Mapping the organizational readiness to change assessment to the Consolidated Framework for Implementation Research

Implementation Strategies to Promote Short-Course Radiation for Bone Metastases

Importance

For patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings.

Objective

To evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions).

Design, Setting, and Participants

This prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023.

Exposures

Three implementation strategies-(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)-were rolled out to physicians.

Main Outcomes and Measures

The primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy.

Results

Forty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly.

Conclusions and Relevance

In this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, xx(x), xx-xx.].

Facilitators and barriers for implementing screening brief intervention and referral for health promotion in a rural hospital in Alberta: using consolidated framework for implementation research

BACKGROUND

Screening, brief intervention, and referral (SBIR) is an evidence-based, comprehensive health promotion approach commonly implemented to reduce alcohol and substance use. Implementation research on SBIR demonstrate that patients find it acceptable, reduces hospital costs, and it is effective. However, SBIR implementation in hospital settings for multiple risk factors (fruit and vegetable consumption, physical activity, alcohol and tobacco use) is still emergent. More evidence is needed to guide SBIR implementation for multiple risk factors in hospital settings.

OBJECTIVE

To explore the facilitators and barriers of SBIR implementation in a rural hospital using the Consolidated Framework for Implementation Research (CFIR).

METHODS

We conducted a descriptive qualitative investigation consisting of both inductive and deductive analyses. We conducted virtual, semi-structured interviews, guided by the CFIR framework. All interviews were audio-recorded, and transcribed verbatim. NVivo 12 Pro was used to organize and code the raw data.

RESULTS

A total of six key informant semi-structured interviews, ranging from 45 to 60 min, were carried out with members of the implementation support team and clinical implementers. Implementation support members reported that collaborating with health departments facilitated SBIR implementation by helping (a) align health promotion risk factors with existing guidelines; (b) develop training and educational resources for clinicians and patients; and (c) foster leadership buy-in. Conversely, clinical implementers reported several barriers to SBIR implementation including, increased and disrupted workflow due to SBIR-related documentation, a lack of knowledge on patients' readiness and motivation to change, as well as perceived patient stigma in relation to SBIR risk factors.

CONCLUSION

The CFIR provided a comprehensive framework to gauge facilitators and barriers relating to SBIR implementation. Our pilot investigation revealed that future SBIR implementation must address organizational, clinical implementer, and patient readiness to implement SBIR at all phases of the implementation process in a hospital.

Perceived Benefits and Barriers to Implementing Occupational Health Recommendations Among Immigrant-Owned Nail Salons in the Greater Philadelphia Region

Introduction. Immigrant nail salon owners and employees face multiple barriers to accessing occupational health training and services. We formed an academic-community-based organization-business owner partnership-unique in that all partners were culturally congruent-to develop a pilot intervention program for the nail salon community. Methods. Eighteen individuals (nine salon owners and nine employees) from the Greater Philadelphia region received the training in their native language and provided feedback through in-depth qualitative interviews. Interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Themes of perceived benefits and barriers were identified and aligned with relevant CFIR constructs to gain better understanding of the implementation challenges. Results. Reported benefits of program were improved knowledge of the workplace hazards and safety practices, and the potential to attract more customers and retain employees. Perceived barriers to implementing recommended practices were limited availability of safer products and high cost, challenges communicating with customers, lack of engagement from some owners, organizational management practices affecting employees' motivation, and limited partnership with local government to assist small immigrant-owned businesses. Conclusions. Our study revealed multiple factors that pit long-term health protection of nail salon workers against the economic viability of the businesses that employ them. Our research highlights the need to (1) advocate for federal policies making safer products to be more accessible to the masses, (2) establish local policy and culturally appropriate technical support programs that engage community-based organizations, and (3) develop economic opportunities and mentorship for immigrant entrepreneurs to operate profitable healthy salons.

Findings from an Organizational Context Survey to Inform the Implementation of a Collaborative Care Study for Co-occurring Disorders

Primary care is an opportune setting to deliver treatments for co-occurring substance use and mental health disorders; however, treatment delivery can be challenging due multi-level implementation barriers. Documenting organizational context can provide insight into implementation barriers and the adaptation of new processes into usual care workflows. This study surveyed primary care and behavioral health staff from 13 clinics implementing a collaborative care intervention for opioid use disorders co-occurring with PTSD and/or depression as part of a multisite randomized controlled trial. A total of 323 completed an online survey for a 60% response rate. The Consolidated Framework for Implementation Research guided this assessment of multi-level factors that influence implementation. Most areas for improvement focused on inner setting (organizational level) constructs whereas individual-level constructs tended to be strengths. This work addresses a research gap regarding how organizational analyses can be used prior to implementation and provides practical implications for researchers and clinic leaders.

Mapping the Theoretical Domain Framework to the Consolidated Framework for Implementation Research: do multiple frameworks add value?

BACKGROUND

Implementation researchers often combine the Theoretical Domain Framework (TDF) and Consolidated Framework for Implementation Research (CFIR) in their studies. However there is some debate on the merits of using multiple frameworks-whether they contribute to results or provide superfluous analysis. Our recent research combined the TDF and CFIR to identify determinants to widespread incorporation of patient held medication lists (PHML) in healthcare practice. The aim of this report is to provide guidance on the use of the TDF and CFIR; by assessing the degree of overlap between the two frameworks in their application to interviews about PHML.

METHODS

Semi-structured telephone interviews were conducted with healthcare professionals (HCPs) and non HCPs (people taking multiple medicines and caregivers).Interview data were transcribed and analysed using the TDF and CFIR. Within paired domains substantial intersection/overlap across constructs and domains within the two frameworks was classified as > 75% of coding references, consistent intersection/overlap was defined as > 50% and ≤ 75%, average intersection/overlap was defined as ≤ 50% and > 25% and non-substantial intersection/overlap was classified as ≤ 25% of coding references.

RESULTS

Interview data were collected from 39 participants - 21 HCPs and 18 non HCPs. Mapping of TDF domains to CFIR domains/constructs identified key determinants in six TDF domains: Environmental context & resources, Beliefs about capabilities, Beliefs about consequences, Social influences, Behavioural regulation and Social/professional role & identity; and five CFIR domains: Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individual and Process. A pattern of substantial intersection/overlap in coding emerged with broad TDF domains such as Environmental context & resources often linked to well-defined CFIR domains and constructs (e.g. design quality & packaging within Intervention Characteristics). Broad CFIR constructs such as knowledge & beliefs about intervention within Characteristics of Individuals also linked to more descriptive TDF domains like Beliefs about capabilities. In addition there was some unexpected non-substantial intersection/overlap in coding with the TDF domain Social influences less frequently linked to the CFIR Inner Setting domain and constructs such as networks and communications.

CONCLUSIONS

Identifying intersections/overlaps in coding between CFIR and TDF can assist interpretation of findings in implementation research. The strengths of each framework were exploited in a reciprocal process which provided more information to broad/poorly defined domains and enabled identification of implementation determinants and innovation determinants.

Strategies to Bridge Equitable Implementation of Telehealth

During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.

Organizational readiness to implement task-strengthening strategy for hypertension management among people living with HIV in Nigeria

BACKGROUND

Hypertension (HTN) is highly prevalent among people living with HIV (PLHIV), but there is limited access to standardized HTN management strategies in public primary healthcare facilities in Nigeria. The shortage of trained healthcare providers in Nigeria is an important contributor to the increased unmet need for HTN management among PLHIV. Evidence-based TAsk-Strengthening Strategies for HTN control (TASSH) have shown promise to address this gap in other resource-constrained settings. However, little is known regarding primary health care facilities' capacity to implement this strategy. The objective of this study was to determine primary healthcare facilities' readiness to implement TASSH among PLHIV in Nigeria.

METHODS

This study was conducted with purposively selected healthcare providers at fifty-nine primary healthcare facilities in Akwa-Ibom State, Nigeria. Healthcare facility readiness data were measured using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA is based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework that identifies evidence, context, and facilitation as the key factors for effective knowledge translation. Quantitative data were analyzed using descriptive statistics (including mean ORCA subscales). We focused on the ORCA context domain, and responses were scored on a 5-point Likert scale, with 1 corresponding to disagree strongly.

FINDINGS

Fifty-nine healthcare providers (mean age 45; standard deviation [SD]: 7.4, 88% female, 68% with technical training, 56% nurses, 56% with 1-5 years providing HIV care) participated in the study. Most healthcare providers provide care to 11-30 patients living with HIV per month in their health facility, with about 42% of providers reporting that they see between 1 and 10 patients with HTN each month. Overall, staff culture (mean 4.9 [0.4]), leadership support (mean 4.9 [0.4]), and measurement/evidence-assessment (mean 4.6 [0.5]) were the topped-scored ORCA subscales, while scores on facility resources (mean 3.6 [0.8]) were the lowest.

CONCLUSION

Findings show organizational support for innovation and the health providers at the participating health facilities. However, a concerted effort is needed to promote training capabilities and resources to deliver services within these primary healthcare facilities. These results are invaluable in developing future strategies to improve the integration, adoption, and sustainability of TASSH in primary healthcare facilities in Nigeria.

TRIAL REGISTRATION

NCT05031819.

Stakeholders' Perspectives on the Feasibility of Adopting a Healthy Nail Salon Recognition Program in Philadelphia: A Qualitative Study

OBJECTIVES

The California Healthy Nail Salon Recognition Program is a statewide initiative to incentivize nail salons to adopt occupational health and safety best practices such as the use of safer nail products without certain harmful chemicals, ventilation systems upgrade, proper personal protective equipment use, and staff training. This public policy intervention is in response to the call to protect nail care workers, mostly women of color, who bear a disproportionate burden of chemical exposure at work. Because there is an interest to adopt a similar program in the Greater Philadelphia region, we conducted this formative research to document stakeholders' perspectives on the feasibility of adopting a Healthy Nail Salon Recognition Program in Philadelphia.

METHODS

We conducted semi-structured interviews with a purposive sample of 31 stakeholders in Philadelphia in 2021. Using the Consolidated Framework for Implementation Science as our theoretical framework, we developed the interview guide and analysed the data using qualitative research methods to identify key facilitators and barriers.

RESULTS

Key facilitating themes were perceived need and benefits of program to improve workers' health and working conditions, and willingness of stakeholders to leverage their organizational resources. Barriers included perceived high cost and time commitment from salon owners and employees, lack of funding and implementation leaders at the city government, community members' willingness to be visible and advocate for the program affected by the stigmas of being immigrant workers, and fear of interacting with authorities, as well as the impact of COVID-19 pandemic.

CONCLUSIONS

Our results suggest successful adoption of a Healthy Nail Salon Recognition Program in Philadelphia will require outreach within the community to raise awareness of the benefits of the program and close partnership with community-based organizations to facilitate mutual understanding between the authorities and the ethnically diverse nail salon communities.

Application of consolidated framework for implementation research to improve Clostridioides difficile infection management in district hospitals

BACKGROUND

Clostridioides difficile infection (CDI) contributes the global threats of drug resistant infections, healthcare acquired infections and antimicrobial resistance. Yet CDI knowledge among healthcare providers in low-resource settings is limited and CDI testing, treatment, and infection prevention measures are often delayed.

OBJECTIVES

to develop a CDI intervention informed by the local context within South African public district level hospitals, and analyze the CDI intervention and implementation process.

METHODS

A CDI checklist intervention was designed and implemented at three district level hospitals in the Western Cape, South Africa that volunteered to participate. Data collection included a retrospective medical records review of patients hospitalized with C. difficile test orders during the 90 days post-implementation. Patient outcomes and checklist components (e.g. antibiotics) were collected. Qualitative interviews (n = 14) and focus groups (n = 6) were conducted with healthcare providers on-site. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) were applied to collected data and observations in order to identify drivers and barriers to implementation and understand differences in uptake.

RESULTS

One of the three hospitals displayed high intervention uptake. Highly relevant CFIR constructs linked to intervention uptake included tension for change, strong peer intervention champions, champions in influential leadership positions, and the intervention's simplicity (CFIR construct: complexity). Tension for change, a recognized need to improve CDI identification and treatment, at the high uptake hospital was also supported by an academic partnership for antimicrobial stewardship.

CONCLUSIONS

This research provides a straight-forward health systems strengthening intervention for CDI that is both needed and uncomplicated, in an understudied low resource setting. Intervention uptake was highest in the hospital with tension for change, influential champions, and existing academic partnerships. Implementation in settings with fewer academic connections requires further testing of collaborative implementation strategies and proactive adaptations.

Leveraging implementation science to increase the translation of deprescribing evidence into practice

Implementation science may address some of the limitations that impede the translation of deprescribing recommendations into practice and policy. Application of principles and standard terminologies from implementation science could improve understanding and interpretation of deprescribing research findings. As such, in this commentary we propose three main avenues to help achieve this. These include: The application of these concepts derived from implementation science could help inform future deprescribing needs for clinicians and researchers. Ultimately, this could help ensure the quality use of medications and examination of meaningful outcomes in deprescribing studies. This could result in more consistent and widespread translation of deprescribing evidence into practice and policy across various healthcare settings.