Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory

Evidence adaptation and tailored implementation of family bereavement support in specialised palliative care: A multi-method study

Background

Families experiencing the loss of their close other following advanced illness have varying degrees of needs that stretch into bereavement. Evidence-based recommendations for bereavement support are often not well implemented in palliative care services due to multiple system barriers and lack of contextual fit. To close this know-do gap, we undertook an implementation science research project.

Objective

To adapt evidence-informed recommendations for supporting bereaved families to the local context, and to develop a tailored implementation strategy for their integration in specialised palliative care services.

Settings and participants

Two specialised palliative care services located at urban teaching hospitals in German-speaking Switzerland. Participants were palliative care staff working in the service, including nurses, physicians, chaplains, psychologists, and two service users.

Methods

Multi-method implementation research project combining community engagement strategies, qualitative contextual analysis, and theory-driven implementation design processes for integrating evidence-informed interventions in new contexts: First, evidence was identified and adapted through co-design staff workshops and service user consultations, following intervention adaptation guidelines. Next, focus group interviews were held to identify barriers and facilitators to implementation, informed by the Consolidated Framework for Implementation Research and analysed using qualitative content analysis. Drawing on implementation mapping methodology, a systematic and participatory process was used to develop an implementation plan that specified activities needed to address identified barriers and support integration into palliative care services.

Results

The study resulted in an adapted bereavement support pathway with three core functions of evidence-informed practices delivered during dying, at death, three-to-six, and if necessary nine-to-twelve months post-loss: screening and assessing family needs and risks, intervention and support activities for families, and team collaboration and coordination within and across providers. Implementation was expected to be influenced by the features of the intervention itself, staff competencies, and organisational conditions, with resources required being a frequent barrier, whereas workplace culture and the project-related network acted as facilitators. A multifaceted implementation strategy with 16 distinct activities was developed to reach 70 % of bereaved families: designing a practical, implementable pathway, creating necessary team capacity and roles, optimizing workflow, offering education and clinician support, ensuring leadership and organisational commitment, and facilitating mutual exchange and learning. An implementation research logic model specified expected mechanisms of impact and outcomes.

Conclusions

The project resulted in an adapted bereavement support intervention fitted to local palliative care contexts and a tailored implementation plan. Adapting evidence to specific contexts and understanding potential barriers and facilitators is necessary to prepare implementation.

Registration

https://osf.io/qgr7y.

Increasing the Accessibility and Relevance of Implementation Science for Front-Line Implementers

BACKGROUND

Implementation science has been heralded as a critical strategy for ending the HIV epidemic, and the United States has made a tremendous financial investment in implementation research. However, several dynamics in its development and organization may alienate front-line implementers and recapitulate some of the same missteps that have stymied past translational work.

SETTING

Increasing the accessibility and relevance of HIV implementation science for front-line implementers (eg, health department and health systems directors, clinic administrators, program managers, clinicians, and other providers) is critical.

METHODS

We review current challenges to the meaningful inclusion of front-line implementers in implementation science research, and consider specific changes to language, frameworks, and methods that would maximize the accessibility and relevance of the field.

RESULTS

Our analysis suggests the need for greater attention to implementation strategies most relevant to front-line implementers, that is, those focused on intervention recipients. We propose a novel, multilayer framework for conceptualizing the strategies necessary to achieve HIV implementation outcomes by organizations, providers, and recipients. There is a compelling rationale to adopt incentive structures that prioritize research questions most important for practice.

CONCLUSIONS

Maximizing the impact of implementation science on ending the HIV epidemic goals requires (1) expanding the focus of implementation science to include more recipient-focused implementation strategies, (2) developing and applying frameworks that better reflect the experience and needs of front-line implementers, (3) using language most relevant and applicable to practice, and (4) prioritizing actionable research questions that directly address the needs and concerns of those doing implementation work.

Barriers and facilitators to implementing polypharmacy management frameworks: a theory based qualitative exploration of key stakeholders

BACKGROUND

Inappropriate polypharmacy arises through many factors including deficiencies in prescribing processes. Most research has focused on solutions at the clinician/patient levels with less at the organisational level.

AIM

To explore key stakeholder identified barriers and facilitators to implementation of an organisational level polypharmacy management framework.

METHOD

Qualitative data were collected within the Ministry of Health in Oman. Key stakeholders were purposively sampled encompassing senior representatives of pharmacy, medicine, and nursing directors; healthcare policymakers; patient safety leaders; and academic leaders. A semi-structured interview schedule was developed informed by a recent scoping review and underpinned by the Consolidated Framework for Implementation Research (CFIR). Interviews, which continued until data saturation, were audio-recorded, transcribed and analysed using the Framework Approach.

RESULTS

Thirteen key stakeholders were interviewed, with representation of each target group. Facilitators largely mapped to the CFIR domain of inner setting (i.e., aspects of stakeholder awareness, the electronic health system and national leadership), intervention characteristic (evidence gaps), characteristics of individuals (stakeholders and champions) and process (change strategy). Barriers also largely mapped to the inner setting (policy absence, communication and health professional practice) and outer setting (resource needs).

CONCLUSION

This study has illuminated the facilitators and barriers to the implementation of an organisational level polypharmacy management framework. Further work is required to translate these themes into an actionable plan to implement the framework. Particular attention is required for aspects of the CFIR domain of inner setting (i.e., the internal context within which implementation occurs) as most barriers mapped to this domain.

Evaluating the implementation of adult smoking cessation programs in community settings: a scoping review

Introduction

Tobacco smoking is a leading contributor to preventable morbidity and premature mortality globally. Although evidence-based smoking cessation programs have been implemented, there is limited evidence on the application of theories, models, and frameworks (TMFs), and implementation strategies to support such programs. This scoping review mapped the evidence for interventions, TMFs, and implementation strategies used for smoking cessation programs in the community.

Methods

We searched four electronic databases in addition to grey literature and conducted hand-searching between February and December 2023. Original studies of qualitative, quantitative, or mixed methods were considered for inclusion. Studies reporting prospectively planned and/or delivered implementation of smoking cessation interventions or programs, incorporating contextual factors, use of implementation TMF, implementation strategies, or other factors influencing implementation were considered for inclusion. Intervention components were categorized using the Template for Intervention Description and Replication (TIDieR) checklist. Implementation strategies were mapped to the Expert Recommendations for Implementing Change (ERIC) Strategy Clusters.

Results

A total of 31 studies were included. We identified 12 discrete interventions, commonly included as part of multicomponent interventions. Most studies reported tailoring or modifying interventions at the population or individual level. We identified 19 distinct implementation TMFs used to prospectively guide or evaluate implementation in 26 out of 31 included studies. Studies reported diverse implementation strategies. Three studies embedded culturally appropriate TMFs or local cultural guidance into the implementation process. These studies took a collaborative approach with the communities through partnership, participation, cultural tailoring, and community-directed implementation.

Discussion

Our findings highlight the methods by which the implementation of smoking cessation may be supported within the community. Whilst there is debate surrounding their necessity, there are practical benefits to applying TMFs for implementing, evaluating, and disseminating findings. We determined that whilst ERIC was well-suited as a framework for guiding the implementation of future smoking cessation programs, there was inconsistent use of implementation strategies across the ERIC domains. Our findings highlight a lack of harmonization in the literature to culturally tailor implementation processes for local communities.

Supporting partnerships in knowledge mobilization: what existing implementation strategies can tell us

BACKGROUND

The need for partnership between knowledge producers and knowledge users to foster effective implementation is well-established in the implementation science literature. While many theories, models, and frameworks (TMF) have been developed to guide knowledge mobilization (KM) activities, seldom do these frameworks inform approaches for establishing and maintaining KM partnerships (i.e., relationships between researchers and individuals with relevant expertise in KM activities). Thus, there is a significant knowledge-to-action gap related to operationalizing engagement in partnerships and leveraging the evidence that exists to support them. Given the abundance of TMFs, it is prudent to consider whether any may be suitable to inform approaches to partnership. The aim of this commentary is to discuss the necessity for strategies to support engagement in partnerships for KM activities, as well as to explore the potential to apply strategies from an existing implementation taxonomy to inform partnerships approaches in KM.

MAIN BODY

Using a case study, this commentary explores the opportunity to apply existing implementation strategies put forward by the Expert Recommendations for Implementing Change (ERIC) taxonomy to inform partnership strategies. This case study utilized qualitative evidence from a qualitative study about KM in children's pain management informed by the Consolidated Framework for Implementation Research (CFIR). It explored partner perspectives (i.e., knowledge producers and users) on factors that supported their engagement in KM activities. The factors generated were subsequently mapped onto the ERIC taxonomy to identify relevant strategies to support partnerships development for KM activities (e.g., shared goals among team members mapped onto the ERIC strategy Build a Coalition). Each factor generated was determined to have a corresponding ERIC strategy to support the operationalization of that factor.

CONCLUSIONS

This case example and discussion bolster the utility of existing taxonomies and frameworks to support the development and sustainability of partnerships to support engagement in KM activities, a promising next step for developing strategies to support partnerships. Opportunities for future development are also discussed, including identifying other theories, models, and frameworks that may contribute to a comprehensive suite of empirically informed partnership strategies, as well as the necessity to make strategies and approaches available to non-specialist audiences.

Implementation strategies for WHO guidelines to prevent, detect, and treat postpartum hemorrhage

RATIONALE

Despite World Health Organization (WHO) guidelines for preventing, detecting, and treating postpartum hemorrhage (PPH), effective implementation has lagged.

OBJECTIVES

To evaluate the clinical benefits and harms of implementation strategies used to promote adherence to WHO clinical guidelines for the prevention, detection, and treatment of PPH.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and two trial registries, along with reference checking, citation searching, and contact with study authors. The latest search date was 25 April 2024.

ELIGIBILITY CRITERIA

We included randomized controlled trials (RCTs), including cluster, pragmatic, and stepped-wedge designs, and non-randomized studies of interventions (NRSIs), including interrupted time series (ITS) studies, controlled before-after (CBA) studies, and follow-up (cohort) studies containing concurrent controls that focused on or described implementation strategies of WHO guidelines for the prevention, detection, and treatment of PPH. Participants were birth attendants and people giving birth in a hospital or healthcare facility. We excluded studies that did not implement a WHO PPH recommendation, had no comparator group, or did not report clinical/implementation outcomes.

OUTCOMES

Our critical outcomes were: adherence to WHO-recommended guidelines for PPH prevention, detection, and treatment; PPH ≥ 500 mL; PPH ≥ 1000 mL; additional uterotonics within 24 hours after birth; blood transfusions; maternal death; severe morbidities (major surgery; admission to intensive care unit [ICU]); and adverse effects (variable and related to the clinical intervention) during hospitalization for birth. Our important outcomes were: breastfeeding at discharge; implementation outcomes such as acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability of the implementation strategy; and health professional outcomes such as knowledge and skill.

RISK OF BIAS

We used the RoB 2 and ROBINS-I tools to assess risk of bias in RCTs and NRSIs, respectively.

SYNTHESIS METHODS

Two review authors independently selected studies, performed data extraction, and assessed risk of bias and trustworthiness. Due to the nature of the data, we reported relevant results for each comparison and outcome but did not attempt quantitative synthesis. We used GRADE to assess the certainty of evidence.

INCLUDED STUDIES

We included 13 studies (9 cluster-RCTs and 4 NRSIs) with a total of 1,027,273 births and more than 4373 birth attendants. The included studies were conducted in 17 different countries. Most trials were conducted in resource-limited settings. None of the included studies reported data on the use of additional uterotonics within 24 hours after birth or adverse effects.

SYNTHESIS OF RESULTS

Single-component implementation strategies versus usual care for PPH prevention, detection, and treatment We do not know if single-component implementation strategies have any effect on adherence to WHO PPH prevention recommendations, PPH ≥ 500 mL, PPH ≥ 1000 mL, or blood transfusion (very low-certainty evidence). Low-certainty evidence suggests that single-component implementation strategies may have little to no effect on maternal death (86,788 births, 3 trials); may increase severe morbidity related to ICU admission (26,985 births, 1 trial); and may reduce severe morbidity related to surgical outcomes (26,985 births, 1 trial). No trials in this comparison measured the effect on adherence to WHO treatment guidelines. Multicomponent implementation strategies versus usual care for PPH prevention, detection, and treatment We do not know if multicomponent implementation strategies have any effect on adherence to WHO PPH treatment recommendations, PPH ≥ 500 mL, blood transfusion, or severe morbidity relating to surgical outcomes (very low-certainty evidence). Multicomponent implementation strategies may have little to no effect on maternal death (274,008 births, 2 trials; low-certainty evidence) compared to usual care. No trials in this comparison measured the effect on adherence to WHO PPH prevention recommendations, PPH ≥ 1000 mL, or severe morbidity (outcomes related to ICU admission). Multicomponent implementation strategies versus enhanced usual care for PPH prevention, detection, and treatment Low-certainty evidence suggests that multicomponent implementation strategies may improve adherence to WHO PPH prevention recommendations (14,718 births, 2 trials) and adherence to WHO PPH treatment recommendations (356,913 births, 2 trials) compared to enhanced usual care. Multicomponent implementation strategies probably have little to no effect on maternal death (224,850 births, 2 trials; moderate-certainty evidence), severe morbidity related to ICU admission (224,850 births, 2 trials; moderate-certainty evidence), and surgical morbidity (210,132 births, 1 trial; moderate-certainty evidence) compared to enhanced usual care. We do not know if multicomponent implementation strategies affect PPH ≥ 500 mL, PPH ≥ 1000 mL, or blood transfusion (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Multicomponent implementation strategies may improve adherence to WHO PPH prevention and treatment recommendations, but they probably result in little to no difference in ICU admissions, surgical morbidity, or maternal death. The majority of available evidence is of low to very low certainty, thus we cannot draw any robust conclusions on the effects of implementation strategies for WHO guidelines to prevent, detect, and treat PPH. While all included studies used the implementation strategy of 'train and educate,' the effects seem to be limited when used as a single strategy. Additional research using pragmatic, hybrid effectiveness-implementation study designs that measure implementation outcomes simultaneously alongside clinical outcomes would be beneficial to understand contextual factors, barriers, and facilitators that affect implementation.

FUNDING

This Cochrane review had no dedicated external funding. Dr Rose Molina, who is employed by Beth Israel Deaconess Medical Center, received funding from Ariadne Labs (Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital) for her time. As a funder, Ariadne Labs had no involvement in the development of the protocol or conduct of the review. The views and opinions expressed therein are those of the review authors and do not necessarily reflect those of Ariadne Labs.

REGISTRATION

Registration: PROSPERO (CRD42024563802) available via https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024563802.

Network analysis of the relationship between error orientation, self-efficacy, and innovative behavior in nurses

Nurses' innovative behavior is essential in the evolving healthcare landscape. This study, guided by the theory of challenge and threat, aims to explore the relationships between nurses' error orientation, self-efficacy, and innovative behavior through network analysis. A cross-sectional study design was utilized, involving 706 participants from 23 hospitals across six provinces and one municipality directly under the jurisdiction of the central government in China. Participants completed an error orientation questionnaire, the general self-efficacy scale, and the nurse innovative behavior scale online. Data analysis was conducted using SPSS and R, with the network structure, symptom centrality, and outcome robustness evaluated through the qgraph and bootnet packages in R. In the network structure encompassing error orientation, self-efficacy, and innovative behavior, self-efficacy demonstrated the strongest closeness and betweenness centrality, followed by innovative behavior and error orientation. Among these variables, self-efficacy was most closely associated with innovative behavior. Within the dimensions of error orientation, the strongest connection with self-efficacy was found in the aspect of thinking about errors, followed by error communication, error competence, learning from errors, and error risk taking. This network analysis identified self-efficacy as the most influential factor in promoting nurses' innovative behavior. The findings suggest that clinical educators and hospital managers should focus on enhancing nurses' self-efficacy to foster their innovative behavior and effectively manage error orientation.

Perineal massage and warm compresses-Implementation study of a complex intervention in health

OBJECTIVES

To determine the effect of using tailored and multifaceted strategies on the acceptability, appropriateness, feasibility and adoption of a perineal massage and warm compress intervention by midwives in a maternity ward of a tertiary hospital in Portugal.

METHODS

The complex intervention in health was developed based on the Medical Research Council framework and guided by the Theory of Change. Tailored and multifaceted strategies, including dissemination, integration and implementing process strategies, were applied. A mixed-methods approach was adopted, with a combination of qualitative (semi-open interviews) and quantitative (surveys, audits and electronic health records) methods. Surveys were applied to assess the acceptability, appropriateness and feasibility of the intervention. In order to evaluate adoption of the intervention, data from interviews were introduced into NVivo Version 10 to perform thematic analysis, and each audit checklist criterion was analysed using McNemar's exact test to determine differences in paired proportion.

RESULTS

This study found high acceptability (mean±standard deviation 4.28±0.45), high appropriateness (4.32±0.47) and high feasibility (4.26±0.43) of the intervention by midwives. Differences were reported for most topics between interviews conducted before and after implementation of the intervention. Pre-intervention, the midwives reported that the main factor affecting the application of perineal protection techniques was the lack of continuous presence of the midwife. The birth position was the alternative birth position (hands and knees, side-lying, squatting and semi-sitting), avoiding the lithotomy position. Techniques used for perineal protection were warm compresses, hands-on techniques, hands-off techniques and spontaneous pushing; and the reasons given for performing an episiotomy were large (high-birthweight) baby, Kristeller manoeuvre, tense perineum and previous obstetric sphincter injury. Post-intervention, the midwives reported that the presence of a second person increases the safety of professionals and women and improves working relations. The technique used for perineal protection was autonomy to adapt the intervention with perineal massage and warm compresses. A comfortable birth position for woman was used, and the rate of episiotomy reduced (only performed in the case of fetal distress). Regarding audits, significant differences (p < 0.05) were found for all audit criteria (pre- and post-intervention), which means that midwives adopted the intervention into their clinical practice.

CONCLUSION

Acceptability, appropriateness, feasibility and adoption of the intervention by midwives were high. Thus, tailored and multifaceted strategies were effective to achieve the implementation outcomes.

Implementing Task-Shared Child and Adolescent Psychological Interventions in Low- and Middle-Income Countries: A Scoping Review

OBJECTIVE

Effective "task shared," or nonspecialist delivered, psychological interventions for children and adolescents have been developed or adapted in low- and middle-income countries with the aim of closing the global treatment gap for youth mental health care. Yet, delivery remains limited, in part due to the lack of knowledge of associated implementation, or process, outcomes. This scoping review aims to describe, examine the quality of, and synthesize findings on implementation outcomes of child and adolescent psychological interventions in low-and middle-income countries.

METHODS

PubMed, Web of Science, and PsycInfo were searched for studies on child and adolescent psychological interventions in low- and middle-income countries reporting on implementation outcomes. After abstract and full-text review, data were extracted and summarized on implementation outcomes and quality of implementation outcomes reporting. Implementation barriers and recommendations for addressing barriers were also charted and narratively synthesized.

RESULTS

Out of 5,207 manuscripts, 86 met inclusion criteria. Younger children were underrepresented. Studies largely reported feasibility and acceptability and did not state hypotheses or use conceptual models. Barriers primarily related to interventions being too complex, not an acceptable fit with participant cultures, and facilitators lacking time for or experiencing distress delivering interventions. Recommendations focused on increasing intervention fit and flexibility, training and support for facilitators, and linkages with existing systems.

CONCLUSIONS

Rigorous, broader implementation outcomes research is needed within child and adolescent psychological intervention research in low-and middle-income countries. Current evidence suggests the importance of the further developing strategies to increase acceptability to participants and better support facilitators.

A randomized controlled trial of the Transdiagnostic Intervention for Sleep and Circadian dysfunction implemented via facilitation and delivered by community mental health providers: Improving the "fit" of psychological treatments by adapting to context

Background

To determine if the use of theory, data and end-user perspectives to guide an adaptation of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) yields better outcomes and improves the "fit" of TranS-C to community mental health centers (CMHCs), relative to the standard version.

Methods

Ten counties in California were cluster-randomized by county to Adapted or Standard TranS-C. Within each county, adults who exhibited sleep and circadian dysfunction and serious mental illness (SMI) were randomized to immediate TranS-C or Usual Care followed by Delayed Treatment with TranS-C (UC-DT). Facilitation was the implementation strategy. The participants were 93 CMHC providers who delivered TranS-C (Standard = 30; Adapted = 63) and 396 CMHC patients (Standard = 74; Adapted = 124; UC-DT = 198). Patient assessments were completed at pre-treatment, post-treatment, and six months after treatment (6FU). Provider assessments were completed at post-training, mid-treatment, and post-treatment.

Results

TranS-C (combining Adapted and Standard), relative to UC-DT before delayed treatment with TranS-C, was associated with improvement from pre- to post-treatment in sleep disturbance (b = -10.91, p < 0.001, d = -1.52), sleep-related impairment (b = -9.52, p < 0.001, d = -1.06), sleep health composite (b = 1.63, p < 0.001, d = 0.95), psychiatric symptoms (b = -6.72, p < 0.001, d = -0.52), and overall functional impairment (b = -5.12, p < 0.001, d = -0.71). TranS-C's benefits for functional impairment and psychiatric symptoms were mediated by improvements in sleep and circadian problems. Adapted versus Standard TranS-C did not differ on provider ratings of fit and better fit did not mediate the relation between TranS-C condition and patient outcome.

Conclusions

TranS-C can be delivered by CMHC providers. Although Adapted and Standard TranS-C both fit the CMHC context, several advantages emerged for the adapted version.

Implementing Reform: Approaches to Alter the Use of Local Jail for People with Behavioral Health Conditions

To reduce the overrepresentation of people with behavioral health conditions in jails, jurisdictions have implemented evidence-based programs/policies (EBPPs) and treatments (EBTs). Using survey data from 519 U.S. counties, the present study classifies and evaluates the impact of strategies used to implement EBPPs and EBTs. Exploratory factor analysis identified four implementation approaches (i.e., clusters of strategies) which counties utilize to different extents depending on their population size: Relationship-Building among agencies (α = .911), infrastructural Capacity-Building (.788), developing Quality Programming (.880), and establishing Shared Definitions of key terms (.913). Relationship-Building and Shared Definitions were significant predictors of increased county-level availability of EBPPs and EBTs. These findings indicate that approaches focusing on interagency collaboration appear especially impactful. However, strategies that require more resources (viz. Capacity-Building) are underutilized. For smaller and/or rural counties with limited resources, an initial emphasis on interagency collaboration approaches can yield positive outcomes, as these require less initial investment and appear especially versatile.

Implementation outcomes from a randomized, controlled trial of a strategy to improve integration of behavioral health and primary care services

BACKGROUND

Integrating behavioral health services in primary care is challenging; a toolkit approach to practice implementation can help. A recent comparative effectiveness randomized clinical trial examined the impact of a toolkit for improving integration on outcomes for patients with multiple chronic conditions. Some aspects of behavioral health integration improved; patient-reported outcomes did not. This report evaluates the implementation strategy (Toolkit) using Proctor's (2011) implementation outcomes model.

METHODS

Using data from the 20 practices randomized to the active (toolkit strategy) arm (education, redesign workbooks, online learning community, remote coaching), we identified 23 measures from practice member surveys, coach interviews, reports, and field logs to assess Toolkit acceptability, appropriateness, feasibility, and fidelity. A practice survey score was high (met expectations) if its average was ≥ 4 on a scale 1-5; all other data were coded dichotomously, with high = 1.

RESULTS

Regarding acceptability, 74% (14) of practices had high scores for willingness of providers and staff to use the Toolkit and 68% (13) for quality improvement teams liking the Toolkit. For appropriateness, 95% (19) of practices had high scores for the structured process being a good match and 63% (12) for the Toolkit being a good match. Feasibility, measured by Toolkit prerequisites, was scored lower by site members at project end (e.g., provider leader available as champion: 53% of practices) compared to remote coaches observing practice teams (74%). For "do-ability," coaches rated feasibility lower for practices (e.g., completion of workbook activities: 32%) than the practice teams (68%). Fidelity was low as assessed across seven measures, with 50% to 78% of practices having high scores across the seven measures.

CONCLUSIONS

Existing data from large trials can be used to describe implementation outcomes. The Toolkit was not implemented with fidelity in at least one quarter of the sites, despite being acceptable and appropriate, possibly due to low feasibility in the form of unmet prerequisites and Toolkit complexity. Variability in fidelity reflects the importance of implementation strategies that fit each organization, suggesting that further study on contextual factors and use of the Toolkit, as well as the relationship of Toolkit use and study outcomes, is needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02868983; date of registration: 08/15/2016.

Tracking modifications to implementation strategies: a case study from SNaP - a hybrid type III randomized controlled trial to scale up integrated systems navigation and psychosocial counseling for PWID with HIV in Vietnam

INTRODUCTION

Evaluation of implementation strategies is core to implementation trials, but implementation strategies often deviate from the original plan to adjust to the real-world conditions. The optimal approach to track modifications to implementation strategies is unclear, especially in low-resource settings. Using data from an implementation trial for people who inject drugs (PWID) with HIV in Vietnam, we describe the tracking of implementation strategy modifications and present findings of this process.

METHODS

SNaP (Systems Navigation and Psychosocial Counseling) is a hybrid type-III effectiveness-implementation randomized controlled trial aiming to scale up the evidence-based intervention, integrated systems navigation and psychosocial counseling, for PWID with HIV in Vietnam. Forty-two HIV testing sites were randomized 1:1 to a standard or tailored arm. While the standard arm (SA) received a uniform package of strategies, implementation strategies for the tailored arm (TA) were tailored to address specific needs of each site. The central research team also met monthly with the TA to document how their tailored strategies were implemented over time. Five components were involved in the tracking process: describing the planned strategies; tracking strategy use; monitoring barriers and solutions; describing modifications; and identifying and describing any additional strategies.

RESULTS

Our approach allowed us to closely track the modifications to implementation strategies in the tailored arms every month. TA sites originally identified 27 implementation strategies prior to implementation. During implementation, five strategies were dropped by four sites and two new strategies were added to twelve sites. Modifications of five strategies occurred at four sites to accommodate their changing needs and resources. Difficulties related to the COVID-19 pandemic, low number of participants recruited, high workload at the clinic, lack of resources for HIV testing and high staff turnover were among barriers of implementing the strategies. A few challenges to tracking modifications were noted, including the considerable amount of time and efforts needed as well as the lack of motivation from site staff to track and keep written documentations of modifications.

CONCLUSIONS

We demonstrated the feasibility of a systematic approach to tracking implementation strategies for a large-scale implementation trial in a low-resource setting. This process could be further enhanced and replicated in similar settings to balance the rigor and feasibility of implementation strategy tracking. Our findings can serve as additional guidelines for future researchers planning to report and track modifications to implementation strategies in large, complex trials.

TRIAL REGISTRATION

clinicaltrials.gov ID: NCT03952520 (first posted 2019-05-16).

Enhancing Clinicians' Use of Electronic Patient-Reported Outcome Measures in Outpatient Care: Mixed Methods Study

BACKGROUND

Despite the increasing use of patient-reported outcome measures (PROMs) for collecting self-reported data among hospital outpatients, clinicians' use of these data remains suboptimal. Insight into this issue and strategies to enhance the use of PROMs are critical but limited.

OBJECTIVE

This study aimed to examine clinicians' use of PROM data for value-based outpatient consultations and identify efforts to enhance their use of PROMs in a Dutch university hospital. First, we aimed to investigate clinicians' use of outpatients' PROM data in 2023, focusing on adoption, implementation, and maintenance. Second, we aimed to develop insights into the organizational-level strategies implemented to enhance clinicians' use of PROM data from 2020 to 2023. This included understanding the underlying rationales for these strategies and identifying strategies that appeared to be missing to address barriers or leverage facilitators. Third, we aimed to explore the key factors driving and constraining clinicians' use of PROMs in 2023.

METHODS

We integrated data from 4 sources: 1-year performance data on clinicians' use of PROMs (n=70 subdepartments), internal hospital documents from a central support team (n=56), a survey among clinicians (n=47), and interviews with individuals contributing to the organizational-level implementation of PROMs (n=20). The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to analyze clinicians' adoption, implementation, and maintenance of PROMs. Strategies were analyzed using the Expert Recommendations for Implementing Change taxonomy, and results were structured around the constructs of capability, opportunity, and motivation.

RESULTS

On average, around 2023, clinicians accessed PROM data for approximately 3 of 20 (14%) patients during their outpatient consultation, despite numerous strategies to improve this practice. We identified issues in adoption, implementation, and maintenance. The hospital's strategies, shaped organically and pragmatically, were related to 27 (37%) out of 73 Expert Recommendations for Implementing Change strategies. These strategies focused on enhancing clinicians' capability, opportunity, and motivation. We found shortcomings in the quality of execution and completeness of strategies in relation to addressing all barriers and leveraging facilitators. We identified variations in the factors influencing the use of PROMs among frequent PROM users, occasional users, and nonusers. Challenges to effective facilitation were apparent, with certain desired strategies being unfeasible or impeded.

CONCLUSIONS

Enhancing clinicians' use of PROMs has remained challenging despite various strategies aimed at improving their capability, opportunity, and motivation. The use of PROMs may require more substantial changes than initially expected, necessitating a shift in clinicians' professional attitudes and practices. Hospitals can facilitate rather than manage clinicians' genuine use of PROMs. They must prioritize efforts to engage clinicians with PROMs for value-based outpatient care. Specific attention to their professionalization may be warranted. Tailored strategies, designed to address within-group differences in clinicians' needs and motivation, hold promise for future efforts.

Strategies for implementation of a transmural fall-prevention care pathway for older adults with fall-related injuries at the emergency department

BACKGROUND

Although indicated, referrals for multifactorial fall risk assessments in older adults with fall related injuries presenting at the emergency department (ED) are not standard. The implementation of a transmural fall-prevention care pathway (TFCP) could bridge this gap by guiding patients to multifactorial fall risk assessments and personalised multidomain interventions in primary care. This study aims to develop and evaluate implementation strategies for a TFCP.

METHODS

In this mixed-methods implementation study, strategies were developed using the Consolidated Framework for Implementation Research Expert Recommendations for Implementing Change Matching Tool. These were evaluated with patients, involved healthcare professionals, and other stakeholders using the Reach, Adoption, Implementation, and Maintenance of the RE-AIM framework in two cycles. Patients of the TFCP consisted of frail community dwelling individuals aged 65 and over presenting at the ED with fall related injuries.

RESULTS

During the first implementation phase, strategies were focussed on assessing readiness, adaptability, local champions, incentives and education for all involved healthcare professions in the TFCP. Only 34.4% of eligible patients were informed of the TFCP at the ED, 30.6% agreed to a fall risk assessment and 8.3% patients received the fall risk assessment. In the second phase, this improved to 67.1%, 64.6%, and 35.4%, respectively. Strategies in this phase focussed on adaptability, obtaining sustainable financial resources, local champions, assessing readiness, and education. The implementation was facilitated by strategies related to awareness, champion recruitment, educational meetings, adaptability of TFCP elements and evaluations of facilitators and barriers.

CONCLUSION

The study outlined strategies for implementing TFCPs in EDs. Strategies included increasing awareness, utilising local champions, educational initiatives, adaptability of the TFCP, and continuous monitoring of facilitators and barriers. These insights can serve as a blueprint for enhancing fall prevention efforts for older adults in emergency department settings.

Implementing Evidence-Based Pain Management Interventions Into an Emergency Department: Outcomes Guided by Use of the Ottawa Model of Research Use

AIM

To implement strategies to improve the care of patients with acute pain in the emergency department (ED).

DESIGN

Pre-post implementation study using a Type 2 hybrid effectiveness-implementation design.

METHODS

Implementation strategies were introduced and monitored through the Ottawa Model of Research Uses' assessment, monitoring and evaluation cycles, supported by focused and sustained facilitation.

RESULTS

Improvements in time-to-analgesia within 30 min (21%-27%), administration of nurse-initiated analgesia (NIA) (17%-27%) and measurement of pain (65%-75%) were achieved post-implementation. NIA was the strongest predictor of receiving analgesia within 30 min. Adoption of pain interventions into practice was not immediate yet responded to sustained facilitation of implementation strategies.

CONCLUSION

Collaboration with local clinicians to introduce simple interventions that did not disrupt workflow or substantially add to workload were effective in improving analgesia administration rates, and the proportion of patients receiving analgesia within 30 min. The assessment, monitoring and evaluation cycles enabled agile and responsive facilitation of implementation activities within the dynamic ED environment. Improvements took time to embed into practice, trending upward over the course of the implementation period, supporting the sustained facilitation approach throughout the study.

IMPLICATIONS

Sustained adoption of evidence-based pain interventions into the care of people presenting to the ED with acute pain can be achieved through sustained facilitation of implementation. NIA should be at the centre of acute pain management in the ED.

IMPACT

This study addressed the lingering gap between evidence and practice for patients with acute pain in the ED. Implementation of locally relevant/informed implementation strategies supported by focused and sustained facilitation improved the care of patients with acute pain in the ED. This research will have an impact on people presenting to EDs with acute pain, and on clinicians treating people with acute pain in the ED. Relevant equator guidelines were followed and the StaRI reporting method used.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution in this study.

Using Systems Engineering and Implementation Science to Design an Implementation Package for Preoperative Comprehensive Geriatric Assessment Among Older Adults Having Major Abdominal Surgery: Protocol for a 3-Phase Study

BACKGROUND

Older Americans, a growing segment of the population, have an increasing need for surgical services, and they experience a disproportionate burden of postoperative complications compared to their younger counterparts. A preoperative comprehensive geriatric assessment (pCGA) is recommended to reduce risk and improve surgical care delivery for this population, which has been identified as vulnerable. The pCGA optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social and environmental support. The pCGA has been shown to decrease postoperative morbidity, mortality, and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of the pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic medical centers. By applying implementation science and human factors engineering methods, this study will provide the necessary evidence to optimize the implementation of the pCGA in a variety of health care settings.

OBJECTIVE

The purpose of this paper is to describe the study protocol to design an adaptable, user-centered pCGA implementation package for use among older adults before major abdominal surgery.

METHODS

This protocol uses systems engineering methods to develop, tailor, and pilot-test a user-centered pCGA implementation package, which can be adapted to community-based hospitals in preparation for a multisite implementation trial. The protocol is based upon the National Institutes of Health Stage Model for Behavioral Intervention Development and aligns with the goal to develop behavioral interventions with an eye to real-world implementation. In phase 1, we will use observation and interviews to map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery. In phase 2, we will apply user-centered design methods, engaging health care providers, patients, and caregivers to co-design a pCGA implementation package. This package will be applicable to a diverse population of older patients undergoing major abdominal surgery at a large academic hospital and an affiliate community site. In phase 3, we will pilot-test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. We anticipate that this study will take approximately 60 months (April 2023-March 2028).

RESULTS

This study protocol will generate (1) a detailed process map of the pCGA; (2) an adaptable, user-centered pCGA implementation package ready for feasibility testing in a pilot trial; and (3) preliminary pilot data on the implementation and effectiveness of the package. We anticipate that these data will serve as the basis for future multisite hybrid implementation-effectiveness clinical trials of the pCGA in older adults undergoing major abdominal surgery.

CONCLUSIONS

The expected results of this study will contribute to improving perioperative care processes for older adults before major abdominal surgery.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59428.

Effectiveness of de-implementation of low-value healthcare practices: an overview of systematic reviews

BACKGROUND

Reducing low-value care (LVC) is crucial to improve the quality of patient care while increasing the efficient use of scarce healthcare resources. Recently, strategies to de-implement LVC have been mapped against the Expert Recommendation for Implementing Change (ERIC) compilation of strategies. However, such strategies' effectiveness across different healthcare practices has not been addressed. This overview of systematic reviews aimed to investigate the effectiveness of de-implementation initiatives and specific ERIC strategy clusters.

METHODS

We searched MEDLINE (Ovid), Epistemonikos.org and Scopus (Elsevier) from 1 January 2010 to 17 April 2023 and used additional search strategies to identify relevant systematic reviews (SRs). Two reviewers independently screened abstracts and full texts against a priori-defined criteria, assessed the SR quality and extracted pre-specified data. We created harvest plots to display the results.

RESULTS

Of 46 included SRs, 27 focused on drug treatments, such as antibiotics or opioids, twelve on laboratory tests or diagnostic imaging and seven on other healthcare practices. In categorising de-implementation strategies, SR authors applied different techniques: creating self-developed strategies (n = 12), focussing on specific de-implementation strategies (n = 14) and using published taxonomies (n = 12). Overall, 15 SRs provided evidence for the effectiveness of de-implementation interventions to reduce antibiotic and opioid utilisation. Reduced utilisation, albeit inconsistently significant, was documented in the use of antipsychotics and benzodiazepines, as well as in laboratory tests and diagnostic imaging. Strategies within the adapt and tailor to context, develop stakeholder interrelationships, and change infrastructure and workflow ERIC clusters led to a consistent reduction in LVC practices.

CONCLUSION

De-implementation initiatives were effective in reducing medication usage, and inconsistent significant reductions were observed for LVC laboratory tests and imaging. Notably, de-implementation clusters such as change infrastructure and workflow and develop stakeholder interrelationships emerged as the most encouraging avenues. Additionally, we provided suggestions to enhance SR quality, emphasising adherence to guidelines for synthesising complex interventions, prioritising appropriateness of care outcomes, documenting the development process of de-implementation initiatives and ensuring consistent reporting of applied de-implementation strategies.

REGISTRATION

OSF Open Science Framework 5ruzw.

Implementation Strategies for Quality Improvement in Palliative Care: A Scoping Review

BACKGROUND

Quality improvement (QI) programs based on person-centred outcome measures (PCOMs) play an important role in promoting optimal palliative care. However, routine use of PCOMs has been slow and difficult to implement, including within QI programs.

OBJECTIVE

This study aimed to identify implementation strategies that support the implementation of PCOMs as routine practice in hospital-based palliative care, as well as the implementation theories, models and frameworks (TMFs) guiding the design of these implementation strategies.

METHODS

A scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) Scoping Review framework. Four databases (Medline, CINAHL, Scopus and PubMed) were systematically searched for literature published between 1 January 1990 and 8 March 2024.

RESULTS

One hundred and fifteen unique implementation strategies, identified from 11 included studies, were mapped onto the 73 Expert Recommendations for Implementing Change (ERIC) discrete implementation strategies, covering 52% of the ERIC strategies. The most commonly used categories were train and educate stakeholders, and support clinicians, followed by develop stakeholder interrelationships and use evaluation and iterative strategies. Three key themes emerged: what to do; how to do it; and who to do it with. Only four studies employed TMFs to guide the design of the implementation strategies in this review.

CONCLUSIONS

To promote the implementation of PCOM-based QI programs, strategies should be developed based on identified/potential barriers and facilitators by using rigorous TMFs. The components of the implementation strategies must be reported transparently and consistently to enable replication and measurement in future research and practice.

PATIENT AND PUBLIC CONTRIBUTION

This scoping review does not directly involve patients or the general public in its design or execution. However, it is part of an implementation study aimed at integrating the Palliative Care Outcome Collaboration (PCOC) model into routine clinical practice at a cancer hospital in China. Before the formal implementation, palliative care professionals from this hospital highlighted the need for a comprehensive analysis of existing evidence to support the effective adoption of the PCOC model in their specific clinical setting.

Expanding a Behavioral View on Digital Health Access: Drivers and Strategies to Promote Equity

The potential and threat of digital tools to achieve health equity has been highlighted for over a decade, but the success of achieving equitable access to health technologies remains challenging. Our paper addresses renewed concerns regarding equity in digital health access that were deepened during the COVID-19 pandemic. Our viewpoint is that (1) digital health tools have the potential to improve health equity if equitable access is achieved, and (2) improving access and equity in digital health can be strengthened by considering behavioral science-based strategies embedded in all phases of tool development. Using behavioral, equity, and access frameworks allowed for a unique and comprehensive exploration of current drivers of digital health inequities. This paper aims to present a compilation of strategies that can potentially have an actionable impact on digital health equity. Multilevel factors drive unequal access, so strategies require action from tool developers, individual delivery agents, organizations, and systems to effect change. Strategies were shaped with a behavioral medicine focus as the field has a unique role in improving digital health access; arguably, all digital tools require the user (individual, provider, and health system) to change behavior by engaging with the technology to generate impact. This paper presents a model that emphasizes using multilevel strategies across design, delivery, dissemination, and sustainment stages to advance digital health access and foster health equity.

Mapping regional implementation of 'Making Every Contact Count': mixed-methods evaluation of implementation stage, strategies, barriers and facilitators of implementation

BACKGROUND

The Making Every Contact Count (MECC) programme provides training and materials to support public-facing workers to encourage health-promoting behaviour change by using the day-to-day interactions between organisations and individuals. This project aimed to analyse MECC implementation through a comparative analysis of implementation stage, strategies used for implementation and enablers/barriers of the implementation process within a region in England-the North East and North Cumbria (NENC).

METHODS

A mixed-methods process evaluation was conducted applying normalisation process theory and theoretical domains framework. MECC programme documents were reviewed and mapped against specific criteria (eg, implementation strategies). An online mapping survey was conducted to establish current implementation/delivery of MECC within NENC settings (eg, local government, healthcare and voluntary community sector). Qualitative research, using individual interviews and group discussions, was conducted to establish further understanding of MECC implementation.

RESULTS

Our findings were informed by reviewing documents (n=5), surveying participants (n=34), interviews (n=18) and group discussions (n=48). Overall, the implementation of MECC within the region was at an early stage, with training mostly delivered between, rather than within, organisations. Qualitative findings highlighted factors that influence stakeholders to implement MECC (eg, organisational goals that were facilitated by MECC implementation, including the prevention agenda), supported resources that facilitate the implementation of MECC (eg, logic models) and enabling factors that promote MECC sustainability across the region (eg, buy-in from leadership and management).

CONCLUSIONS

The NENC MECC programme is built around regional leadership that supports the implementation process. This process evaluation identified key influences of MECC implementation across the region. We discuss evidence-based recommendation for policy and practice that can be taken forward to develop targeted strategies to support future MECC implementation. For example, a co-ordinated infrastructure and strategy is needed to combat delivery and implementation issues identified.

How is tailored implementation undertaken using a self-guided toolkit? Qualitative study of the ItFits-toolkit in the ImpleMentAll project

BACKGROUND

The process of tailored implementation is ill-defined and under-explored. The ItFits-toolkit was developed and subsequently tested as a self-guided online platform to facilitate implementation of tailored strategies for internet-based cognitive behavioural therapy (iCBT) services. In ImpleMentAll, ItFits-toolkit had a small but positive effect on the primary outcome of iCBT normalisation. This paper investigates, from a qualitative perspective, how implementation teams developed and undertook tailored implementation using the toolkit within the trial.

METHODS

Implementation teams in thirteen sites from nine countries (Europe and Australia) used the ItFits-toolkit for six months minimum, consistent with the trial protocol. A qualitative process evaluation was conducted. Descriptive data regarding goals, barriers, strategies, and implementation plans collected within the toolkit informed qualitative data collection in real time. Qualitative data included remote longitudinal interviews (n = 55) with implementation team members (n = 30) and observations of support calls (n = 19) with study sites. Qualitative data were analysed thematically, using a team-based approach.

RESULTS

Implementation teams developed and executed tailored implementation projects across all steps in the toolkit process. Working in a structured way but with room for flexibility, decisions were shaped by team members' ideas and goals, iterative stakeholder engagement, internal and external influences, and the context of the ImpleMentAll project. Although teams reported some positive impacts of their projects, 'time', both for undertaking the work, and for seeing project impacts, was described as a key factor in decisions about implementation strategies and assessments of success.

CONCLUSION

This study responds directly to McHugh et al.'s (2022) call for empirical description of what implementation tailoring looks like in action, in service settings. Self-guided facilitation of tailored implementation enables implementers in service settings to undertake tailoring within their organisations. Implementation tailoring takes considerable time and involves detailed work but can be supported through the provision of implementation science informed guidance and materials, iterative and ongoing stakeholder engagement, and working reflectively in response to external influencing factors. Directions for advancement of tailored implementation are suggested.

Trauma-Informed Care Interventions Used in Pediatric Inpatient or Residential Treatment Mental Health Settings and Strategies to Implement Them: A Scoping Review

Trauma-informed care (TIC) is an approach to care emerging in research and in practice that involves addressing the needs of individuals with histories of trauma. The aim of this scoping review was to examine the current literature relating to TIC interventions used in pediatric mental health inpatient and residential settings. We sought to answer the following two research questions: (a) What are the TIC interventions used in pediatric inpatient and residential treatment mental healthcare settings and what are their components? and (b) What are the implementation goals and strategies used with these TIC interventions? We conducted this scoping review according to JBI (formerly Joanna Briggs Institute) methodology for scoping reviews. We included any primary study describing a TIC intervention that was implemented at a specific site which identified and described implementation strategies used. Of 1,571 identified citations and 54 full-text articles located by handsearching, 49 met the eligibility criteria and were included, representing 21 distinct TIC interventions. We present the reported aim, ingredients, mechanism, and delivery (AIMD) of TIC interventions as well as the implementation goals and strategies used, which varied in detail, ranging from very little information to more detailed descriptions. In the context of these findings, we emphasize the complexity of TIC and of TIC interventions, and the importance of identifying and clearly reporting TIC intervention goals, intervention details, and implementation strategies. We suggest applying intervention frameworks or reporting guidelines to support clear and comprehensive reporting, which would better facilitate replication and synthesis of published TIC interventions.

Intervention Optimization: A Paradigm Shift and Its Potential Implications for Clinical Psychology

To build a coherent knowledge base about what psychological intervention strategies work, develop interventions that have positive societal impact, and maintain and increase this impact over time, it is necessary to replace the classical treatment package research paradigm. The multiphase optimization strategy (MOST) is an alternative paradigm that integrates ideas from behavioral science, engineering, implementation science, economics, and decision science. MOST enables optimization of interventions to strategically balance effectiveness, affordability, scalability, and efficiency. In this review we provide an overview of MOST, discuss several experimental designs that can be used in intervention optimization, consider how the investigator can use experimental results to select components for inclusion in the optimized intervention, discuss the application of MOST in implementation science, and list future issues in this rapidly evolving field. We highlight the feasibility of adopting this new research paradigm as well as its potential to hasten the progress of psychological intervention science.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022

BACKGROUND

Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes.

METHODS

We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes.

FINDINGS

Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions.

CONCLUSION

This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

Optimizing implementation: elucidating the role of behavior change techniques and corresponding strategies on determinants and implementation performance: a cross-sectional study

INTRODUCTION

Behavior change techniques (BCTs) are considered as active components of implementation strategies, influencing determinants and, ultimately, implementation performance. In our previous Delphi study, experts formulated 'implementation hypotheses', detailing how specific combinations of BCTs and strategies (referred to as BCT-strategy combinations) might influence determinants and guideline implementation within youth care. For example, educational meetings providing instructions on guideline use were hypothesized to enhance practitioners' knowledge and, consequently, guideline implementation. However, these hypotheses have not been verified in practice yet.

METHOD

We conducted a cross-sectional study involving practitioners and management professionals from youth (health)care organizations. Using questionnaires, we obtained data on the presence of BCT-strategy combinations and their perceived influence on determinants and implementation performance. Chi-squared tests and regression analyses were employed to determine the influence of specific BCT-strategy combinations on determinants and implementation performance.

RESULTS

Our analyses included data from 104 practitioners and 34 management professionals. Most of the management professionals indicated that the BCT-strategy combinations positively influenced or had the potential to influence their implementation performance. At the practitioner level, half of the combinations were perceived to have a positive influence on determinants and implementation performance. Furthermore, practitioners who reported the absence of BCT-strategy combinations were more skeptical about their potential influence on determinants and implementation performance.

CONCLUSION

Several BCT-strategy combinations were perceived to improve or potentially improve implementation performance of both practitioners and management professionals. In the development and evaluation of implementation efforts, we advocate for clearly describing the implementation effort's objective and using frameworks that detail the BCTs inducing behavior change, the strategy employed, and the processes driving the observed changes. Understanding these interconnected processes is important in designing targeted, evidence-based behavior change interventions. This understanding optimizes resource allocation and contributes to the overall success of implementation efforts in youth care.

A streamlined approach to classifying and tailoring implementation strategies: recommendations to speed the translation of research to practice

BACKGROUND

Implementation science emerged from the recognized need to speed the translation of effective interventions into practice. In the US, the science has evolved to place an ever-increasing focus on implementation strategies. The long list of implementation strategies, terminology used to name strategies, and time required to tailor strategies all may contribute to delays in translating evidence-based interventions (EBIs) into practice. To speed EBI translation, we propose a streamlined approach to classifying and tailoring implementation strategies.

MAIN TEXT

A multidisciplinary team of eight scholars conducted an exercise to sort the Expert Recommendations for Implementing Change (ERIC) strategies into three classes: implementation processes (n = 25), capacity-building strategies (n = 20), and integration strategies (n = 28). Implementation processes comprise best practices that apply across EBIs and throughout the phases of implementation from exploration through sustainment (e.g., conduct local needs assessment). Capacity-building strategies target either general or EBI-specific knowledge and skills (e.g., conduct educational meetings). Integration strategies include "methods and techniques" that target barriers or facilitators to implementation of a specific EBI beyond those targeted by capacity building. Building on these three classes, the team collaboratively developed recommendations for a pragmatic, five-step approach that begins with the implementation processes and capacity-building strategies practice-settings are already using prior to tailoring integration strategies. A case study is provided to illustrate use of the five-step approach to tailor the strategies needed to implement a transitional care intervention in skilled nursing facilities.

CONCLUSIONS

Our proposed approach streamlines the formative work required prior to implementing an EBI by building on practice partner preferences, expertise, and infrastructure while also making the most of prior research findings.

Gastroenterologist and surgeon perceptions of recommendations for optimal endoscopic localization of colorectal neoplasms

National consensus recommendations have recently been developed to standardize colorectal tumour localization and documentation during colonoscopy. In this qualitative semi-structured interview study, we identified and contrast the perceived barriers and facilitators to using these new recommendations according to gastroenterologists and surgeons in a large central Canadian city. Interviews were analyzed according to the Consolidated Framework for Implementation Research (CFIR) through directed content analysis. Solutions were categorized using the Expert Recommendations for Implementing Change (ERIC) framework. Eleven gastroenterologists and ten surgeons participated. Both specialty groups felt that the new recommendations were clearly written, adequately addressed current care practice tensions, and offered a relative advantage versus existing practices. The new recommendations appeared appropriately complex, applicable to most participants, and could be trialed and adapted prior to full implementation. Major barriers included a lack of relevant external or internal organizational incentives, non-existing formal feedback processes, and a lack of individual familiarity with the evidence behind some recommendations. With application of the ERIC framework, common barriers could be addressed through accessing new funding, altering incentive structures, changing record systems, educational interventions, identifying champions, promoting adaptability, and employing audit/feedback processes. Future research is needed to test strategies for feasibility and effectiveness.

Healthcare professionals' perspectives on optimizing pain care-related education at a Canadian children's hospital: A qualitative study

Objectives

Pain affects all children and youth, yet acute and procedural pain remains undertreated in Canadian hospitals. To improve pain management practices in paediatric hospitals, it is necessary to understand how healthcare professionals (HCPs) wish for educational interventions to be designed to improve their pain management practice.

Methods

Semi-structured interviews were conducted with 18 HCPs between October and December 2020. Snowball sampling was used to first recruit interested members from the hospital's Pediatric Pain Management Committee. Interviews were conducted per participant preference and included Zoom, telephone, and in-person interviews. Recruitment ceased when data were determined sufficiently rich. A thematic analysis of verbatim transcripts and reflexive field notes were used to create a data set focused on knowledge mobilization and clinical education.

Results

Three core themes were identified: (a) the necessity for just-in-time education for HCPs; (b) the availability of clinical pain champions to educate staff; and (c) the provision of resources to educate children and their families about available pain management interventions. Just-in-time education included suggestions for in-service training, hands-on training, and regular updates on the latest research. Pain champions, including clinical nurse educators, were stressed as being important in motivating staff to improve their pain management practices. Participants noted the lack of resources for patient and family education on pain management and suggested providing more multimodal resources and educational opportunities.

Conclusion

Having local champions introduce pain management initiatives and just-in-time education positively impacts the implementation climate, which also helps HCPs provide evidence-based education and resources to patients and families.

Building a sharable literature collection to advance the science and practice of implementation facilitation

Background

Implementation science seeks to produce generalizable knowledge on strategies that promote the adoption and sustained use of evidence-based innovations. Literature reviews on specific implementation strategies can help us understand how they are conceptualized and applied, synthesize findings, and identify knowledge gaps. Although rigorous literature reviews can advance scientific knowledge and facilitate theory development, they are time-consuming and costly to produce. Improving the efficiency of literature review processes and reducing redundancy of effort is especially important for this rapidly developing field. We sought to amass relevant literature on one increasingly used evidence-based strategy, implementation facilitation (IF), as a publicly available resource.

Methods

We conducted a rigorous systematic search of PubMed, CINAHL, and Web of Science citation databases for peer-reviewed, English-language articles with "facilitation" and a combination of other terms published from January 1996 to December 2021. We searched bibliographies of articles published from 1996 to 2015 and identified articles during the full text review that reported on the same study. Two authors screened 3,168 abstracts. After establishing inter-rater reliability, they individually conducted full-text review of 786 relevant articles. A multidisciplinary team of investigators provided recommendations for preparing and disseminating the literature collection.

Findings

The literature collection is comprised of 510 articles. It includes 277 empirical studies of IF and 77 other articles, including conceptual/theoretical articles, literature reviews, debate papers and descriptions of large-scale clinical initiatives. Over half of the articles were published between 2017 and 2021. The collection is publicly available as an Excel file and as an xml file that can be imported into reference management software.

Conclusion

We created a publicly accessible collection of literature about the application of IF to implement evidence-based innovations in healthcare. The comprehensiveness of this collection has the potential to maximize efficiency and minimize redundancy in scientific inquiry about this strategy. Scientists and practitioners can use the collection to more rapidly identify developments in the application of IF and to investigate a wide range of compelling questions on its use within and across different healthcare disciplines/settings, countries, and payer systems. We offer several examples of how this collection has already been used.

Getting to Fidelity: Consensus Development Process to Identify Core Activities of Implementation Facilitation

Transferring successful implementation strategies from research to practice requires approaches for assessing fidelity to the strategy's core components. Implementation facilitation (IF) is a strategy involving an interactive process of problem-solving, enabling, and supporting individuals in efforts to implement clinical innovations that occurs in the context of a recognized need for improvement and supportive interpersonal relationships. Because IF is a dynamic strategy involving numerous activities, our objective was to conduct a rigorous consensus development process to identify core activities for monitoring fidelity to IF when applied in clinical settings. We first conducted a scoping literature review to identify the range of activities used when IF has been applied in clinical settings, searching multiple citation databases for English-language articles including "facilitation" or other commonly-used terms for the strategy published from 1996-2015. Through multi-stage screening, 135 articles (from 94 studies) were identified for data extraction on IF activities, frequency with which IF activities were identified as 'core' by study authors, and study outcomes. From the literature review, we identified 32 distinct IF activities and developed definitions/examples for each. Next, we conducted a 3-stage, modified-Delphi expert panel consensus development process to identify core IF activities across three implementation phases (i.e., Pre-Implementation, Implementation, Sustainment). The expert panel identified 8 core activities for the Pre-Implementation Phase, 8 core activities for the Implementation Phase, and 4 core activities for the Sustainment Phase. This work provides an important foundation for developing measures/tools to assess use of core IF activities to ensure the strategy is delivered with fidelity.

Stakeholder and Equity Data-Driven Implementation: a Mixed Methods Pilot Feasibility Study

We conducted a mixed methods pilot feasibility study of a Stakeholder and Equity Data-Driven Implementation (SEDDI) process to facilitate using healthcare data to identify patient groups experiencing gaps in the use of evidence-based interventions (EBIs) and rapidly adapt EBIs to achieve greater access and equitable outcomes. We evaluated the feasibility and acceptability of SEDDI in a pilot hybrid type 2 effectiveness-implementation trial of a paired colorectal cancer (CRC) and social needs screening intervention at four federally qualified community health centers (CHCs). An external facilitator partnered with CHC teams to support initial implementation, followed by the SEDDI phase focused on advancing health equity. Facilitation sessions were delivered over 8 months. Preliminary evaluation of SEDDI involved convergent mixed methods with quantitative survey and focus group data. CHCs used data to identify gaps in outreach and completion of CRC screening with respect to race/ethnicity, gender, age, and language. Adaptations to improve access and use of the intervention included cultural, linguistic, and health literacy tailoring. CHC teams reported that facilitation and systematic review of data were helpful in identifying and prioritizing gaps. None of the four CHCs completed rapid cycle testing of adaptations largely due to competing priorities during the COVID-19 response. SEDDI has the potential for advancing chronic disease prevention and management by providing a stakeholder and data-driven approach to identify and prioritize health equity targets and guide adaptations to improve health equity. ClinicalTrials.gov Identifier: NCT04585919.

Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping

BACKGROUND

Evidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa.

METHODS

Purposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies.

RESULTS

Thirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials.

CONCLUSIONS

Multiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up

BACKGROUND

High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years.

METHODS

The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis.

RESULTS

The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time.

CONCLUSIONS

The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

Preparing community pharmacy teams for health information exchange (HIE)

BACKGROUND

Health information exchanges (HIEs) facilitate health care professionals' electronic sharing of patient information across different organizations. When community pharmacists have access to HIE, they can further contribute to improved patient outcomes. However, several implementation challenges are noted, which impede sustained pharmacist access to HIE. To our knowledge, no bidirectional HIE interface design and pharmacy team-informed implementation process has been documented. In response, our research team designed and developed an HIE interface prototype for use specifically by community pharmacy teams to access local HIE data through their pharmacy dispensing software.

OBJECTIVES

To 1) identify barriers, facilitators, and recommendations for using HIE data in community pharmacies and 2) create a curated list of resources addressing identified implementation needs to aid future implementation of a fully functional, bidirectional HIE interface by community pharmacy teams.

METHODS

Pharmacists, pharmacy technicians, and patients from three pharmacy sites within the Community Pharmacy Enhanced Services Network of Indiana participated in individual semi-structured interviews. Interview questions were mapped to select constructs across all domains of the Consolidated Framework for Implementation Research. Interview transcripts were deductively coded. A subset of participants participated in Evidence-Based Quality Improvement sessions to iteratively update planned resource items needed to support future HIE implementation.

RESULTS

We interviewed 23 total participants: 8 pharmacists, 8 pharmacy technicians, and 7 patients. Five facilitators, four barriers, and two recommendations were identified. These were further characterized into four key implementation needs: instruction on how to use HIE; guidance on workflow and team roles; resources that are patient-facing; and resources that are provider-facing, resulting in 16 planned implementation resources.

CONCLUSION

Our study provides the first-of-its-kind list of pharmacy team-informed resources to facilitate sustainability and scalability of HIE implementation in community pharmacies.

Implementation strategies in suicide prevention: a scoping review

BACKGROUND

Implementation strategies can be a vital leveraging point for enhancing the implementation and dissemination of evidence-based suicide prevention interventions and programming. However, much remains unknown about which implementation strategies are commonly used and effective for supporting suicide prevention efforts.

METHODS

In light of the limited available literature, a scoping review was conducted to evaluate implementation strategies present in current suicide prevention studies. We identified studies that were published between 2013 and 2022 that focused on suicide prevention and incorporated at least one implementation strategy. Studies were coded by two independent coders who showed strong inter-rater reliability. Data were synthesized using descriptive statistics and a narrative synthesis of findings.

RESULTS

Overall, we found that studies most commonly utilized strategies related to iterative evaluation, training, and education. The majority of studies did not include direct measurement of suicide behavior outcomes, and there were few studies that directly tested implementation strategy effectiveness.

CONCLUSION

Implementation science strategies remain an important component for improving suicide prevention and intervention implementation. Future research should consider the incorporation of more type 3 hybrid designs as well as increased systematic documentation of implementation strategies.

TRIAL REGISTRATION

< de-identified > .

Barriers and facilitators associated with the upscaling of the Transmural Trauma Care Model: a qualitative study

BACKGROUND

To assess the barriers and facilitators associated with upscaling the Transmural Trauma Care Model (TTCM), a multidisciplinary and patient-centred transmural rehabilitation care model.

METHODS

Semi-structured interviews were conducted with eight trauma surgeons, eight hospital-based physiotherapists, eight trauma patients, and eight primary care physiotherapists who were part of a trauma rehabilitation network. Audio recordings of the interviews were made and transcribed verbatim. Data were analysed using a framework method based on the "constellation approach". Identified barriers and facilitators were grouped into categories related to structure, culture, and practice.

RESULTS

Various barriers and facilitators to upscaling were identified. Under structure, barriers and facilitators belonged to one of five themes: "financial structure", "communication structure", "physical structures and resources", "rules and regulations", and "organisation of the network". Under culture, the five themes were "commitment", "job satisfaction", "acting as a team", "quality and efficiency of care", and "patients' experience". Under practice, the two themes were "practical issues at the outpatient clinic" and "knowledge gained".

CONCLUSION

The success of upscaling the TTCM differed across hospitals and settings. The most important prerequisites for successfully upscaling the TTCM were adequate financial support and presence of "key actors" within an organisation who felt a sense of urgency for change and/or expected the intervention to increase their job satisfaction.

TRIAL REGISTRATION

NL8163 The Netherlands National Trial Register, date of registration 16-11-2019.

Veteran Cultural Competence Training: Initial Effectiveness and National-Level Implementation

OBJECTIVE

Because service professionals often lack cultural competence in working with veterans, veterans often perceive such professionals as "not understanding." The authors developed, evaluated, and implemented Veteran Cultural Competence Training (VCCT), combining educational and experiential components in an in-person training focused on building awareness, knowledge, and skills to better work with veterans.

METHODS

Study 1 was a type 1 effectiveness-implementation hybrid trial examining VCCT effectiveness in a sample of social service professionals (N=41) compared with a matched comparison group (N=41) via the Multicultural Counseling Self-Efficacy Scale-Veteran Form (MCSE-V) instrument. In study 2, the authors used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to conduct a type 2 effectiveness-implementation hybrid trial and implemented VCCT with an expanded population (N=312) during eight training sessions in three U.S. states.

RESULTS

Results from study 1 indicated that VCCT significantly increased self-efficacy of trainees in veteran cultural competence compared with the matched group (p<0.001). In study 2, the RE-AIM framework highlighted the importance of building coalitions and utilizing implementation facilitation to maintain fidelity. The within-group effectiveness of VCCT was statistically significant and maintained across settings and professions (p<0.001), and trainees were satisfied with VCCT. Maintenance analysis revealed expansion of VCCT after implementation in terms of the number of training sessions (N=9), regions hosting the training (N=5), staff hired (N=13), and trainee applications (N=1,018).

CONCLUSIONS

VCCT effectively increases self-efficacy in veteran cultural competence. Gains appeared across different professions, demographic characteristics, and locations. Participation in VCCT may increase professionals' competence in understanding veteran culture, thereby potentially improving veteran services.

Using ERIC to Assess Implementation Science in Drowning Prevention Interventions in High-Income Countries: A Systematic Review

This systematic review identifies and describes the use of the Expert Recommendation for Implementing Change (ERIC) concepts and strategies using public health approaches to drowning prevention interventions as a case study. International calls for action have identified the need to better understand the implementation of drowning prevention interventions so that intervention design and implementation is improved. In high-income countries (HICs), interventions are sophisticated but still little is known or written about their implementation. The review was registered on PROSPERO (number CRD42022347789) and followed the PRISMA guidelines. Eight databases were searched. Articles were assessed using the Public Health Ontario Meta-tool for quality appraisal of public health evidence. Forty-nine articles were included. Where ERIC strategies were reported, the focus was on evaluative and iterative strategies, developing partnerships and engaging the target group. The review identified few articles that discussed intervention development and implementation sufficiently for strategies to be replicated. Findings will inform further research into the use and measurement of implementation strategies by practitioners and researchers undertaking work in drowning prevention in HICs and supports a call to action for better documentation of implementation in public health interventions.

Tailored implementation of the FICUS multicomponent family support intervention in adult intensive care units: findings from a mixed methods contextual analysis

BACKGROUND

The Family in Intensive Care UnitS (FICUS) trial investigates the clinical effectiveness of a multicomponent, nurse-led interprofessional family support intervention (FSI) and explores its implementation in intensive care units (ICUs). The local context of each ICU strongly influences intervention performance in practice. To promote FSI uptake and to reduce variation in intervention delivery, we aimed to develop tailored implementation strategies.

METHODS

A mixed method contextual analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed from March to June 2022 on eight ICUs assigned to the intervention group. ICU key clinical partners were asked to complete a questionnaire on CFIR inner setting measures (i.e., organizational culture, resources, learning climate and leadership engagement) and the Organizational Readiness for Implementing Change (ORIC) scale prior to group interviews, which were held to discuss barriers and facilitators to FSI implementation. Descriptive analysis and pragmatic rapid thematic analysis were used. Then, tailored implementation strategies were developed for each ICU.

RESULTS

In total, 33 key clinical partners returned the questionnaire and 40 attended eight group interviews. Results showed a supportive environment, with CFIR inner setting and ORIC measures each rated above 3 (scale: 1 low-5 high value), with leadership engagement scoring highest (median 4.00, IQR 0.38). Interview data showed that the ICU teams were highly motivated and committed to implementing the FSI. They reported limited resources, new interprofessional information exchange, and role adoption of nurses as challenging.

CONCLUSION

We found that important pre-conditions for FSI implementation, such as leadership support, a supportive team culture, and a good learning climate were present. Some aspects, such as available resources, interprofessional collaboration and family nurses' role adoption were of concern and needed attention. An initial set of implementation strategies were relevant to all ICUs, but some additions and adaptation to local needs were required. Multi-component interventions are challenging to implement within complex systems, such as ICUs. This pragmatic, theory-guided, mixed methods contextual analysis demonstrated high readiness and commitment to FSI implementation in the context of a clinical trial and enabled the specification of a tailored, multifaceted implementation strategy.

Partnering with social service staff to implement pragmatic clinical trials: an interim analysis of implementation strategies

BACKGROUND

With recent growth in the conduct of pragmatic clinical trials, the reliance on frontline staff to contribute to trial-related activities has grown as well. Active partnerships with staff members are often critical to pragmatic trial implementation, but rarely do research teams track and evaluate the specific "implementation strategies" used to support staff's involvement in trial procedures (e.g., participant recruitment). Accordingly, we adapted implementation science methodologies and conducted an interim analysis of the strategies deployed with social service staff involved in one multi-site pragmatic clinical trial.

METHODS

We used a naturalistic, observational study design to characterize strategies our research team deployed with staff during monthly, virtual meetings. Data were drawn from meeting notes and recordings from the trial's 4-month Preparation phase and 8-month Implementation phase. Strategies were mapped to the Expert Recommendations for Implementing Change taxonomy and categorized into nine implementation clusters. Survey data were also collected from staff to identify the most useful strategies the research team should deploy when onboarding new staff members in the trial's second year.

RESULTS

A total of 287 strategies were deployed. Strategies in the develop stakeholder interrelationships cluster predominated in both the Preparation (35%) and Implementation (31%) phases, followed by strategies in the use iterative and evaluative approaches cluster, though these were more prevalent during trial Preparation (24%) as compared to trial Implementation (18%). When surveyed on strategy usefulness, strategies in the provide interactive assistance, use financial approaches, and support staff clusters were most useful, per staff responses.

CONCLUSIONS

While strategies to develop stakeholder interrelationships were used most frequently during trial Preparation and Implementation, program staff perceived strategies that provided technical assistance, supported clinicians, and used financial approaches to be most useful and should be deployed when onboarding new staff members. Research teams are encouraged to adapt and apply implementation strategy tracking methods when partnering with social service staff and deploy practical strategies that support pragmatic trial success given staff needs and preferences.

TRIAL REGISTRATION

NCT05357261. May 2, 2022.

Design, implementation, and inferential issues associated with clinical trials that rely on data in electronic medical records: a narrative review

Real world evidence is now accepted by authorities charged with assessing the benefits and harms of new therapies. Clinical trials based on real world evidence are much less expensive than randomized clinical trials that do not rely on "real world evidence" such as contained in electronic health records (EHR). Consequently, we can expect an increase in the number of reports of these types of trials, which we identify here as 'EHR-sourced trials.' 'In this selected literature review, we discuss the various designs and the ethical issues they raise. EHR-sourced trials have the potential to improve/increase common data elements and other aspects of the EHR and related systems. Caution is advised, however, in drawing causal inferences about the relationships among EHR variables. Nevertheless, we anticipate that EHR-CTs will play a central role in answering research and regulatory questions.

Implementation and dissemination of home- and community-based interventions for informal caregivers of people living with dementia: a systematic scoping review

BACKGROUND

Informal caregivers of people with dementia (PwD) living at home are often the primary source of care, and, in their role, they often experience loss of quality of life. Implementation science knowledge is needed to optimize the real-world outcomes of evidence-based interventions (EBIs) for informal caregivers. This scoping review aims to systematically synthesize the literature that reports implementation strategies employed to deliver home- and community-based EBIs for informal caregivers of PwD, implementation outcomes, and the barriers and facilitators to implementation of these EBIs.

METHODS

Embase, MEDLINE, Web of Science, and Cochrane Library were searched from inception to March 2021; included studies focused on "implementation science," "home- and community-based interventions," and "informal caregivers of people with dementia." Titles and abstracts were screened using ASReview (an innovative AI-based tool for evidence reviews), and data extraction was guided by the ERIC taxonomy, the Implementation Outcome Framework, and the Consolidated Framework for Implementation Science Research; each framework was used to examine a unique element of implementation.

RESULTS

Sixty-seven studies were included in the review. Multicomponent (26.9%) and eHealth (22.3%) interventions were most commonly reported, and 31.3% of included studies were guided by an implementation science framework. Training and education-related strategies and provision of interactive assistance were the implementation strategy clusters of the ERIC taxonomy where most implementation strategies were reported across the reviewed studies. Acceptability (82.1%), penetration (77.6%), and appropriateness (73.1%) were the most frequently reported implementation outcomes. Design quality and packaging (intervention component suitability) and cosmopolitanism (partnerships) constructs, and patient's needs and resources and available resources (infrastructure) constructs as per the CFIR framework, reflected the most frequently reported barriers and facilitators to implementation.

CONCLUSION

Included studies focused largely on intervention outcomes rather than implementation outcomes and lacked detailed insights on inner and outer setting determinants of implementation success or failure. Recent publications suggest implementation science in dementia research is developing but remains in nascent stages, requiring future studies to apply implementation science knowledge to obtain more contextually relevant findings and to structurally examine the mechanisms through which implementation partners can strategically leverage existing resources and regional networks to streamline local implementation. Mapping local evidence ecosystems will facilitate structured implementation planning and support implementation-focused theory building.

TRIAL REGISTRATION

Not applicable.

A Clinical Leadership Lens on Implementing Progress Feedback in Three Countries: Development of a Multidimensional Qualitative Coding Scheme

BACKGROUND

Progress feedback, also known as measurement-based care (MBC), is the routine collection of patient-reported measures to monitor treatment progress and inform clinical decision-making. Although a key ingredient to improving mental health care, sustained use of progress feedback is poor. Integration into everyday workflow is challenging, impacted by a complex interrelated set of factors across patient, clinician, organizational, and health system levels. This study describes the development of a qualitative coding scheme for progress feedback implementation that accounts for the dynamic nature of barriers and facilitators across multiple levels of use in mental health settings. Such a coding scheme may help promote a common language for researchers and implementers to better identify barriers that need to be addressed, as well as facilitators that could be supported in different settings and contexts.

METHODS

Clinical staff, managers, and leaders from two Dutch, three Norwegian, and four mental health organizations in the USA participated in semi-structured interviews on how intra- and extra-organizational characteristics interact to influence the use of progress feedback in clinical practice, supervision, and program improvement. Interviews were conducted in the local language, then translated to English prior to qualitative coding.

RESULTS

A team-based consensus coding approach was used to refine an a priori expert-informed and literature-based qualitative scheme to incorporate new understandings and constructs as they emerged. First, this hermeneutic approach resulted in a multi-level coding scheme with nine superordinate categories and 30 subcategories. Second-order axial coding established contextually sensitive categories for barriers and facilitators.

CONCLUSIONS

The primary outcome is an empirically derived multi-level qualitative coding scheme that can be used in progress feedback implementation research and development. It can be applied across contexts and settings, with expectations for ongoing refinement. Suggestions for future research and application in practice settings are provided. Supplementary materials include the coding scheme and a detailed playbook.

Clinicians' perceptions on implementation strategies used to facilitate ABCDEF bundle adoption: A multicenter survey

BACKGROUND

Intensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability.

OBJECTIVES

To identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost.

METHODS

We conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts.

RESULTS

Nineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3).

CONCLUSIONS

Our results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies.

A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions

PURPOSE

Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities.

METHODS

We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration.

RESULTS

Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7).

CONCLUSION

Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review

BACKGROUND

The Expert Recommendations for Implementing Change (ERIC) project developed a compilation of implementation strategies that are intended to standardize reporting and evaluation. Little is known about the application of ERIC in low- and middle-income countries (LMICs). We systematically reviewed the literature on the use and specification of ERIC strategies for health intervention implementation in LMICs to identify gaps and inform future research.

METHODS

We searched peer-reviewed articles published through March 2023 in any language that (1) were conducted in an LMIC and (2) cited seminal ERIC articles or (3) mentioned ERIC in the title or abstract. Two co-authors independently screened all titles, abstracts, and full-text articles, then abstracted study, intervention, and implementation strategy characteristics of included studies.

RESULTS

The final sample included 60 studies describing research from all world regions, with over 30% published in the final year of our review period. Most studies took place in healthcare settings (n = 52, 86.7%), while 11 (18.2%) took place in community settings and four (6.7%) at the policy level. Across studies, 548 distinct implementation strategies were identified with a median of six strategies (range 1-46 strategies) included in each study. Most studies (n = 32, 53.3%) explicitly matched implementation strategies used for the ERIC compilation. Among those that did, 64 (87.3%) of the 73 ERIC strategies were represented. Many of the strategies not cited included those that target systems- or policy-level barriers. Nearly 85% of strategies included some component of strategy specification, though most only included specification of their action (75.2%), actor (57.3%), and action target (60.8%). A minority of studies employed randomized trials or high-quality quasi-experimental designs; only one study evaluated implementation strategy effectiveness.

CONCLUSIONS

While ERIC use in LMICs is rapidly growing, its application has not been consistent nor commonly used to test strategy effectiveness. Research in LMICs must better specify strategies and evaluate their impact on outcomes. Moreover, strategies that are tested need to be better specified, so they may be compared across contexts. Finally, strategies targeting policy-, systems-, and community-level determinants should be further explored.

TRIAL REGISTRATION

PROSPERO, CRD42021268374.

Machine learning-based prediction of low-value care for hospitalized patients

Objective

Low-value care (i.e., costly health care treatments that provide little or no benefit) is an ongoing problem in United States hospitals. Traditional strategies for reducing low-value care are only moderately successful. Informed by behavioral science principles, we sought to use machine learning to inform a targeted prompting system that suggests preferred alternative treatments at the point of care but before clinicians have made a decision.

Methods

We used intravenous administration of albumin for fluid resuscitation in intensive care unit (ICU) patients as an exemplar of low-value care practice, identified using the electronic health record of a multi-hospital health system. We divided all ICU episodes into 4-h periods and defined a set of relevant clinical features at the period level. We then developed two machine learning models: a single-stage model that directly predicts if a patient will receive albumin in the next period; and a two-stage model that first predicts if any resuscitation fluid will be administered and then predicts albumin only among the patients with a high probability of fluid use.

Results

We examined 87,489 ICU episodes divided into approximately 1.5 million 4-h periods. The area under the receiver operating characteristic curve was 0.86 for both prediction models. The positive predictive value was 0.21 (95% confidence interval: 0.20, 0.23) for the single-stage model and 0.22 (0.20, 0.23) for the two-stage model. Applying either model in a targeted prompting system could prevent 10% of albumin administrations, with an attending physician receiving one prompt every 4.2 days of ICU service.

Conclusion

Prediction of low-value care is feasible and could enable a point-of-care, targeted prompting system that offers suggestions ahead of the moment of need before clinicians have already decided. A two-stage approach does not improve performance but does interject new levers for the calibration of such a system.

Implementation of interprofessional quality circles on deprescribing in Swiss nursing homes: an observational study

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are still frequent among older adults in nursing homes. Deprescribing is an intervention that has been shown to be effective in reducing their use. However, the implementation of deprescribing in clinical practice has not yet been widely evaluated. The Quality Circle Deprescribing Module (QC-DeMo) intervention has been trialled through an effectiveness-implementation hybrid type 2 design. The intervention consists of a quality circle workshop session between healthcare professionals HCPs (physicians, nurses, and pharmacists) within a nursing home, in which they define a consensus to deprescribe specific PIMs classes. The aim of this study was to evaluate the implementation of the QC-DeMo intervention in nursing homes.

METHODS

This observational study focuses on the implementation part of the QC-DeMo trial. Implementation was based on the Framework for Implementation of Pharmacy Services (FISpH). Questionnaires at baseline and follow-up were used to evaluate reach, adoption, implementation effectiveness, fidelity, implementation, maintenance and the implementation strategies. Other data were collected from the QC-DeMo trial and routine data collected as part of the integrated pharmacy service where the QC-Demo trial was embedded. Implementation strategies included training of pharmacists, integration of the intervention into an existing quality circle dynamic and definition of tailored strategies to operationalise the consensus by each nursing home.

RESULTS

The QC-DeMo intervention was successfully implemented in 26 nursing homes in terms of reach, fidelity, adoption, implementation and implementation effectiveness. However, the intervention was found to be implemented with low maintenance as none of the nursing homes repeated the intervention after the trial. Implementation strategies were well received by HCPs: training was adequate according to pharmacists. Pre-existing quality circle dynamic facilitated interprofessional collaboration as involvement and support of each HCP was rated as high. HCPs recognized a specific and important role for each HCP in the deprescribing process. The most relevant tailored strategies to implement the consensus defined by each nursing home were identification of the patients by the pharmacist and a systematic review of medication's patients.

CONCLUSIONS

The implementation of a Quality Circle on Deprescribing is feasible but its maintenance in practice remains challenging. This study explores multiple implementation outcomes to better inform future implementation efforts of these types of interventions.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018.

Implementation strategies preferred by primary care clinicians to facilitate cancer prevention and control activities

Key clinical and community members need to be involved in the identification of feasible and impactful implementation strategies for translation of evidence-based interventions into practice. While a wide range of implementation strategies has been developed, there is little research on their applicability for cancer prevention and control (CPC) efforts in primary care. We conducted a survey of primary care physicians to identify implementation strategies they perceive as most feasible and impactful. The survey included both primary prevention behavior change counseling and cancer screening issues. Analyses contrasted ratings of feasibility and impact of nine implementation strategies, and among clinicians in different settings with a focus on comparisons between clinicians in rural vs. non-rural settings. We recruited a convenience sample of 326 respondents from a wide range of practice types from four practice-based research networks in 49 states and including 177 clinicians in rural settings. Ratings of impact were somewhat higher than those for feasibility. Few of the nine implementation strategies were high on both impact and feasibility. Only 'adapting to my practice' was rated higher than a 4 ("moderate") on both impact and feasibility. There were relatively few differences between rural and non-rural clinicians or associated with other clinician or setting characteristics. There is considerable variability in perceived impact and feasibility of implementation strategies for CPC activities among family medicine clinicians. It is important to assess both feasibility and impact of implementation strategies as well as their generalizability across settings. Our results suggest that optimal strategies to implement evidence-based CPC activities will likely need to be adapted for primary care settings. Future research is needed to replicate these findings and identify practical, implementation partner informed implementation strategies.