifestyle modification clinic or program. Among Veterans with prediabetes, metformin was prescribed to 1.1% overall, a proportion that marginally increased to 1.6% in the subset of individuals at highest risk for progression to T2DM.

Understanding Uganda's early adoption of novel differentiated HIV treatment services: a qualitative exploration of drivers of policy uptake

BACKGROUND

Although differentiated service delivery (DSD) for HIV treatment was endorsed by the WHO in its landmark 2016 guidelines to lessen patients' need to frequently visit clinics and hence to reduce unnecessary burdens on health systems, uptake has been uneven globally. This paper is prompted by the HIV Policy Lab's annual report of 2022 which reveals substantial variations in programmatic uptake of differentiated HIV treatment services across the globe. We use Uganda as a case study of an 'early adopter' to explore the drivers of programmatic uptake of novel differentiated HIV treatment services.

METHODS

We conducted a qualitative case-study in Uganda. In-depth interviews were held with national-level HIV program managers (n = 18), district health team members (n = 24), HIV clinic managers (n = 36) and five focus groups with recipients of HIV care (60 participants) supplemented with documentary reviews. Our thematic analysis of the qualitative data was guided by the Consolidated Framework for Implementation Research (CFIR)'s five domains (inner context, outer setting, individuals, process of implementation).

RESULTS

Our analysis reveals that drivers of Uganda's 'early adoption' of DSD include: having a decades-old HIV treatment intervention implementation history; receiving substantial external donor support in policy uptake; the imperatives of having a high HIV burden; accelerated uptake of select DSD models owing to Covid-19 'lockdown' restrictions; and Uganda's participation in clinical trials underpinning WHO guidance on DSD. The identified processes of implementation entailed policy adoption of DSD (such as the role of local Technical Working Groups in domesticating global guidelines, disseminating national DSD implementation guidelines) and implementation strategies (high-level health ministry buy-in, protracted patient engagement to enhance model uptake, devising metrics for measuring DSD uptake progress) for promoting programmatic adoption.

CONCLUSION

Our analysis suggests early adoption derives from Uganda's decades-old HIV intervention implementation experience, the imperative of having a high HIV burden which prompted innovations in HIV treatment delivery as well as outer context factors such as receiving substantial external assistance in policy uptake. Our case study of Uganda offers implementation research lessons on pragmatic strategies for promoting programmatic uptake of differentiated treatment HIV services in other countries with a high HIV burden.

Rural engagement in primary care for optimizing weight reduction (REPOWER): A mixed methods study of patient perceptions

OBJECTIVE

To report on patients' satisfaction and experience of care across three different modes of weight loss counseling.

METHODS

1407 patients with obesity in the rural Midwest were enrolled to a 2-year weight management trial through their primary care practice and assigned to one of three treatment conditions: in-clinic individual, in-clinic group, phone group counseling. Patients completed surveys assessing seven domains of satisfaction and experience of care at 6 and 24-months. Post-treatment interviews were conducted to add context to survey responses.

RESULTS

1295 (92.0%) and 1230 (87.4%) completed surveys at 6 and 24-months, respectively. Patients in phone group counseling reported lower satisfaction than patients who received in-clinic group or in-clinic individual counseling across all domains at 6-months and five out of seven domains at 24-months. Interviews revealed that patients were more satisfied when they received face-to-face counseling and had meaningful interactions with their primary care provider (PCP) about their weight.

CONCLUSION

Rural patients with obesity have higher satisfaction and experience of care when weight loss counseling is delivered in a face-to-face environment and when their PCP is involved with their treatment.

PRACTICE IMPLICATIONS

Primary care practices looking to offer weight loss treatment should consider incorporating some level of face-to-face treatment plans that involves meaningful interaction with the PCP.

Implementation of a diabetes prevention program within two community sites: a qualitative assessment

Background

Despite numerous translations of diabetes prevention programs, implementation evaluations are rarely conducted. The purpose of this study was to examine the implementation process and multilevel contextual factors as an evidence-based diabetes prevention program was implemented into two local community organization sites to inform future scale-up. To build the science of implementation, context and strategies must be identified and explored to understand their impact.

Methods

The program was a brief-counseling diet and exercise modification program for individuals at risk of developing type 2 diabetes. A 1-year collaborative planning process with a local not-for-profit community organization co-developed an implementation plan to translate the program. A pragmatic epistemology guided this research. Semi-structured interviews were conducted with staff who delivered the program (n = 8), and a focus group was completed with implementation support staff (n = 5) at both community sites. Interviews were transcribed verbatim and thematically analyzed using a template approach. The consolidated framework for implementation research (CFIR) is a well-researched multilevel implementation determinant framework and was used to guide the analysis of this study. Within the template approach, salient themes were first inductively identified, then identified themes were deductively linked to CFIR constructs.

Results

Implementation strategies used were appropriate, well-received, and promoted effective implementation. The implementation plan had an impact on multiple levels as several CFIR constructs were identified from all five domains of the framework: (a) process, (b) intervention characteristics, (c) outer setting, (d) inner setting, and (e) individual characteristics. Specifically, results revealed the collaborative 1-year planning process, program components and structure, level of support, and synergy between program and context were important factors in the implementation.

Conclusion

This study offers insights into the process of implementing a community-based diabetes prevention program in two local sites. Successful implementation benefited from a fully engaged, partnered approach to planning, and subsequently executing, an implementation effort. The CFIR was a useful and thorough framework to evaluate and identify multilevel contextual factors impacting implementation. Results can be used to inform future implementation and scale-up efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00258-6.

The Aging, Community and Health Research Unit Community Partnership Program (ACHRU-CPP) for older adults with diabetes and multiple chronic conditions: study protocol for a randomized controlled trial

BACKGROUND

Older adults (≥65 years) with diabetes and multiple chronic conditions (MCC) (> 2 chronic conditions) experience reduced function and quality of life, increased health service use, and high mortality. Many community-based self-management interventions have been developed for this group, however the evidence for their effectiveness is limited. This paper presents the protocol for a randomized controlled trial (RCT) comparing the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) to usual care in older adults with diabetes and MCC and their caregivers.

METHODS

We will conduct a cross-jurisdictional, multi-site implementation-effectiveness type II hybrid RCT. Eligibility criteria are: ≥65 years, diabetes diagnosis (Type 1 or 2) and at least one other chronic condition, and enrolled in a primary care or diabetes education program. Participants will be randomly assigned to the intervention (ACHRU-CPP) or control arm (1:1 ratio). The intervention arm consists of home/telephone visits, monthly group wellness sessions, multidisciplinary case conferences, and system navigation support. It will be delivered by registered nurses and registered dietitians/nutritionists from participating primary care or diabetes education programs and program coordinators from community-based organizations. The control arm consists of usual care provided by the primary care setting or diabetes education program. The primary outcome is the change from baseline to 6 months in mental functioning. Secondary outcomes will include, for example, the change from baseline to 6 months in physical functioning, diabetes self-management, depressive symptoms, and cost of use of healthcare services. Analysis of covariance (ANCOVA) models will be used to analyze all outcomes, with intention-to-treat analysis using multiple imputation to address missing data. Descriptive and qualitative data from older adults, caregivers and intervention teams will be used to examine intervention implementation, site-specific adaptations, and scalability potential.

DISCUSSION

An interprofessional intervention supporting self-management may be effective in improving health outcomes and client/caregiver experience and reducing service use and costs in this complex population. This pragmatic trial includes a scalability assessment which considers a range of effectiveness and implementation criteria to inform the future scale-up of the ACHRU-CPP.

TRIAL REGISTRATION

Clinical Trials.gov Identifier NCT03664583 . Registration date: September 10, 2018.

Adapting Evidence-Based Early Psychosis Intervention Services for Virtual Delivery: Protocol for a Pragmatic Mixed Methods Implementation and Evaluation Study

BACKGROUND

Timely and comprehensive treatment in the form of early psychosis intervention (EPI) has become the standard of care for youth with psychosis. While EPI services were designed to be delivered in person, the COVID-19 pandemic required many EPI programs to rapidly transition to virtual delivery, with little evidence to guide intervention adaptations or to support the effectiveness and satisfaction with virtual EPI services.

OBJECTIVE

This study aims to explore the adaptations required to deliver NAVIGATE, a model of coordinated specialty care used in EPI, in a virtual format. This study will evaluate implementation of the NAVIGATE model delivered virtually by describing the nature of the adaptations to the intervention, assessing fidelity to the EPI model and the satisfaction of clients, family members, and care providers. We will investigate barriers and facilitators to virtual NAVIGATE implementation, service engagement, and health equity impacts of this work.

METHODS

The Centre for Addiction and Mental Health (Toronto, Ontario, Canada) transitioned to delivering NAVIGATE virtually early in the COVID-19 pandemic. The Framework for Reporting Adaptations and Modifications for Evidence-Based Interventions will be used to describe the adaptations required to deliver NAVIGATE virtually. Fidelity to the EPI model will be measured using the First Episode Psychosis Services Fidelity Scale and fidelity to NAVIGATE will be assessed by investigating adherence to its core components. Implementation facilitators and barriers will be explored using semistructured interviews with providers informed by the Consolidated Framework for Implementation Research. Satisfaction with virtually delivered NAVIGATE will be assessed with virtual client and provider experience surveys and qualitative interviews with clients, family members, and providers. Service engagement data will be collected through review of medical records, and potential impacts of virtually delivered NAVIGATE on different population groups will be assessed with the Health Equity Impact Assessment.

RESULTS

Virtual clinical delivery of NAVIGATE started in March 2020 with additional adaptations and data collection is ongoing. Data will be analyzed using descriptive statistics and survival analysis for quantitative data. Qualitative data will be analyzed using thematic content analysis. Integration of qualitative and quantitative data will occur at the data collection, interpretation, and reporting levels following a convergent design.

CONCLUSIONS

This study will provide information regarding the type of intervention adaptations required for virtual delivery of NAVIGATE for youth with early psychosis, ensuring access to high-quality care for this population during the pandemic and beyond by guiding future implementation in similar contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34591.

Protocol for a caregiver psychosocial support intervention for populations affected by displacement in Uganda

BACKGROUND

Child psychological distress in refugee settings is a significant public health concern, which is exacerbated by poor caregiver mental health and functioning. However, there are limited studies about effective interventions to improve caregiver mental health in support of child wellbeing. The objective of the current study is to evaluate the effectiveness and implementation of the Journey of Life (JoL) intervention to improve caregiver mental health in a refugee camp in Western Uganda.

METHODS

A waitlist-control quasi-experimental design is being implemented in the Kiryandongo refugee settlement (intervention n = 600, control n = 600). Caregiver mental distress, measured using the Kessler-6, was selected as the primary outcome. Secondary outcomes include (a) functioning measured by the World Health Organization Disability Assessment Schedule, (b) social support measured by the Medical Outcomes Study Social Support Survey, and (c) caregiving behaviors according to the Parental Acceptance and Rejection Questionnaire and the Child Protection Index. The study aims to examine the implementation of the JoL intervention through qualitative assessments of intervention feasibility, adaptations, and reach.

DISCUSSION

This trial will add much-needed evidence for the implementation of caregiver psychosocial programming within the humanitarian community. Findings will be disseminated amongst local, regional, and global actors in order to guide potential scale up within humanitarian settings.

TRIAL REGISTRATION

Clinical Trials NCT04817098 (Registered: 3/24/21).

Implementation fidelity of the Systems for Person-Centered Elder Care (SPEC): a process evaluation study

BACKGROUND

The Systems for Person-Centered Elder Care (SPEC), a complex intervention, was conducted to examine its effectiveness as a technology-enhanced, multidisciplinary, and integrated care model for frail older persons among ten nursing homes (NHs) in South Korea where formal long-term care has recently been introduced. The purpose of this study was to evaluate the implementation fidelity of the SPEC intervention and to identify moderating factors that influence the implementation fidelity.

METHODS

This study was a process evaluation based on an evidence-based framework for implementation fidelity using a mixed-methods design. Quantitative data from consultant logbooks, NH documentations, an information and communications technology (ICT) system, and a standardized questionnaire were collected from April 2015 to December 2016 and analyzed by calculating the descriptive statistics. Semi-structured focus group interviews were held with multidisciplinary teams from the participating NHs. Qualitative data from a semi-structured questionnaire and the focus group interviews were analyzed using content analysis.

RESULTS

The SPEC program demonstrated good implementation fidelity, and adherence to the SPEC program was strong in all aspects, such as content, coverage, frequency, and duration. Of the participating on-site coordinators, 60% reported that the SPEC model positively impacted needs assessment and the reporting system for resident care. The important facilitating factors were tailored facilitating strategies, assurance of the quality of delivery, and recruitment strategies.

CONCLUSION

The effectiveness of the SPEC program was driven by good implementation fidelity. The key factors of good implementation fidelity were tailored delivery of evidence-based interventions over process evaluation work, facilitating strategies, and ICT support. Larger implementation studies with a more user-friendly ICT system are recommended.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN11972147 . Registered on 16 March 2015.

Interaction of diabetes genetic risk and successful lifestyle modification in the Diabetes Prevention Programme

AIM

To test whether diabetes genetic risk modifies the association of successful lifestyle changes with incident diabetes.

MATERIALS AND METHODS

We studied 823 individuals randomized to the intensive lifestyle intervention (ILS) arm of the Diabetes Prevention Programme who were diabetes-free 1 year after enrolment. We tested additive and multiplicative interactions of a 67-variant diabetes genetic risk score (GRS) with achievement of three ILS goals at 1 year (≥7% weight loss, ≥150 min/wk of moderate leisure-time physical activity, and/or a goal for self-reported total fat intake) on the primary outcome of incident diabetes over 3 years of follow-up.

RESULTS

A lower GRS and achieving each or all three ILS goals were each associated with lower incidence of diabetes (all P < 0.05). Additive interactions were significant between the GRS and achievement of the weight loss goal (P < 0.001), physical activity goal (P = 0.02), and all three ILS goals (P < 0.001) for diabetes risk. Achievement of all three ILS goals was associated with 1.8 (95% CI 0.3, 3.4), 3.1 (95% CI 1.5, 4.7), and 3.9 (95% CI 1.6, 6.2) fewer diabetes cases/100-person-years in the first, second and third GRS tertiles (P < 0.001 for trend). Multiplicative interactions between the GRS and ILS goal achievement were significant for the diet goal (P < 0.001), but not for weight loss (P = 0.18) or physical activity (P = 0.62) goals.

CONCLUSIONS

Genetic risk may identify high-risk subgroups for whom successful lifestyle modification is associated with greater absolute reduction in the risk of incident diabetes.

A cluster randomized controlled trial comparing Virtual Learning Collaborative and Technical Assistance strategies to implement an early palliative care program for patients with advanced cancer and their caregivers: a study protocol

BACKGROUND

Virtual Learning Collaboratives (VLC), learning communities focused on a common purpose, are used frequently in healthcare settings to implement best practices. Yet, there is limited research testing the effectiveness of this approach compared to other implementation strategies. This study evaluates the effectiveness of a VLC compared to Technical Assistance (TA) among community oncology practices implementing ENABLE (Educate, Nurture, Advise, Before Life Ends), an evidence-based, early palliative care telehealth, psycho-educational intervention for patients with newly diagnosed advanced cancer and their caregivers.

METHODS

Using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Proctor's Implementation Outcomes Frameworks, this two-arm hybrid type-III cluster-randomized controlled trial (RCT) will compare two implementation strategies, VLC versus TA, among the 48 National Cancer Institute Community Oncology Research Program (NCORP) practice clusters that have not historically provided palliative care to all patients with advanced cancer. Three cohorts of practice clusters will be randomized to the study arms. Each practice cluster will recruit 15-27 patients and a family caregiver to participate in ENABLE. The primary study outcome is ENABLE uptake (patient level), i.e., the proportion of eligible patients who complete the ENABLE program (receive a palliative care assessment and complete the six ENABLE sessions over 12 weeks). The secondary outcome is overall program implementation (practice cluster level), as measured by the General Organizational Index at baseline, 6, and 12 months. Exploratory aims assess patient and caregiver mood and quality of life outcomes at baseline, 12, and 24 weeks. Practice cluster randomization will seek to keep the proportion of rural practices, practice sizes, and minority patients seen within each practice balanced across the two study arms.

DISCUSSION

This study will advance the field of implementation science by evaluating VLC effectiveness, a commonly used but understudied, implementation strategy. The study will advance the field of palliative care by building the capacity and infrastructure to implement an early palliative care program in community oncology practices.

TRIAL REGISTRATION

Clinicaltrials.gov . NCT04062552; Pre-results. Registered: August 20, 2019. https://clinicaltrials.gov/ct2/show/NCT04062552?term=NCT04062552&draw=2&rank=1.

Study protocol for evaluating Six Building Blocks for opioid management implementation in primary care practices

Background

The Six Building Blocks for improving opioid management (6BBs) is a program for improving the management of patients in primary care practices who are on long-term opioid therapy for chronic pain. The 6BBs include building leadership and consensus; aligning policies, patient agreements, and workflows; tracking and monitoring patient care; conducting planned, patient-centered visits; tailoring care for complex patients; and measuring success. The Agency for Healthcare Research and Quality funded the development of a 6BBs implementation guide: a step-by-step approach for independently implementing the 6BBs in a practice. This mixed-method study seeks to assess practices’ use of the implementation guide to implement the 6BBs and the effectiveness of 6BBs implementation on opioid management processes of care among practices using the implementation guide.

Methods

Data collection is guided by the Consolidated Framework for Implementation Research, Proctor’s taxonomy of implementation outcomes, and the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain. A diverse group of health care organizations with primary care clinics across the USA will participate in the study over 15 months. Qualitative data collection will include semi-structured interviews with stakeholders at each organization at two time points, notes from routine check-in calls, and document review. These data will be used to understand practices’ motivation for participation, history with opioid management efforts, barriers and facilitators to implementation, and implementation progress. Quantitative data collection will consist of a provider and staff survey, an implementation milestones assessment, and quarterly opioid prescribing quality measures. These data will supplement our understanding of implementation progress and will allow us to assess changes over time in providers’ opioid prescribing practices, prescribing self-efficacy, challenges to providing guideline-driven care, and practices’ opioid prescribing quality measures. Qualitative data will be coded and analyzed for emergent themes. Quantitative data will be analyzed using descriptive statistics and clustered multivariate regression.

Discussion

This study contributes to the knowledge of the implementation and effectiveness of a team-based approach to opioid management in primary care practices. Information gleaned from this study can be used to inform efforts to curtail opioid prescribing and assist primary care practices considering implementing the 6BBs.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART)

BACKGROUND

There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM).

METHODS

In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed.

RESULTS

At least 296 participants and approximately 75 peer supporters will be enrolled.

DISCUSSION

Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes.

TRIAL REGISTRATION

The ClinicalTrials.gov registration number is NCT03689530.

Early Psychosis Intervention-Spreading Evidence-based Treatment (EPI-SET): protocol for an effectiveness-implementation study of a structured model of care for psychosis in youth and emerging adults

INTRODUCTION

While early psychosis intervention (EPI) has proliferated in recent years amid evidence of its effectiveness, programmes often struggle to deliver consistent, recovery-based care. NAVIGATE is a manualised model of EPI with demonstrated effectiveness consisting of four components: individualised medication management, individual resiliency training, supported employment and education and family education. We aim to implement NAVIGATE in geographically diverse EPI programmes in Ontario, Canada, evaluating implementation and its effect on fidelity to the EPI model, as well as individual-level outcomes (patient/family member-reported and interviewer-rated), system-level outcomes (captured in provincial administrative databases) and engagement of participants with lived experience.

METHODS AND ANALYSIS

This is a multisite, non-randomised pragmatic hybrid effectiveness-implementation type III mixed methods study coordinated at the Centre for Addiction and Mental Health (CAMH) in Toronto. Implementation is supported by the Provincial System Support Program, a CAMH-based programme with provincial offices across Ontario, and Extension of Community Healthcare Outcomes Ontario Mental Health at CAMH and the University of Toronto. The primary outcome is fidelity to the EPI model as measured using the First Episode Psychosis Services-Fidelity Scale. Four hundred participants in the EPI programmes will be recruited and followed using both individual-level assessments and health administrative data for 2 years following NAVIGATE initiation. People with lived experience will be engaged in all aspects of the project, including through youth and family advisory committees.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained from CAMH and institutions overseeing the local EPI programmes. Study findings will be reported in scientific journal articles and shared with key stakeholders including youth, family members, programme staff and policymakers.

TRIAL REGISTRATION NUMBER

NCT03919760; Pre-results.

An effectiveness-implementation hybrid type 1 trial assessing the impact of group versus individual antenatal care on maternal and infant outcomes in Malawi

BACKGROUND

Sub-Saharan Africa has the world's highest rates of maternal and perinatal mortality and accounts for two-thirds of new HIV infections and 25% of preterm births. Antenatal care, as the entry point into the health system for many women, offers an opportunity to provide life-saving monitoring, health promotion, and health system linkages. Change is urgently needed, because potential benefits of antenatal care are not realized when pregnant women experience long wait times and short visits with inconsistent provisioning of essential services and minimal health promotion, especially for HIV prevention. This study answers WHO's call for the rigorous study of group antenatal care as a transformative model that provides a positive pregnancy experience and improves outcomes.

METHODS

Using a hybrid type 1 effectiveness-implementation design, we test the effectiveness of group antenatal care by comparing it to individual care across 6 clinics in Blantyre District, Malawi. Our first aim is to evaluate the effectiveness of group antenatal care through 6 months postpartum. We hypothesize that women in group care and their infants will have less morbidity and mortality and more positive HIV prevention outcomes. We will test hypotheses using multi-level hierarchical models using data from repeated surveys (four time points) and health records. Guided by the consolidated framework for implementation research, our second aim is to identify contextual factors related to clinic-level degree of implementation success. Analyses use within and across-case matrices.

DISCUSSION

This high-impact study addresses three global health priorities, including maternal and infant mortality, HIV prevention, and improved quality of antenatal care. Results will provide rigorous evidence documenting the effectiveness and scalability of group antenatal care. If results are negative, governments will avoid spending on less effective care. If our study shows positive health impacts in Malawi, the results will provide strong evidence and valuable lessons learned for widespread scale-up in other low-resource settings. Positive maternal, neonatal, and HIV-related outcomes will save lives, impact the quality of antenatal care, and influence health policy as governments make decisions about whether to adopt this innovative healthcare model.

TRIAL REGISTRATION

ClinicalTrials.gov registration number NCT03673709. Registered on September 17, 2018.

Clarity out of chaos: Use of theory in implementation research

Implementation science has been recognized as a potential catalyst for health system reform, in part, because of its contribution of well-grounded conceptual theories, often encapsulated in frameworks. Well-designed frameworks provide a semantic structure, a common language by which to guide systematic approaches to studying implementation and testing interventions. An overview of the types and roles of theory in advancing implementation science is offered in this article. Resources for selecting appropriate frameworks are described along with illustrative examples. The case is made that well-developed theory is what enables knowledge to emerge out of seeming chaos and for translation of that knowledge to be widely and reliably implemented into routine practice so that health and well-being of patients is maximized by delivery of interventions that are rooted in that knowledge.

Cardiovascular disease-related chronic conditions among Veterans Affairs nonmetastatic colorectal cancer survivors: a matched case-control analysis

Purpose

The growing number of colorectal cancer (CRC) survivors often have multiple chronic conditions. Comparing nonmetastatic CRC survivors and matched noncancer controls, our objectives were to determine the odds of CRC survivors being diagnosed with cardiovascular disease (CVD)-related chronic conditions and their likelihood of control during the year after CRC diagnosis.

Patients and methods

We retrospectively identified patients diagnosed with nonmetastatic CRC in the Veterans Affairs health care system from fiscal years 2009 to 2012 and matched each with up to 3 noncancer control patients. We used logistic regression to assess differences in the likelihood of being diagnosed with CVD-related chronic conditions and control between nonmetastatic CRC survivors and noncancer controls.

Results

We identified 9,758 nonmetastatic CRC patients and matched them to 29,066 noncancer controls. At baseline, 69.4% of CRC survivors and their matched controls were diagnosed with hypertension, 52.4% with hyperlipidemia, and 36.7% with diabetes. Compared to matched noncancer controls, CRC survivors had 57% higher odds of being diagnosed with hypertension (OR=1.57, 95% CI=1.49–1.64) and 7% higher odds of controlled blood pressure (OR=1.07, 95% CI 1.02, 1.13) in the subsequent year. Compared to matched noncancer control patients, CRC survivors had half the odds of being diagnosed with hyperlipidemia (OR=0.50, 95% CI=0.48–0.52) and lower odds of low-density lipoprotein (LDL) control (OR 0.88, 95% CI 0.81–0.94). There were no significant differences between groups for diabetes diagnoses or control.

Conclusion

Compared to noncancer controls, nonmetastatic CRC survivors have 1) greater likelihood of being diagnosed with hypertension and worse blood pressure control in the year following diagnosis; 2) lower likelihood of being diagnosed with hyperlipidemia or LDL control; and 3) comparable diabetes diagnoses and control. There may be a need for hypertension control interventions targeting cancer survivors.

An implementation science study to enhance cardiovascular disease prevention in Mukono and Buikwe districts in Uganda: a stepped-wedge design

BACKGROUND

Uganda is experiencing a shift in major causes of death with cases of stroke, heart attack, and heart failure reportedly on the rise. In a study in Mukono and Buikwe in Uganda, more than one in four adults were reportedly hypertensive. Moreover, very few (36.5%) reported to have ever had a blood pressure measurement. The rising burden of CVD is compounded by a lack of integrated primary health care for early detection and treatment of people with increased risk. Many people have less access to effective and equitable health care services which respond to their needs. Capacity gaps in human resources, equipment, and drug supply, and laboratory capabilities are evident. Prevention of risk factors for CVD and provision of effective and affordable treatment to those who require it prevent disability and death and improve quality of life. The aim of this study is to improve health profiles for people with intermediate and high risk factors for CVD at the community and health facility levels. The implementation process and effectiveness of interventions will be evaluated.

METHODS

The overall study is a type 2-hybrid stepped-wedge (SW) design. The design employs mixed methods evaluations with incremental execution and adaptation. Sequential crossover take place from control to intervention until all are exposed. The study will take place in Mukono and Buikwe districts in Uganda, home to more than 1,000,000 people at the community and primary healthcare facility levels. The study evaluation will be guided by; 1) RE-AIM an evaluation framework and 2) the CFIR a determinant framework. The primary outcomes are implementation - acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, coverage, and sustainability.

DISCUSSION

The study is envisioned to provide important insight into barriers and facilitators of scaling up CVD prevention in a low income context. This project is registered at the ISRCTN Registry with number ISRCTN15848572. The trial was first registered on 03/01/2019.

How do we identify people at high risk of Type 2 diabetes and help prevent the condition from developing?

AIMS

To review the evidence regarding the identification of those at high risk of Type 2 diabetes and the conceptual and clinical criteria defining high risk, the prevention or delay of onset of Type 2 diabetes through lifestyle interventions, and the evolution of evidence from efficacy trials, through effectiveness trials in real-world settings, to implementation programmes at scale.

METHOD

The wide scope of this review precluded a systematic approach, therefore, we present a narrative review that highlights key themes and contemporary developments, drawing on landmark studies, previous systematic and expert reviews, and previous meta-analyses.

RESULTS

While the diagnostic thresholds for Type 2 diabetes are accepted, international consensus on whether, and how, to classify those at high risk of Type 2 diabetes has not been achieved. There is ongoing debate about which laboratory test to use and each test's corresponding inclusion threshold, about where the balance of clinical benefits and harms sit when defining thresholds, and about how affordability of subsequent preventative interventions might influence the derivation of such thresholds within any particular population. A remarkable international effort has seen the evolution of interventions for those at high risk move from efficacy trials, through effectiveness trials, to implementation at scale, and the evidence supporting each stage is reviewed.

CONCLUSIONS

To achieve healthcare system sustainability, many countries are now focusing on disease prevention. To complement population-level interventions that address the obesogenic environment, lifestyle interventions that empower individuals at high risk of Type 2 diabetes to modify this risk beneficially are now being implemented at scale.

Innovations in Mixed Methods Evaluations

Mixed methods research-i.e., research that draws on both qualitative and quantitative methods in varying configurations-is well suited to address the increasing complexity of public health problems and their solutions. This review focuses specifically on innovations in mixed methods evaluations of intervention, program or policy (i.e., practice) effectiveness, and implementation. The article begins with an overview of the structure, function, and process of different mixed methods designs and then provides illustrations of their use in effectiveness studies, implementation studies, and combined effectiveness-implementation hybrid studies. The article then examines four specific innovations: procedures for transforming (or "quantitizing") qualitative data, application of rapid assessment and analysis procedures in the context of mixed methods studies, development of measures to assess implementation outcomes, and strategies for conducting both random and purposive sampling, particularly in implementation-focused evaluation research. The article concludes with an assessment of challenges to integrating qualitative and quantitative data in evaluation research.

Older Adults and Diabetes Prevention Programs in the Veterans Health Administration

OBJECTIVE

To investigate whether older veterans enrolled in two diabetes prevention programs (DPPs) in the Veterans Health Administration will have similar weight loss as younger veterans.

RESEARCH DESIGN AND METHODS

Post hoc analysis of data from two prospective, pragmatic, nonrandomized studies of behavioral weight management interventions that were delivered in-person (Department of Veterans Affairs [VA]-DPP) or online (Online-DPP), comparing participation and weight loss between participants aged ≥65 years (N = 120) vs. <65 years (N = 258).

RESULTS

Over 70% of participants in both age groups completed eight or more sessions within 6 months; a higher proportion completed eight or more sessions in the Online-DPP intervention than in the VA-DPP intervention (P < 0.05). The overall weight changes at 6 and 12 months were similar across the two age groups: ∼5 kg or 5% weight loss compared with baseline (P > 0.05).

CONCLUSIONS

DPPs delivered in person or online can be similarly effective in older and younger veterans. Online programs may be an important means to improve the reach of DPPs for older adults.

Results From a Trial of an Online Diabetes Prevention Program Intervention

INTRODUCTION

Online Diabetes Prevention Programs (DPPs) can be scaled up and delivered broadly. However, little is known about real-world effectiveness and how outcomes compare with in-person DPP. This study examined online DPP weight loss and participation outcomes and secondarily compared outcomes among participating individuals with parallel in-person interventions.

STUDY DESIGN

A large non-randomized trial supplemented by a comparative analysis of participating individuals from a concurrent trial of two parallel in-person programs: in-person DPP and the Veterans Administration's standard of care weight loss program (MOVE!).

SETTING/PARTICIPANTS

Obese/overweight Veterans with prediabetes enrolled in online DPP (n = 268) between 2013 and 2014. Similar eligibility criteria were used to enroll in-person participants between 2012 and 2014 (n = 273 in-person DPP, n = 114 MOVE!) within a separate trial.

INTERVENTION

Online DPP included a virtual group format, live e-coach, weekly modules delivered asynchronously, and wireless home scales. In-person programs included eight to 22 group-based, face-to-face sessions.

MAIN OUTCOMES MEASURES

Weight change at 6 and 12 months using wirelessly uploaded home scale data or electronic medical record weights from clinical in-person visits. Outcomes were analyzed between 2015 and 2017.

RESULTS

From 1,182 invitations, 268 (23%) participants enrolled in online DPP. Among these, 158 (56%) completed eight or more modules; mean weight change was -4.7kg at 6 months and -4.0kg at 12 months. In a supplemental analysis of participants completing one or more sessions/modules, online DPP participants were most likely to complete eight or more sessions/modules (87% online DPP vs 59% in-person DPP vs 55% MOVE!, p < 0.001). Online and in-person DPP participants lost significantly more weight than MOVE! participants at 6 and 12 months; there was no significant difference in weight change between online and in-person DPP.

CONCLUSIONS

An intensive, multifaceted online DPP intervention had higher participation but similar weight loss compared to in-person DPP. An intensive, multifaceted online DPP intervention may be as effective as in-person DPP and help expand reach to those at risk.

Does mental health influence weight loss in adults with prediabetes? Findings from the VA Diabetes Prevention Program

OBJECTIVES

Mental illness may impact outcomes from structured behavioral weight loss interventions. This secondary analysis investigated the influence of mental health on weight loss among Veterans with prediabetes enrolled in either an in-person diabetes prevention program (DPP) or the usual care weight management program (MOVE!) designed to help patients achieve weight loss through changes in physical activity and diet.

METHODS

Prediabetes was defined by Hemoglobin A1c between 5.7 and 6.4% or Fasting Plasma Glucose 100-125 mg/dL and no use of antiglycemic medications during the past six months. Veterans Health Administrative data were used to assign Veterans into one of three mental health diagnoses: severe mental illness (SMI), affective disorder (AD) without SMI, or No SMI/No AD. The influence of mental health on weight changes at 6 and 12 months was modeled using linear mixed-effects regression.

RESULTS

On average, Veterans with prediabetes (n = 386) were 59 years old (SD = 10.0 years), with a BMI of 34.8 kg/m² (SD = 5.3 kg/m²) and A1c of 6.0% (SD = 0.2%). The sample consisted of 12% (n = 47), 39% (n = 150), and 49% (n = 189) diagnosed with SMI, AD and No SMI/No AD, respectively. Across interventions, Veterans with SMI lost less weight than those with AD or No SMI/No AD. From baseline to 6 months, weight loss was significantly less for Veterans with SMI (1.53 kg) compared to Veterans with AD (3.85 kg) or No SMI/No AD (3.73 kg). This weight loss trend by mental health diagnosis continued from baseline to 12 months but was no longer statistically significant at 12 months.

CONCLUSION

Weight loss was not clinically or statistically different among Veterans with prediabetes diagnosed with AD or No SMI/No AD. However, Veterans diagnosed with SMI exhibited less weight loss over 6 months than Veterans with AD or No SMI/No AD and though not statistically significant, the trend continued to 12 months, suggesting that SMI may influence weight loss outcomes.

Systematic Review of Behavioral Weight Management Program MOVE! for Veterans

CONTEXT

Since 2006, the Veterans Health Administration has delivered a population-based behavioral weight management program (MOVE!) to Veterans, which numerous studies have examined. The purpose of this study was to systematically review these studies to understand MOVE! participation rates and the association between MOVE! participation and weight change.

EVIDENCE ACQUISITION

A December 2016 PubMed search identified 320 English-language abstracts published between January 1, 2005 and December 31, 2016, of which 42 underwent full-text review. Twenty-six articles were determined to be eligible for final inclusion and data elements extracted from these articles included study years, study design, content of MOVE! and control intervention (if any), inclusion/exclusion criteria, initial sample size and sample loss, intervention duration and follow-up, patient characteristics, and outcomes. Quality was assessed using the Newcastle-Ottawa Quality Scale.

EVIDENCE SYNTHESIS

Studies were judged to be of good quality. Twenty-one of the 26 studies were retrospective cohort studies, one was a prospective cohort study and four were randomized trials. Program participation varied substantially (2%-12%) across studies. Six-month weight loss ranged from -0.95 kg to -1.84 kg, whereas 12-month weight loss ranged from -0.13 kg to -3.3 kg. A maximum of 25% of MOVE! users engaged in intense and sustained participation (eight or more visits within 6 months), but higher participation levels were consistently associated with greater weight change (-1.18 kg to -5.3 kg at 6 months, -1.68 kg to -3.58 kg at 12 months).

CONCLUSIONS

MOVE! participation is associated with modest short-term weight loss, with greater weight loss as participation increases. More research is needed to understand the barriers and facilitators to participation and the effect of MOVE! participation on long-term health and economic outcomes.

Improving the care of veterans: The role of nurse practitioners in team-based population health management

BACKGROUND AND PURPOSE

Improving healthcare delivery for U.S. veterans is a national priority. The Veterans Health Administration (VHA) employs a variety of team-based, population health strategies to address critical issues in veterans' health including the effective management of chronic disease. Nurse practitioners (NPs) are integral members of the VHA patient care team with a substantial role to play in the organization and delivery of healthcare services for veterans. This report explores the contributions of NPs in team-based, population health strategies within the VHA.

METHODS

This review of the literature examines peer-reviewed articles published between 2006 and 2017 to explore the contributions of NPs in team-based, population health strategies within the VHA. Search words include veterans, VHA, NPs, population health, panel management, and chronic disease.

CONCLUSIONS

NPs are vital members of the VHA primary care team; however, there is a dearth of available evidence reflecting the unique contribution of NPs within VHA team-based, population health management strategies.

IMPLICATIONS FOR PRACTICE

The VHA adoption of full practice authority for NP practice provides NPs with an expanded capacity to lead improvements in veterans' health. Future research is needed to fully understand the unique role of the NP in the delivery of population health management strategies for veterans.

Implementation findings from a hybrid III implementation-effectiveness trial of the Diabetes Prevention Program (DPP) in the Veterans Health Administration (VHA)

Background

The Diabetes Prevention Program (DPP) is an effective lifestyle intervention to reduce incidence of type 2 diabetes. However, there are gaps in knowledge about how to implement DPP. The aim of this study was to evaluate implementation of DPP via assessment of a clinical demonstration in the Veterans Health Administration (VHA).

Methods

A 12-month pragmatic clinical trial compared weight outcomes between the Veterans Affairs Diabetes Prevention Program (VA-DPP) and the usual care MOVE!® weight management program (MOVE!). Eligible participants had a body mass index (BMI) ≥30 kg/m² (or BMI ≥ 25 kg/m² with one obesity-related condition), prediabetes (glycosylated hemoglobin (HbA1c) 5.7–6.5% or fasting plasma glucose (FPG) 100–125 mg/dL), lived within 60 min of their VA site, and had not participated in a weight management program within the last year. Established evaluation and implementation frameworks were used to guide the implementation evaluation. Implementation barriers and facilitators, delivery fidelity, participant satisfaction, and implementation costs were assessed. Using micro-costing methods, costs for assessment of eligibility and scheduling and maintaining adherence per participant, as well as cost of delivery per session, were also assessed.

Results

Several barriers and facilitators to Reach, Adoption, Implementation, Effectiveness and Maintenance were identified; barriers related to Reach were the largest challenge encountered by site teams. Fidelity was higher for VA-DPP delivery compared to MOVE! for five of seven domains assessed. Participant satisfaction was high in both programs, but higher in VA-DPP for most items. Based on micro-costing methods, cost of assessment for eligibility was $68/individual assessed, cost of scheduling and maintaining adherence was $328/participant, and cost of delivery was $101/session.

Conclusions

Multi-faceted strategies are needed to reach targeted participants and successfully implement DPP. Costs for assessing patients for eligibility need to be carefully considered while still maximizing reach to the targeted population.

Diabetes Prevention Program Translation in the Veterans Health Administration

INTRODUCTION

This clinical demonstration trial compared the effectiveness of the Veterans Affairs Diabetes Prevention Program (VA-DPP) with an evidence-based usual care weight management program (MOVE!^®) in the Veterans Health Administration health system.

DESIGN

Prospective, pragmatic, non-randomized comparative effectiveness study of two behavioral weight management interventions.

SETTING/PARTICIPANTS

Obese/overweight Veterans with prediabetes were recruited from three geographically diverse VA sites between 2012 and 2014.

INTERVENTION

VA-DPP included 22 group-based intensive lifestyle change sessions.

MAIN OUTCOME MEASURES

Weight change at 6 and 12 months, hemoglobin A1c (HbA1c) at 12 months, and VA health expenditure changes at 15 months were assessed using VA electronic health record and claims data. Between- and within-group comparisons for weight and HbA1c were done using linear mixed-effects models controlling for age, gender, race/ethnicity, baseline outcome values, and site. Analyses were conducted in 2015-2016.

RESULTS

A total of 387 participants enrolled (273 VA-DPP, 114 MOVE!). More VA-DPP participants completed at least one (73.3% VA-DPP vs 57.5% MOVE! p=0.002); four (57.5% VA-DPP vs 42.5% MOVE!, p=0.007); and eight or more sessions (42.5% VA-DPP vs 31% MOVE!, p=0.035). Weight loss from baseline was significant at both 6 (p<0.001) and 12 months (p<0.001) for VA-DPP participants, but only significant at 6 months for MOVE! participants (p=0.004). Between groups, there were significant differences in 6-month weight loss (-4.1 kg VA-DPP vs -1.9 kg MOVE!, p<0.001), but not 12-month weight loss (-3.4 kg VA-DPP vs -2.0 kg MOVE!, p=0.16). There were no significant differences in HbA1c change or outpatient, inpatient, and total VA expenditures.

CONCLUSIONS

VA-DPP participants had higher participation rates and weight loss at 6 months, but similar weight, HbA1c, and health expenditures at 12 months compared to MOVE!

PARTICIPANTS

Features of VA-DPP may help enhance the capability of MOVE! to reach a larger proportion of the served population and promote individual-level weight maintenance.

ForgIng New paths in DIabetes PrevenTion (FINDIT): Study Protocol for a Randomized Controlled Trial

BACKGROUND

Prediabetes is an asymptomatic condition in which patients' blood glucose levels are higher than normal but do not meet diagnostic criteria for type 2 diabetes mellitus (T2DM). A key window of opportunity to increase engagement of patients with prediabetes in strategies to prevent T2DM is when they are screened for T2DM and found to have prediabetes, yet the effects of this screening and brief counseling are unknown.

METHODS

In this parallel-design randomized controlled trial we will recruit 315 non-diabetic patients from the Ann Arbor VA Medical Center (AAVA) who have one or major risk factors for T2DM and an upcoming primary care appointment at the AAVA, but have not had a hemoglobin A1c (HbA1c) test to screen for T2DM in the previous 12 months. After informed consent, participants will complete a baseline survey and be randomly assigned to, at the time of their next primary care appointment, one of two arms: (1) to have a hemoglobin A1c (HbA1c) test to screen for T2DM and receive brief, standardized counseling about these results or (2) to review a brochure about clinical preventive services. Participants will complete surveys 2 weeks, 3 months, and 12 months after their primary care appointment, and a weight measurement 12 months after their primary care appointment. The primary outcome is weight change after 12 months. The secondary outcomes are changes in perception of risk for T2DM; knowledge of T2DM prevention; self-efficacy and motivation to prevent T2DM; use of pharmacotherapy for T2DM prevention; physical activity; participation in weight management programs; and mental health. Quantitative analyses will compare outcomes among participants in the HbA1c test arm found to have prediabetes with participants in the brochure arm. Among participants in the HbA1c test arm found to have prediabetes we will conduct semi-structured interviews about their understanding of and reactions to receiving a prediabetes diagnosis.

DISCUSSION

This trial will generate foundational data on the effects of a prediabetes diagnosis and brief counseling on patients' preventive behaviors and mediators of these behaviors that will enable the development of novel strategies to improve patient engagement in T2DM prevention.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02747108 . Registered on 18 April 2016.

Practical partnered research to improve weight loss among overweight/obese veterans: lessons from the trenches

BACKGROUND

Obesity and obesity-related conditions, such as type 2 diabetes, are a major issue for Veteran health. Veterans Health Administration (VA) researchers and health systems leaders have worked separately and together to provide more effective weight management programs for Veterans. Although randomized clinical trials are often considered the gold standard for establishing efficacy of interventions in controlled circumstances, pragmatic clinical trials (PCTs) provide agility for translation.

MAIN TEXT

VA researchers and health system leaders collaboratively designed a PCT to compare the Diabetes Prevention Program (VA-DPP) to usual care (MOVE!®) in promoting weight loss and glycemic control among overweight/obese Veterans with prediabetes. Together, they navigated the tensions that exist between quality improvement and research activities, facing challenges but reaping significant rewards. Early findings led to updated national guidance for delivering obesity treatment in VA.

SHORT CONCLUSION

Partnered research and the use of PCTs can be powerful strategies for accelerating evidence-based findings into practice. Collaborative partnerships between researchers and health systems leaders can help enhance and sustain translation in real-world settings.

Introduction to special issue: Self-regulation of appetite-it's complicated

OBJECTIVE

A meeting of multidisciplinary biobehavioral scientists and National Institutes of Health (NIH) program staff was convened by the Office of Behavioral and Social Sciences Research, Division of Program Coordination, Planning, and Strategic Initiatives, Office of the Director, NIH to examine mechanisms associated with humans' ability to self-regulate appetite and appetitive behavior.

METHODS

Based upon prior discussions of the NIH Obesity Research Task Force Behavioral Phenotyping Work Group, the premise was adopted that, in modern society, multiple factors on multiple levels interact to create circumstances wherein self-control of appetite is difficult, leading to overconsumption of unhealthy foods versus healthy eating patterns, contributing to our current levels of obesity. Through presentations and group discussions, the panel examined how foundational processes/mechanisms directly and indirectly affect appetitive behavior and how these processes can be manipulated to affect food intake and thereby weight. The meeting identified evidence-based mechanisms with the potential to impact self-regulation of appetite and appetitive states (hunger, satiety, food wanting, restraint, reward) and associated behaviors such as overconsumption, eating in the absence of hunger, food seeking, and decision-making that could inform novel weight intervention strategies in free-living, nonlaboratory settings.

CONCLUSION

The three summary papers contained in this issue represent the synthesis of the material presented at the meeting and the panel's recommendations on how existing evidence regarding mechanisms and pathways to appetitive behavior can be used to inform future research and novel prevention and intervention strategies to impact prevalence of obesity.

Enhancing the reporting of implementation research

In the 10 years since the inception of Implementation Science, we have witnessed a continued rise in the number of submissions received, reflecting the continued global interest in methods to enhance the uptake of research findings into healthcare practice and policy. We receive over 750 submissions annually, and there is now a large gap between what is submitted and what gets published. In this editorial, we restate the journal scope and current boundaries. We also identify some specific reporting issues that if addressed will help enhance the scientific reporting quality and transparency of the manuscripts we receive. We hope that this editorial acts as a further guide to researchers seeking to publish their work in Implementation Science.