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Kim B, Petrakis BA, Griesemer I, Sliwinski SK, Midboe AM, Raciborski RA, Byrne TH, Gingell MB, Blue-Howells J, Clark SC, Tsai J, Harvey KLL, McInnes DK. Legal Services for Veterans (LSV): Protocol for evaluating the grant-based LSV initiative supporting community organizations' delivery of legal services to veterans. PLoS One 2024; 19:e0297424. [PMID: 38625878 PMCID: PMC11020365 DOI: 10.1371/journal.pone.0297424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND 1.8 million Veterans are estimated to need legal services, such as for housing eviction prevention, discharge upgrades, and state and federal Veterans benefits. While having one's legal needs met is known to improve one's health and its social determinants, many Veterans' legal needs remain unmet. Public Law 116-315 enacted in 2021 authorizes VA to fund legal services for Veterans (LSV) by awarding grants to legal service providers including nonprofit organizations and law schools' legal assistance programs. This congressionally mandated LSV initiative will award grants to about 75 competitively selected entities providing legal services. This paper describes the protocol for evaluating the initiative. The evaluation will fulfill congressional reporting requirements, and inform continued implementation and sustainment of LSV over time. METHODS Our protocol calls for a prospective, mixed-methods observational study with a repeated measures design, aligning to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) frameworks. In 2023, competitively selected legal services-providing organizations will be awarded grants to implement LSV. The primary outcome will be the number of Veterans served by LSV in the 12 months after the awarding of the grant. The evaluation has three Aims. Aim 1 will focus on measuring primary and secondary LSV implementation outcomes aligned to RE-AIM. Aim 2 will apply the mixed quantitative-qualitative Matrixed Multiple Case Study method to identify patterns in implementation barriers, enablers, and other i-PARIHS-aligned factors that relate to observed outcomes. Aim 3 involves a mixed-methods economic evaluation to understand the costs and benefits of LSV implementation. DISCUSSION The LSV initiative is a new program that VA is implementing to help Veterans who need legal assistance. To optimize ongoing and future implementation of this program, it is important to rigorously evaluate LSV's outcomes, barriers and enablers, and costs and benefits. We have outlined the protocol for such an evaluation, which will lead to recommending strategies and resource allocation for VA's LSV implementation.
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Affiliation(s)
- Bo Kim
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Beth Ann Petrakis
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, United States of America
| | - Ida Griesemer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Samantha K. Sliwinski
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Amanda M. Midboe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States of America
- University of California at Davis School of Medicine, Sacramento, California, United States of America
| | - Rebecca A. Raciborski
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, United States of America
- Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, United States of America
| | - Thomas H. Byrne
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, United States of America
- Boston University School of Social Work, Boston, Massachusetts, United States of America
| | - Madolyn B. Gingell
- Veterans Health Administration Homeless Programs Office, Washington, District of Columbia, United States of America
| | - Jessica Blue-Howells
- Veterans Health Administration Homeless Programs Office, Washington, District of Columbia, United States of America
| | - Sean C. Clark
- Veterans Health Administration Homeless Programs Office, Washington, District of Columbia, United States of America
| | - Jack Tsai
- Veterans Health Administration Homeless Programs Office, Washington, District of Columbia, United States of America
- University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Kim L. L. Harvey
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - D. Keith McInnes
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, United States of America
- Boston University School of Public Health, Boston, Massachusetts, United States of America
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Chong DWQ, Jayaraj VJ, Ab Rahim FI, Syed Soffian SS, Azmi MF, Mohd Yusri MY, Mohamed Sidek AS, Azmi N, Md Said R, Md Salleh MF, Abu Bakar N, Shahar H, Abdul Rashid RM, Samad SA, Ahmad Z, Ismail MS, A. Bakar A, Hj Jobli NM, Sararaks S. Study protocol for a mixed methods approach to optimize colorectal cancer screening in Malaysia: Integrating stakeholders insights and knowledge-to-action framework. PLoS One 2024; 19:e0299659. [PMID: 38593177 PMCID: PMC11003698 DOI: 10.1371/journal.pone.0299659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/12/2024] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION Colorectal cancer is a growing global health concern and the number of reported cases has increased over the years. Early detection through screening is critical to improve outcomes for patients with colorectal cancer. In Malaysia, there is an urgent need to optimize the colorectal cancer screening program as uptake is limited by multiple challenges. This study aims to systematically identify and address gaps in screening service delivery to optimize the Malaysian colorectal cancer screening program. METHODS This study uses a mixed methods design. It focuses primarily on qualitative data to understand processes and strategies and to identify specific areas that can be improved through stakeholder engagement in the screening program. Quantitative data play a dual role in supporting the selection of participants for the qualitative study based on program monitoring data and assessing inequalities in screening and program implementation in healthcare facilities in Malaysia. Meanwhile, literature review identifies existing strategies to improve colorectal cancer screening. Additionally, the knowledge-to-action framework is integrated to ensure that the research findings lead to practical improvements to the colorectal cancer screening program. DISCUSSION Through this complex mix of qualitative and quantitative methods, this study will explore the complex interplay of population- and systems-level factors that influence screening rates. It involves identifying barriers to effective colorectal cancer screening in Malaysia, comparing current strategies with international best practices, and providing evidence-based recommendations to improve the local screening program.
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Affiliation(s)
- Diane Woei-Quan Chong
- Institute for Health Systems Research, National Institutes of Health, Centre for Health Services Research, Ministry of Health Malaysia, Shah Alam, Malaysia
| | - Vivek Jason Jayaraj
- National Institutes of Health, Sector for Biostatistics and Data Repository, NIH Manager’s Office, Ministry of Health Malaysia, Shah Alam, Malaysia
| | - Fathullah Iqbal Ab Rahim
- Institute for Health Systems Research, National Institutes of Health, Centre for Health Equity Research, Ministry of Health Malaysia, Shah Alam, Malaysia
| | | | | | - Mohd Yusaini Mohd Yusri
- Bandar Sri Jempol Health Clinic, Ministry of Health Malaysia, Bandar Seri Jempol, Negeri Sembilan, Malaysia
| | - Ahmad Shanwani Mohamed Sidek
- Department of General Surgery, Hospital Raja Perempuan Zainab II, Ministry of Health Malaysia, Kota Bahru, Kelantan, Malaysia
| | - Norfarizan Azmi
- Department of General Surgery, Hospital Tuanku Ja’afar, Ministry of Health Malaysia, Seremban, Negeri Sembilan, Malaysia
| | - Rosaida Md Said
- Department of Medicine, Hospital Serdang, Ministry of Health Malaysia, Kajang, Selangor, Malaysia
| | - Muhammad Firdaus Md Salleh
- Department of Medicine, Hospital Sultanah Aminah, Ministry of Health Malaysia, Johor Bahru, Johor, Malaysia
| | - Norasiah Abu Bakar
- Department of Medicine, Hospital Raja Perempuan Zainab II, Ministry of Health Malaysia, Kota Bahru, Kelantan, Malaysia
| | - Hamiza Shahar
- Department of Medicine, Hospital Tengku Ampuan Rahimah, Ministry of Health Malaysia, Klang, Selangor, Malaysia
| | | | - Shazimah Abdul Samad
- Family Health Development Division, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Zanita Ahmad
- Family Health Development Division, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Mohd Safiee Ismail
- Family Health Development Division, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Adilah A. Bakar
- Medical Development Division, Ministry of Health Malaysia, Putrajaya, Malaysia
| | | | - Sondi Sararaks
- Institute for Health Systems Research, National Institutes of Health, Director’s Office, Ministry of Health Malaysia, Shah Alam, Malaysia
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Carrandi A, Grove A, Skouteris H, Melder A, Hu Y, Dever M, Higgins A. Economic evaluations performed alongside randomized implementation trials in clinical settings: a systematic review. Implement Sci Commun 2024; 5:24. [PMID: 38491542 PMCID: PMC10943844 DOI: 10.1186/s43058-024-00562-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/23/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Economic evaluations alongside implementation trials compare the outcomes and costs of competing implementation strategies to identify the most efficient strategies. The aims of this systematic review were to investigate how economic evaluations are performed in randomized implementation trials in clinical settings and to assess the quality of these evaluations. METHODS A systematic literature review was conducted on 23 March 2023 to identify studies that reported on economic evaluations embedded in randomized implementation trials in clinical settings. A systematic search was applied across seven databases, and references of relevant reviews were screened for additional studies. The Drummond Checklist was used to assess the quality and risk of bias of included economic evaluations. Study characteristics and quality assessments were tabulated and described. RESULTS Of the 6,550 studies screened for eligibility, 10 met the inclusion criteria. Included studies were published between 1990 and 2022 and from North America, the United Kingdom, Europe, and Africa. Most studies were conducted in the primary and out-patient care setting. Implementation costs included materials, staffing, and training, and the most common approach to collecting implementation costs was obtaining expense and budget reports. Included studies scored medium to high in terms of economic methodological quality. CONCLUSIONS Economic evidence is particularly useful for healthcare funders and service providers to inform the prioritization of implementation efforts in the context of limited resources and competing demands. The relatively small number of studies identified may be due to lack of guidance on how to conduct economic evaluations alongside implementation trials and the lack of standardized terminology used to describe implementation strategies in clinical research. We discuss these methodological gaps and present recommendations for embedding economic evaluations in implementation trials. First, reporting implementation strategies used in clinical trials and aligning these strategies with implementation outcomes and costs are an important advancement in clinical research. Second, economic evaluations of implementation trials should follow guidelines for standard clinical trial economic evaluations and adopt an appropriate costing and data collection approach. Third, hybrid trial designs are recommended to generate evidence for effective and cost-effective implementation strategies alongside clinical effectiveness and cost-effectiveness. TRIAL REGISTRATION The review was prospectively registered with PROSPERO (CRD42023410186).
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Affiliation(s)
- Alayna Carrandi
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Amy Grove
- Warwick Medical School, University of Warwick, Coventry, UK.
| | - Helen Skouteris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela Melder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Yanan Hu
- Monash Centre for Health Research and Implementation, Clayton, Australia
| | - Michelle Dever
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alisa Higgins
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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White A, Sabatino SA, White MC, Vinson C, Chambers DA, Richardson LC. Twenty years of collaborative research to enhance community practice for cancer prevention and control. Cancer Causes Control 2023; 34:1-5. [PMID: 37191768 PMCID: PMC10185931 DOI: 10.1007/s10552-023-01700-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
The Cancer Prevention and Control Research Network (CPCRN) was established in 2002 to conduct applied research and undertake related activities to translate evidence into practice, with a special focus on the unmet needs of populations at higher risk of getting cancer and dying from it. A network of academic, public health and community partners, CPCRN is a thematic research network of the Prevention Research Centers Program at the Centers for Disease Control and Prevention (CDC). The National Cancer Institute's Division of Cancer Control and Population Sciences (DCCPS) has been a consistent collaborator. The CPCRN has fostered research on geographically dispersed populations through cross-institution partnerships across the network. Since its inception, the CPCRN has applied rigorous scientific methods to fill knowledge gaps in the application and implementation of evidence-based interventions, and it has developed a generation of leading investigators in the dissemination and implementation of effective public health practices. This article reflects on how CPCRN addressed national priorities, contributed to CDC's programs, emphasized health equity and impacted science over the past twenty years and potential future directions.
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Affiliation(s)
- Arica White
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Susan A. Sabatino
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Mary C. White
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Cynthia Vinson
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - David A. Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - Lisa C. Richardson
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
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O'Leary MC, Hassmiller Lich K, Mayorga ME, Hicklin K, Davis MM, Brenner AT, Reuland DS, Birken SA, Wheeler SB. Engaging stakeholders in the use of an interactive simulation tool to support decision-making about the implementation of colorectal cancer screening interventions. Cancer Causes Control 2023; 34:135-148. [PMID: 37147411 PMCID: PMC10689514 DOI: 10.1007/s10552-023-01692-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/29/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE We aimed to understand how an interactive, web-based simulation tool can be optimized to support decision-making about the implementation of evidence-based interventions (EBIs) for improving colorectal cancer (CRC) screening. METHODS Interviews were conducted with decision-makers, including health administrators, advocates, and researchers, with a strong foundation in CRC prevention. Following a demonstration of the microsimulation modeling tool, participants reflected on the tool's potential impact for informing the selection and implementation of strategies for improving CRC screening and outcomes. The interviews assessed participants' preferences regarding the tool's design and content, comprehension of the model results, and recommendations for improving the tool. RESULTS Seventeen decision-makers completed interviews. Themes regarding the tool's utility included building a case for EBI implementation, selecting EBIs to adopt, setting implementation goals, and understanding the evidence base. Reported barriers to guiding EBI implementation included the tool being too research-focused, contextual differences between the simulated and local contexts, and lack of specificity regarding the design of simulated EBIs. Recommendations to address these challenges included making the data more actionable, allowing users to enter their own model inputs, and providing a how-to guide for implementing the simulated EBIs. CONCLUSION Diverse decision-makers found the simulation tool to be most useful for supporting early implementation phases, especially deciding which EBI(s) to implement. To increase the tool's utility, providing detailed guidance on how to implement the selected EBIs, and the extent to which users can expect similar CRC screening gains in their contexts, should be prioritized.
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Affiliation(s)
- Meghan C O'Leary
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria E Mayorga
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, USA
| | - Karen Hicklin
- Department of Industrial and Systems Engineering, Herbert Wertheim College of Engineering, University of Florida, Gainesville, FL, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, OR, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
- School of Public Health, Oregon Health & Science University, Portland State University, Portland, OR, USA
| | - Alison T Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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O'Leary MC, Hassmiller Lich K, Reuland DS, Brenner AT, Moore AA, Ratner S, Birken SA, Wheeler SB. Optimizing process flow diagrams to guide implementation of a colorectal cancer screening intervention in new settings. Cancer Causes Control 2023; 34:89-98. [PMID: 37731072 PMCID: PMC10689519 DOI: 10.1007/s10552-023-01769-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 07/26/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE The goal of this study was to assess acceptability of using process flow diagrams (or process maps) depicting a previously implemented evidence-based intervention (EBI) to inform the implementation of similar interventions in new settings. METHODS We developed three different versions of process maps, each visualizing the implementation of the same multicomponent colorectal cancer (CRC) screening EBI in community health centers but including varying levels of detail about how it was implemented. Interviews with community health professionals and practitioners at other sites not affiliated with this intervention were conducted. We assessed their preferences related to the map designs, their potential utility for guiding EBI implementation, and the feasibility of implementing a similar intervention in their local setting given the information available in the process maps. RESULTS Eleven community health representatives were interviewed. Participants were able to understand how the intervention was implemented and engage in discussions around the feasibility of implementing this type of complex intervention in their local system. Potential uses of the maps for supporting implementation included staff training, role delineation, monitoring and quality control, and adapting the components and implementation activities of the existing intervention. CONCLUSION Process maps can potentially support decision-making about the adoption, implementation, and adaptation of existing EBIs in new contexts. Given the complexities involved in deciding whether and how to implement EBIs, these diagrams serve as visual, easily understood tools to inform potential future adopters of the EBI about the activities, resources, and staffing needed for implementation.
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Affiliation(s)
- Meghan C O'Leary
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Alison T Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexis A Moore
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shana Ratner
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Smith NR, Hassmiller Lich K, Ng SW, Hall MG, Trogdon JG, Frerichs L. Implementation costs of sugary drink policies in the United States. J Public Health Policy 2023; 44:566-587. [PMID: 37714964 PMCID: PMC10841536 DOI: 10.1057/s41271-023-00435-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/17/2023]
Abstract
To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.
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Affiliation(s)
- Natalie Riva Smith
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Shu Wen Ng
- Department of Nutrition, Gillings School of Global Public Health, Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Marissa G Hall
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Leah Frerichs
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Eisman AB, Whitman J, Palinkas LA, Fridline J, Harvey C, Kilbourne AM, Hutton DW. A mixed methods partner-focused cost and budget impact analysis to deploy implementation strategies for school-based prevention. Implement Sci Commun 2023; 4:133. [PMID: 37946235 PMCID: PMC10636820 DOI: 10.1186/s43058-023-00511-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/09/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Obtaining information on implementation strategy costs and local budget impacts from multiple perspectives is essential to data-driven decision-making about resource allocation for successful evidence-based intervention delivery. This mixed methods study determines the costs and priorities of deploying Enhanced Replicating Effective Programs (REP) to implement the Michigan Model for Health™, a universal school-based prevention intervention, from key shareholder perspectives. METHODS Our study included teachers in 8 high schools across 3 Michigan counties as part of a pilot cluster randomized trial. We used activity-based costing, mapping key Enhanced REP activities across implementation phases. We included multiple perspectives, including state agencies, regional education service agencies, lead organization, and implementers. We also conducted a budget impact analysis (BIA, assessing the potential financial impact of adopting Enhanced REP) and a scenario analysis to estimate replication and account for cost variability. We used an experimental embedded mixed methods approach, conducting semi-structured interviews and collecting field notes during the trial to expand and explain the cost data and the implications of costs across relevant perspectives. RESULTS Based on trial results, we estimate costs for deploying Enhanced REP are $11,903/school, with an estimated range between $8263/school and $15,201/school. We estimate that adding four additional schools, consistent with the pilot, would cost $8659/school. Qualitative results indicated misalignment in school and teacher priorities in some cases. Implementation activities, including training and implementation facilitation with the health coordinator, were sometimes in addition to regular teaching responsibilities. The extent to which this occurred was partly due to leadership priorities (e.g., sticking to the district PD schedule) and organizational priorities (e.g., budget). CONCLUSIONS Previous research findings indicate that, from a societal perspective, universal prevention is an excellent return on investment. However, notable misalignment in cost burden and priorities exists across shareholder groups. Our results indicate significant personal time costs by teachers when engaging in implementation strategy activities that impose an opportunity cost. Additional strategies are needed to improve the alignment of costs and benefits to enhance the success and sustainability of implementation. We focus on those perspectives informed by the analysis and discuss opportunities to expand a multi-level focus and create greater alignment across perspectives. TRIAL REGISTRATION ClinicalTrials.gov NCT04752189. Registered on 12 February 2021.
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Affiliation(s)
- Andria B Eisman
- Division of Kinesiology, Health, and Sport Studies, College of Education, Wayne State University, 2153 Faculty/Administration Building, 656 West Kirby Street, Detroit, MI, 48202, USA.
| | - Jacob Whitman
- Department of Economics, College of Liberal Arts, Wayne State University, 656 West Kirby Street, Detroit, MI, 48202, USA
| | - Lawrence A Palinkas
- School of Social Work, University of Southern California, 669 W 34th Street, Los Angeles, CA, 90089, USA
| | - Judy Fridline
- Genesee Intermediate School District, 2143 Maple Road, Flint, MI, 48507, USA
| | - Christina Harvey
- Oakland Intermediate School District, 2111 Pontiac Lake Road, Waterford Township, MI, 48328, USA
| | - Amy M Kilbourne
- VA Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Road, Bldg 16, Ann Arbor, MI, 48109, USA
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, M3525 SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
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Gyllensten H, Tistad M, Fridberg H, Wallin L. Analysis on personnel costs and working time for implementing a more person-centred care approach: a case study with embedded units in a Swedish region. BMJ Open 2023; 13:e073829. [PMID: 37821128 PMCID: PMC10582865 DOI: 10.1136/bmjopen-2023-073829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVES Our aim was to describe the time and costs used during the implementation of a more person-centred care (PCC) approach as part of ordinary practice. DESIGN A case study with embedded units. SETTING Region Dalarna, Sweden. PARTICIPANTS The Department for Development (DD) staff who provided a central support function in the implementation and six healthcare units: nephrology, two geriatric care and rehabilitation units, two psychiatry units and primary care. INTERVENTIONS More PCC. PRIMARY AND SECONDARY OUTCOME MEASURES Working days and related salary costs reported by categories indicating costs for implementation strategies, service delivery, and research/development costs. RESULTS The healthcare units logged on average 5.5 working days per staff member. In the healthcare units, 6%-57% of the time reported was used for implementation strategies, 40%-90% for service delivery and 2%-12% for research/development. Of the time reported by the DD, 88% was assigned to implementation strategies. Costs associated with reported time indicated 23% of costs for this implementation occurred in the DD. Using the budgeted cost, this proportion increased to 48%. The budget for the DD corresponded to SEK 2.30 per citizen per year and 0.009% of the total healthcare budget of the region. CONCLUSIONS The study found that a large part of resources used for this implementation of more PCC occurred in the DD, although at least half of the costs occurred in the healthcare units. Moreover, the cost of providing a central support function corresponds to a tiny proportion of the total health budget.
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Affiliation(s)
- Hanna Gyllensten
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
- University of Gothenburg Centre for Person-Centred Care, Gothenburg, Sweden
| | - Malin Tistad
- School of Health and Welfare, Dalarna University, Falun, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Helena Fridberg
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Lars Wallin
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
- School of Health and Welfare, Dalarna University, Falun, Sweden
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Smith NR, Simione M, Farrar-Muir H, Granadeno J, Moreland JW, Wallace J, Frost HM, Young J, Craddock C, Sease K, Hambidge SJ, Taveras EM, Levy DE. Costs to Implement a Pediatric Weight Management Program Across 3 Distinct Contexts. Med Care 2023; 61:715-725. [PMID: 37943527 PMCID: PMC10478682 DOI: 10.1097/mlr.0000000000001891] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND The Connect for Health program is an evidence-based program that aligns with national recommendations for pediatric weight management and includes clinical decision support, educational handouts, and community resources. As implementation costs are a major driver of program adoption and maintenance decisions, we assessed the costs to implement the Connect for Health program across 3 health systems that primarily serve low-income communities with a high prevalence of childhood obesity. METHODS We used time-driven activity-based costing methods. Each health system (site) developed a process map and a detailed report of all implementation actions taken, aligned with major implementation requirements (eg, electronic health record integration) or strategies (eg, providing clinician training). For each action, sites identified the personnel involved and estimated the time they spent, allowing us to estimate the total costs of implementation and breakdown costs by major implementation activities. RESULTS Process maps indicated that the program integrated easily into well-child visits. Overall implementation costs ranged from $77,103 (Prisma Health) to $84,954 (Denver Health) to $142,721 (Massachusetts General Hospital). Across implementation activities, setting up the technological aspects of the program was a major driver of costs. Other cost drivers included training, engaging stakeholders, and audit and feedback activities, though there was variability across systems based on organizational context and implementation choices. CONCLUSIONS Our work highlights the major cost drivers of implementing the Connect for Health program. Accounting for context-specific considerations when assessing the costs of implementation is crucial, especially to facilitate accurate projections of implementation costs in future settings.
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Affiliation(s)
- Natalie Riva Smith
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital
| | - Meg Simione
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Haley Farrar-Muir
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
| | - Jazmin Granadeno
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
| | | | | | - Holly M. Frost
- Department of Pediatrics, Denver Health
- Center for Health Systems Research, Denver Health, Denver
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Cassie Craddock
- Department of Ambulatory Quality and Reliability, Prisma Health
| | - Kerry Sease
- Department of Pediatrics, University of South Carolina School of Medicine
- Prisma Health Children’s Hospital, Greenville, SC
| | - Simon J. Hambidge
- Ambulatory Care Services, Denver Health, Denver
- Harvard Medical School, Boston, MA
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Douglas E. Levy
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
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11
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Acquilano SC, Forcino RC, Schubbe D, Engel J, Tomaino M, Johnson LC, Durand MA, Elwyn G. The Costs of Implementing a Conversation Aid for Uterine Fibroids in Multiple Health Care Settings. Med Care 2023; 61:689-698. [PMID: 37943524 PMCID: PMC10478675 DOI: 10.1097/mlr.0000000000001897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND Health care organizations considering adopting a conversation aid (CA), a type of patient decision aid innovation, need information about the costs of implementation. OBJECTIVES The aims of this study were to: (1) calculate the costs of introducing a CA in a study of supported implementation in 5 gynecologic settings that manage individuals diagnosed with uterine fibroids and (2) estimate the potential costs of future clinical implementation efforts in hypothetical settings. RESEARCH DESIGN We used time-driven activity-based costing to estimate the costs of CA implementation at multiple steps: integration with an electronic health record, preimplementation, implementation, and sustainability. We then estimated costs for 2 disparate hypothetical implementation scenarios. SUBJECTS AND DATA COLLECTION We conducted semistructured interviews with participants and examined internal documentation. RESULTS We interviewed 41 individuals, analyzed 51 documents and 100 emails. Overall total implementation costs over ∼36 months of activities varied significantly across the 5 settings, ranging from $14,157 to $69,134. Factors influencing costs included size/complexity of the setting, urban/rural location, practice culture, and capacity to automate patient identification. Initial investments were substantial, comprising mostly personnel time. Settings that embedded CA use into standard workflows and automated identification of appropriate patients had the lowest initial investment and sustainability costs. Our estimates of the costs of sustaining implementation were much lower than initial investments and mostly attributable to CA subscription fees. CONCLUSION Initiation and implementation of the interventions require significant personnel effort. Ongoing costs to maintain use are much lower and are a small fraction of overall organizational operating costs.
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12
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Ferrari RM, Leeman J, Brenner AT, Correa SY, Malo TL, Moore AA, O'Leary MC, Randolph CM, Ratner S, Frerichs L, Farr D, Crockett SD, Wheeler SB, Lich KH, Beasley E, Hogsed M, Bland A, Richardson C, Newcomer M, Reuland DS. Implementation strategies in the Exploration and Preparation phases of a colorectal cancer screening intervention in community health centers. Implement Sci Commun 2023; 4:118. [PMID: 37730659 PMCID: PMC10512568 DOI: 10.1186/s43058-023-00485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 08/06/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Adoption of colorectal cancer (CRC) screening has lagged in community health center (CHC) populations in the USA. To address this implementation gap, we developed a multilevel intervention to improve screening in CHCs in our region. We used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide this effort. Here, we describe the use of implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) compilation in both the Exploration and Preparation phases of this project. During these two EPIS phases, we aimed to answer three primary questions: (1) What factors in the inner and outer contexts may support or hinder colorectal cancer screening in North Carolina CHCs?; (2) What evidence-based practices (EBPs) best fit the needs of North Carolina CHCs?; and (3) How can we best integrate the selected EBPs into North Carolina CHC systems? METHODS During the Exploration phase, we conducted local needs assessments, built a coalition, and conducted local consensus discussions. In the Preparation phase, we formed workgroups corresponding to the intervention's core functional components. Workgroups used cyclical small tests of change and process mapping to identify implementation barriers and facilitators and to adapt intervention components to fit inner and outer contexts. RESULTS Exploration activities yielded a coalition of stakeholders, including two rural CHCs, who identified barriers and facilitators and reached consensus on two EBPs: mailed FIT and navigation to colonoscopy. Stakeholders further agreed that the delivery of those two EBPs should be centralized to an outreach center. During Preparation, workgroups developed and refined protocols for the following centrally-delivered intervention components: a registry to identify and track eligible patients, a centralized system for mailing at-home stool tests, and a process to navigate patients to colonoscopy after an abnormal stool test. CONCLUSIONS This description may be useful both to implementation scientists, who can draw lessons from applied implementation studies such as this to refine their implementation strategy typologies and frameworks, as well as to implementation practitioners seeking exemplars for operationalizing strategies in early phases of implementation in healthcare.
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Affiliation(s)
- Renée M Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA.
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
| | - Jennifer Leeman
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
- School of Nursing, University of North Carolina at Chapel Hill, 120 North Medical Drive, Chapel Hill, NC, 27599, USA
| | - Alison T Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
- School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC, 27599, USA
| | - Sara Y Correa
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
| | - Teri L Malo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
| | - Alexis A Moore
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
| | - Meghan C O'Leary
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Connor M Randolph
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
| | - Shana Ratner
- School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC, 27599, USA
- UNC Institute for Healthcare Quality Improvement, CB #8005, Chapel Hill, NC, 27599, USA
| | - Leah Frerichs
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Deeonna Farr
- College of Health and Human Performance, East Carolina University, 2307 Carol G. Belk Building, Greenville, NC, 27858, USA
| | - Seth D Crockett
- School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC, 27599, USA
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR, 97239, USA
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Kristen Hassmiller Lich
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Evan Beasley
- Blue Ridge Health, UNC Health, 2579 Chimney Rock Road, Hendersonville, NC, 28792, USA
| | - Michelle Hogsed
- Blue Ridge Health, 2759 Chimney Rock Road, Hendersonville, NC, 28792, USA
| | - Ashley Bland
- Blue Ridge Health, 2759 Chimney Rock Road, Hendersonville, NC, 28792, USA
| | - Claudia Richardson
- Ahoskie Comprehensive Care, Roanoke Chowan Community Health Center, 120 Health Center Drive, Ahoskie, NC, 27910, USA
| | - Mike Newcomer
- Digestive Health Partners, 191 Biltmore Avenue, Asheville, NC, 28801, USA
- Western Carolina Medical Society, 304 Summit Street, Asheville, NC, 28803, USA
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC, 27599, USA
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Levy DE, Singh D, Aschbrenner KA, Davies ME, Pelton-Cairns L, Kruse GR. Challenges and recommendations for measuring time devoted to implementation and intervention activities in health equity-focused, resource-constrained settings: a qualitative analysis. Implement Sci Commun 2023; 4:108. [PMID: 37658387 PMCID: PMC10474749 DOI: 10.1186/s43058-023-00491-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND There is little guidance for conducting health equity-focused economic evaluations of evidence-based practices in resource-constrained settings, particularly with respect to staff time use. Investigators must balance the need for low-touch, non-disruptive cost data collection with the need for data on providing services to priority subpopulations. METHODS This investigation took place within a pilot study examining the implementation of a bundled screening intervention combining screening for social determinants of health and colorectal cancer at four federally qualified health centers (FQHCs) in the Boston metropolitan area. Methods for collecting data on personnel costs for implementation and intervention activities, including passive (automatic) and active (non-automatic, requiring staff time and effort) data collection, as well as three alternate wordings for self-reporting time-use, were evaluated qualitatively using data collected through interviews with FQHC staff (including clinicians, population health staff, and community health workers) and assessments of data completeness. RESULTS Passive data collection methods were simple to execute and resulted in no missing data, but missed implementation and intervention activities that took place outside planned meetings. Active cost data collection using spreadsheets was simple for users when applied to care processes already tracked in this fashion and yielded accurate time use data. However, for tasks where this was not typical, and when tasks were broken up over multiple sessions, spreadsheets were more challenging to use. Questions asking about time use for a typical rather than specific time period, and for typical patients, yielded the most reliable and actionable data. Still, even the best-performing question had substantial variability in time use estimates. Participants noted that patient characteristics of interest for equity-focused research, including language spoken, adverse social determinants of health, and issues related to poverty or mental health, all contributed significantly to this variability. CONCLUSIONS Passively collected time use data are the least burdensome and should be pursued in research efforts when possible, but should be accompanied by qualitative assessments to ensure the data are an accurate reflection of effort. When workflows are already tracked by active data collection, these are also strong data collection methods. Self-reported time use will be most accurate when questions inquire about "typical" tasks and specific types of patients.
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Affiliation(s)
- Douglas E Levy
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, 02115, USA.
| | - Deepinder Singh
- Kraft Center for Community Health, Massachusetts General Hospital, 125 Nashua St, Boston, MA, 02114, USA
| | - Kelly A Aschbrenner
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 46 Centerra Parkway, Lebanon, NH, 03766, USA
| | - Madeline E Davies
- Kraft Center for Community Health, Massachusetts General Hospital, 125 Nashua St, Boston, MA, 02114, USA
| | - Leslie Pelton-Cairns
- Massachusetts League of Community Health Centers, 40 Court St, Boston, MA, 02108, USA
| | - Gina R Kruse
- Harvard Medical School, Boston, MA, 02115, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
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Falkenbach P, Raudasoja AJ, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Tikkinen KAO, Sipilä R, Turpeinen M, Komulainen J. Reporting of costs and economic impacts in randomized trials of de-implementation interventions for low-value care: a systematic scoping review. Implement Sci 2023; 18:36. [PMID: 37605243 PMCID: PMC10440866 DOI: 10.1186/s13012-023-01290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND De-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research. METHODS We searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool. RESULTS We screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%). CONCLUSION De-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers. TRIAL REGISTRATION OSF (Open Science Framework): https://osf.io/ueq32 .
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Affiliation(s)
- Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, University of Oulu, Oulu, Finland.
| | - Aleksi J Raudasoja
- Finnish Medical Society Duodecim, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Herney A Garcia-Perdomo
- Department of Surgery, Division of Urology/Uro-Oncology, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Faculty of Medicine and Health Technologies, Imaging Centre, Tampere University Hospital, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Wellbeing Services County of Pirkanmaa, Unit of Health Sciences, Faculty of Social Sciences, Hatanpää Health Center, Tampere University, Tampere, Finland
| | - Eero Raittio
- Department of Dentistry and Oral Health, Oral Health Care, Institute of Dentistry, Aarhus University, University of Eastern, Kuopio, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Miia Turpeinen
- Oulu University Hospital, University of Oulu, Oulu, Finland
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15
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Harris A, Jordan N, Carroll AJ, Graham AK, Wilson C, Wilson FA, Berkel C, Smith JD. A budget impact analysis of cost to implement a whole child health focused, family-based intervention in primary care for children with elevated BMI. Implement Sci Commun 2023; 4:59. [PMID: 37277878 DOI: 10.1186/s43058-023-00429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 04/16/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Although the cost of implementing evidence-based interventions (EBIs) is a key determinant of adoption, lack of cost information is widespread. We previously evaluated the cost of preparing to implement Family Check-Up 4 Health (FCU4Health), an individually tailored, evidence-based parenting program that takes a whole child approach, with effects on both behavioral health and health behavior outcomes, in primary care settings. This study estimates the cost of implementation, including preparation. METHODS We assessed the cost of FCU4Health across the preparation and implementation phases spanning 32 months and 1 week (October 1, 2016-June 13, 2019) in a type 2 hybrid effectiveness-implementation study. This family-level randomized controlled trial took place in Arizona with n = 113 predominantly low-income, Latino families with children ages > 5.5 to < 13 years. Using electronic cost capture and time-based activity-driven methods, budget impact analysis from the perspective of a future FCU4Health adopting entity-namely, ambulatory pediatric care clinicians-was used to estimate the cost of implementation. Labor costs were based on 2021 Bureau of Labor Statistics Occupational Employment Statistics, NIH-directed salary cap levels or known salaries, plus fringe benefits at a standard rate of 30%. Non-labor costs were based on actual amounts spent from receipts and invoices. RESULTS The cost of FCU4Health implementation to 113 families was $268,886 ($2380 per family). Actual per family cost varied widely, as individual tailoring resulted in families receiving a range of 1-15 sessions. The estimated cost of replicating implementation for future sites ranged from $37,636-$72,372 ($333-$641 per family). Using our previously reported preparation costs (i.e., $174,489; $1544 per family), with estimated replication costs of $18,524-$21,836 ($164-$193 per family), the total cost of delivering FCU4Health was $443,375 ($3924 per family), with total estimated replication costs of $56,160-$94,208 ($497-$834 per family). CONCLUSIONS This study provides a baseline for costs associated with implementation of an individually tailored parenting program. Results provide critical information for decision makers and a model for future economic analysis and can be used to inform optimization thresholds for implementation and, when necessary, benchmarks for program adaptation to promote scale-up. TRIAL REGISTRATION This trial was prospectively registered on January 6, 2017, at ClinicalTrials.gov (NCT03013309).
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Affiliation(s)
- Alexandra Harris
- Health Sciences Integrated PhD Program, Center for Education in Health Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil Jordan
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Allison J Carroll
- Center for Prevention Implementation Methodology, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrea K Graham
- Center for Behavioral Intervention Technologies, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Fernando A Wilson
- Department of Population Health Sciences, University of Utah Intermountain Healthcare, Spencer Fox Eccles School of Medicine, College of Social and Behavioral Science Department of Economics, Matheson Center for Health Care Studies, University of Utah, Salt Lake City, UT, USA
| | - Cady Berkel
- Population Health & Integrated Behavioral Health, College of Health Solutions, Arizona State University, Tempe, AZ, USA
| | - Justin D Smith
- Department of Population Health Sciences, University of Utah Intermountain Healthcare, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Blatnik P, Bojnec Š. Analysis of impact of nosocomial infections on cost of patient hospitalisation. Cent Eur J Public Health 2023; 31:90-96. [PMID: 37451240 DOI: 10.21101/cejph.a7631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/22/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES The scale of the economic problem of the occurrence of nosocomial infections and the resulting high additional costs of treatment can only be assessed using economic analyses. The aim of the study was to analyse the impact of a nosocomial infection in a patient in the treatment process and the direct costs of patient hospitalisation. The article contributes to a cost analysis, which is a relevant basis for adopting effective solutions and decisions on the introduction of new programmes and measures to reduce nosocomial infections and associated costs. METHODS In the first phase of the micro-economic analysis, we analysed the course of hospitalisation of a non-colonised patient treated in an ordinary hospital room. In the second phase, we analysed the process of hospitalisation of a patient who developed a nosocomial infection and was transferred to an isolation room. The difference in cost of both types of treatment allowed us to carry out an economic analysis to estimate the direct costs of nosocomial infection, which are not related to the initial diagnosis of the patient but only to the patient hospitalisation. To calculate the individual types of direct costs of both alternative treatments, we first used the process flow diagram method, which then enabled us to analyse the impact of the occurrence of nosocomial infection on the efficiency and costs of the hospital. RESULTS The results showed that the total direct cost of hospitalisation of a non-colonised patient was 1,317.58 euro per day, and the direct cost of hospitalisation of a patient with a nosocomial infection was 2,268.14 euro per day of hospitalisation. CONCLUSIONS We found that reducing nosocomial infections would have a significant impact on the savings or reduction in healthcare costs associated with a different work process for patients in isolation. It would save 950.56 euro per patient for each day of hospitalisation for individual treatment of a patient hospitalised in an isolation room as consequence of a nosocomial infection.
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Affiliation(s)
- Patricia Blatnik
- Department of Economics, Faculty of Management, University of Primorska, Koper, Slovenia
| | - Štefan Bojnec
- Department of Economics, Faculty of Management, University of Primorska, Koper, Slovenia
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Kang SK, Gold HT. How to Perform Economic Evaluation in Implementation Studies: Imaging-Specific Considerations and Comparison of Financial Models. J Am Coll Radiol 2023; 20:292-298. [PMID: 36922103 PMCID: PMC10112005 DOI: 10.1016/j.jacr.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 03/14/2023]
Abstract
Economic evaluation for implementation science merits unique considerations for a local context, including the main audience of local decision makers. This local context is in contrast with traditional methods for developing coverage policy for medical tests and interventions, which typically emphasize benefits and costs more broadly, for society. Regardless of the strength of evidence backing the efficacy or effectiveness of a clinical intervention, local context is paramount when implementing evidence-based practices. Understanding the costs throughout the processes of implementing a program will inform the decision of whether to plan for and adopt the program, how to sustain the program, and whether to scale up widely. To guide economic evaluation for implementation of evidence-based imaging practices, we describe approaches that consider local stakeholders' needs and connect these with outcomes of cost and clinical utility. Illustrative examples of implementation strategies and economic evaluation are explored in areas of cancer screening and care delivery.
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Affiliation(s)
- Stella K Kang
- Associate Chair and Associate Professor, Department of Radiology, NYU Grossman School of Medicine, New York, New York; Chair, ACR Steering Committee on Incidental Findings; and Specialty Chair, Appropriateness Criteria Expert Panel on Gynecologic and Obstetrical Imaging.
| | - Heather T Gold
- Professor, Department of Population Health and Chief, Section on Value and Effectiveness Research, Department of Population Health, NYU Grossman School of Medicine, New York, New York
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Al-Aqeel S, Alsugair J, Alghamdi R. Economic evaluation of interventions to improve medication adherence among patients with chronic diseases: an overview of systematic reviews. Expert Rev Pharmacoecon Outcomes Res 2023; 23:153-179. [PMID: 36562404 DOI: 10.1080/14737167.2023.2161516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION This overview aimed to find, assess, and synthesize systematic reviews that compared the cost-effectiveness of interventions designed to improve medication adherence among patients with chronic disease. AREAS COVERED PubMed, Web of Science, Cochrane Database of Systematic Reviews, and Center for Review and Dissemination were searched. The quality of the included reviews was assessed using two validated checklists. The review characteristics and findings were summarized narratively. A total of 9 systematic reviews were included. Interventions reported to be cost-effective were simplification of the medication regimen, financial incentives, improved coverage or reduced out-of-pocket spending, and pharmacist care. The most common interventions were patient education and counseling, with mixed results of cost-effectiveness. This evidence comes from economic evaluations with varying degrees of quality. EXPERT OPINION Future evaluations of adherence interventions' cost-effectiveness will be improved in quality as our understanding of the reasons behind intentional and unintentional nonadherence and factors associated with this behavior advances. The development of criteria for the value assessment of medication adherence-enhancing interventions will contribute to improving the quality of adherence intervention cost-effectiveness research.
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Affiliation(s)
- Sinaa Al-Aqeel
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Joud Alsugair
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ruba Alghamdi
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Carpenter CR, Southerland LT, Lucey BP, Prusaczyk B. Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities. J Am Geriatr Soc 2022; 70:3620-3630. [PMID: 36005482 PMCID: PMC10538952 DOI: 10.1111/jgs.17993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.
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Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University in St Louis School of Medicine, St. Louis, Missouri, USA
| | - Beth Prusaczyk
- Department of Medicine Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Kohler S, Dalal S, Hettema A, Matse S, Bärnighausen T, Paul N. Human resource needs and costs for HIV pre-exposure prophylaxis provision in nurse-led primary care in Eswatini and opportunities for task sharing. HUMAN RESOURCES FOR HEALTH 2022; 20:75. [PMID: 36274118 PMCID: PMC9590230 DOI: 10.1186/s12960-022-00770-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The global expansion of HIV pre-exposure prophylaxis (PrEP) includes health systems that face a shortage of skilled health care workers (HCWs). We estimated the human resource needs and costs for providing PrEP in nurse-led primary care clinics in Eswatini. Furthermore, we assessed potential cost savings from task sharing between nurses and other HCW cadres. METHODS We conducted a time-and-motion and costing study in a PrEP demonstration project between August 2017 and January 2019. A form for recording time and performed activities ("motion") was filled by HCWs of six primary care clinics. To estimate the human resource needs for specific PrEP activities, we allocated recorded times to performed PrEP activities using linear regression with and without adjusting for a workflow interruption, that is, if a client was seen by different HCWs or by the same HCW at different times. We assessed a base case in which a nurse provides all PrEP activities and five task shifting scenarios, of which four include workflow interruptions due to task sharing between different HCW cadres. RESULTS On average, PrEP initiation required 29 min (95% CI 25-32) of HCW time and PrEP follow-up 16 min (95% CI 14-18). The HCW time cost $4.55 (uncertainty interval [UI] 1.52-9.69) for PrEP initiation and $2.54 (UI 1.07-4.64) for PrEP follow-up when all activities were performed by a nurse. Time costs were $2.30-4.25 (UI 0.62-9.19) for PrEP initiation and $1.06-2.60 (UI 0.30-5.44) for PrEP follow-up when nurses shared tasks with HCWs from lower cadres. Interruptions of the workflow added, on average, 3.4 min (95% CI 0.69-6.0) to the time HCWs needed for a given number of PrEP activities. The cost of an interrupted workflow was estimated at $0.048-0.87 (UI 0.0098-1.63) depending on whose time need increased. CONCLUSIONS A global shortage of skilled HCWs could slow the expansion of PrEP. Task shifting to lower-cadre HCW in nurse-led PrEP provision can free up nurse time and reduce the cost of PrEP provision even if interruptions associated with task sharing increase the overall human resource need.
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Affiliation(s)
- Stefan Kohler
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
- Institute for Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Shona Dalal
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | | | - Sindy Matse
- Eswatini Ministry of Health, Mbabane, Eswatini
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Nicolas Paul
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
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Smith NR, Knocke KE, Hassmiller Lich K. Using decision analysis to support implementation planning in research and practice. Implement Sci Commun 2022; 3:83. [PMID: 35907894 PMCID: PMC9338582 DOI: 10.1186/s43058-022-00330-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 07/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The process of implementing evidence-based interventions, programs, and policies is difficult and complex. Planning for implementation is critical and likely plays a key role in the long-term impact and sustainability of interventions in practice. However, implementation planning is also difficult. Implementors must choose what to implement and how best to implement it, and each choice has costs and consequences to consider. As a step towards supporting structured and organized implementation planning, we advocate for increased use of decision analysis. MAIN TEXT When applied to implementation planning, decision analysis guides users to explicitly define the problem of interest, outline different plans (e.g., interventions/actions, implementation strategies, timelines), and assess the potential outcomes under each alternative in their context. We ground our discussion of decision analysis in the PROACTIVE framework, which guides teams through key steps in decision analyses. This framework includes three phases: (1) definition of the decision problems and overall objectives with purposeful stakeholder engagement, (2) identification and comparison of different alternatives, and (3) synthesis of information on each alternative, incorporating uncertainty. We present three examples to illustrate the breadth of relevant decision analysis approaches to implementation planning. CONCLUSION To further the use of decision analysis for implementation planning, we suggest areas for future research and practice: embrace model thinking; build the business case for decision analysis; identify when, how, and for whom decision analysis is more or less useful; improve reporting and transparency of cost data; and increase collaborative opportunities and training.
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Affiliation(s)
- Natalie Riva Smith
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, 02115, USA.
| | - Kathleen E Knocke
- Department of Health Policy and Management, Gillings School of Global Public Health, UNC Chapel Hill, Chapel Hill, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, UNC Chapel Hill, Chapel Hill, USA
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