Coming together for something good: recommendations from a scoping review for dissemination and implementation science to improve indigenous substance use disorder treatment

Introduction

Dissemination and Implementation (D&I) science is growing among Indigenous communities. Indigenous communities are adapting and implementing evidence-based treatments for substance use disorders (SUD) to fit the needs of their communities. D&I science offers frameworks, models, and theories to increase implementation success, but research is needed to center Indigenous knowledge, enhancing D&I so that it is more applicable within Indigenous contexts. In this scoping review, we examined the current state of D&I science for SUD interventions among Indigenous communities and identified best-practice SUD implementation approaches.

Methods

PubMed and PsycINFO databases were queried for articles written in English, published in the United States, Canada, Australia, and New Zealand. We included key search terms for Indigenous populations and 35 content keywords. We categorized the data using the adapted and extended Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework that emphasizes equity and sustainability. RE-AIM has also been used as a primary model to consistently identify implementation outcomes.

Results

Twenty articles were identified from the original unduplicated count of over 24,000. Over half the articles discussed processes related to Reach, Adoption, and Implementation. Effectiveness was discussed by 50% of the studies (n = 10), with 25% of the articles discussing Maintenance/sustainability (n = 4). Findings also highlighted the importance of the application of each RE-AIM domain for meaningful, well-defined community-engaged approaches.

Conclusion

Finding indicated a need to prioritize Indigenous methods to culturally center, re-align and adapt Western treatments and frameworks to increase health equity and improve SUD treatment outcomes. Utility in the use of the modified RE-AIM and the continued modification for Indigenous communities was also noted.

Developing and testing a COVID-19 vaccination acceptance intervention: A pragmatic trial comparing vaccine acceptance intervention vs usual care - Rationale, methods, and implementation

BACKGROUND

COVID-19 has resulted in significant disability and loss of life. COVID-19 vaccines effectively prevent severe illness, hospitalization, and death. Nevertheless, many people remain hesitant to accept vaccination. Veterans perceive healthcare providers (HCP) and staff as trusted vaccine information sources and thereby are well suited to initiate vaccine discussions. The overall objective of this study is to implement and test a virtual COVID-19 Vaccine Acceptance Intervention (VAI) training that is informed by motivational interviewing (MI) techniques.

METHODS

The VAI training is being delivered to VA HCPs and staff within a Hybrid Type 2 pragmatic implementation-effectiveness trial using Implementation Facilitation as the implementation strategy. The implementation team includes external facilitators paired with VA Healthcare System (VAHCS)-level internal facilitators. The trial has three aims: 1) Examine the effectiveness of the VAI versus usual care on unvaccinated veterans' vaccination rates in a one-year cluster randomized controlled trial, with randomization at the level of VAHCS. 2) Determine factors associated with veterans' decisions to accept or decline primary COVID-19 vaccination, and better understand how these factors influence vaccination decisions, through survey and qualitative data; and 3) Use qualitative interviews with HCPs and staff from clinics with high and low vaccination rates to learn what was helpful and not helpful about the VAI and implementation strategies.

CONCLUSION

This is the first multisite randomized controlled trial to test an MI-informed vaccine acceptance intervention to improve COVID-19 vaccine acceptance. Information gained can be used to inform healthcare systems' approaches to improve future vaccination and other public health campaigns.

CLINICALTRIALS

gov Identifier: NCT05027464.

Centering culture in the treatment of opioid use disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board

American Indian/Alaska Native (AI/AN) communities are disproportionally impacted by the opioid overdose epidemic. There remains a dearth of research evaluating methods for effectively implementing treatments for opioid use disorder (OUD) within these communities. We describe proceedings from a 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the delivery of medications to treat OUD (MOUD). The CB was comprised of Elders, cultural leaders, providers, individuals with lived experience with OUD, and researchers from over 25 communities, organizations, and academic institutions. Conversations were audio-recorded, transcribed, and coded by two academic researchers with interpretation oversight provided by the CB. These proceedings provided a foundation for ongoing CB work and a frame for developing the program-level implementation intervention using a strength-based and holistic model of OUD recovery and wellbeing. Topics of discussion posed to the CB included engagement and recovery strategies, integration of extended family traditions, and addressing stigma and building trust with providers and clients. Integration of traditional healing practices, ceremonies, and other cultural practices was recommended. The importance of centering AI/AN culture and involving family were highlighted as priorities for the intervention.

Lagniappes: "A Little Something Extra" or Unintended Positive Consequences of Implementation Facilitation

OBJECTIVE

Implementation facilitation is an effective strategy that increases uptake of behavioral health interventions. Facilitation is grounded in partnerships with leadership and clinical stakeholders. Researchers have documented some negative consequences of facilitation-time, financial, and opportunity costs. Clinical leaders often agree to facilitation with the promise of increased implementation of an intervention. This study examined whether unintended positive consequences of facilitation might offset known costs.

METHODS

This study was part of a stepped-wedge, hybrid type 2, pragmatic trial that used implementation facilitation to implement primary care mental health integration (PCMHI) via telehealth technology in six satellite Veterans Health Administration (VHA) clinics. Two facilitators provided facilitation for at least 6 months. This study included a focused analysis of an emerging phenomenon captured through weekly debriefing interviews with facilitators: unintended positive consequences of implementation facilitation, termed "lagniappes" here. A rapid content analysis was conducted to identify and categorize these consequences.

RESULTS

The authors documented unintended positive consequences of the facilitation across the six VHA sites and categorized them into three clinically relevant domains: supporting PCMHI outreach at other clinics not in the original catchment area (e.g., providing tools to other sites), strengthening patient access (e.g., resolving unnecessary patient travel), and improving or modifying work processes (e.g., clarifying suicide assessment protocols). The positive consequences benefited sites and strengthened ongoing partnerships.

CONCLUSIONS

Documenting unintended positive consequences of implementation facilitation may increase leadership engagement. Facilitators should consider leveraging unintended positive consequences as advantages for the site that may add efficiency to facility processes and workflows.

Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design

Background

Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics.

Methods

This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation.

Discussion

This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics.

Trial registration

ClinicalTrials.gov registration number NCT02713217. Registered on 18 March 2016

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0875-5) contains supplementary material, which is available to authorized users.

Family care map: Sustaining family-centered care in Polytrauma Rehabilitation Centers

The study assessed sustainability of the Family Care Map, a family-centered approach to providing care for Veterans with polytrauma-related injuries, in four Department of Veterans Affairs Polytrauma Rehabilitation Centers. We applied a mixed-methods approach. Staff surveys used standardized measures of sustainability, commitment to change, information, and participation during implementation. Qualitative inquiry assessed Family Care Map implementation and facilitators and barriers to sustainability. Staff sustainability perceptions had a significant positive correlation with affective commitment to change, participation, and information received about the change process. Family Care Map integration into standard practices and use of its concepts with patients and families related to staff perceptions about sustainability. The degree of use and integration of the Family Care Map in traumatic brain injury/polytrauma care varied among the Polytrauma Rehabilitation Centers. Some successful sustainability strategies included integration into daily workflow and organizational culture. Examples of sustainability barriers included staff awareness and use and outdated information. Some practices, such as measuring and documenting the use of the Family Care Map in treatment plans, may not routinely occur. The focus on family-centered care will require further evaluation of organization-, staff-, and innovation-level attributes that influence sustainability of changes designed to improve family-centered care.

Abstract P6-12-02: Use of cytochrome P450 interacting medications in the setting of adjuvant therapy for breast cancer

Background: In the current era of personalized medicine, oral targeted therapies are increasingly used in cancer treatment. In breast cancer, oral anti-estrogen agents have historically been part of standard treatment for hormone receptor positive disease. More recently, other targeted agents have been introduced in the metastatic setting, and are being evaluated as adjuvant therapies. Many oral medications, including anticancer therapies, are metabolized by cytochrome P450 (CYP450) enzymes raising possibility of drug-drug interactions that may affect toxicities or breast cancer outcomes. We sought to evaluate concomitant CYP450 medication use among women seeing a medical oncologist to discuss adjuvant systemic therapy for breast cancer.

Methods: We performed an electronic medical record database extraction. Adult women diagnosed with breast cancer from 1/2008-7/2011 were identified from the University of Wisconsin Hospital and Clinics Cancer Registry. Medication lists were extracted from the first encounter with a medical oncologist after the initial breast cancer diagnosis. Non-systemic medications were excluded. Cytochrome P450 (CYP450) enzyme-interacting medications were categorized as inhibitors, inducers, and/or substrates of specific enzymes including CYP1A2, CYP2A6, CYP2B6, CYP2C19, CYP2C8, CYP2C9, CYP2D6, CYP2E1, and CYP3A4. CYP450 inhibitors and inducers were further characterized as strong, moderate or weak acting.

Results: A total of 455 women with non-metastatic breast cancer were identified. Mean age was 56.6 years (range of 23–90) and 413 (91%) were Caucasian. Polypharmacy, defined as use of 3–5 medications, was seen in 123 (27.0%) women. A total of 236 (51.9%) women were on 0–4; 109 (24.0%) on 5–10; and 13 (2.9%) on > 10 medications at the time of first encounter with a medical oncologist after a breast cancer diagnosis. 23 (5.05%) women were on strong CYP450 enzyme inhibitors while 72 (15.8%) were on strong inducers. CYP450 enzymes most commonly affected were CYP3A4, CYP2C9, and CYP2D6. Among medications taken on a fixed schedule, levothyroxine and simvastatin were the most commonly used, while simvastatin and ranitidine were the most common CYP450 interacting medications. Further classification of potential CYP450 interactions is ongoing.

Conclusions: A significant proportion of patients were on one or more CYP450 interacting medications in the setting of adjuvant therapy for breast cancer. Given the number of new oral cancer agents that are also CYP450 interacting, the potential for drug interactions should be recognized and appropriate management strategies implemented.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-12-02.

Sustainability in primary care and Mental Health Integration projects in Veterans Health Administration

OBJECTIVE

To explore staff perceptions about sustainability, commitment to change, participation in change process, and information received about the change project within the Veterans Administration Primary Care and Mental Health Integration (PC-MHI) initiative and to examine differences from the Veterans Health Administration Mental Health Systems Redesign (MHSR) initiative.

DATA SOURCES

Surveys of change team members involved in the Veterans Affairs PC-MHI and MHSR initiatives.

STUDY DESIGN

One-way analysis of variance examined the relationship between commitment, participation and information, and sustainability. Differences in PC-MHI sustainability were explored by location and job classification. Staff sustainability perceptions were compared with MHSR results.

PRINCIPAL FINDINGS

Sustainability differed by staff discipline. Difference between MHSR and PC-MHI existed by job function and perceptions about the change benefits. Participation in the change process and information received about the change process were positively correlated with sustainability. Staff commitment to change was positively associated with staff perceptions about the benefits of change and staff attitudes toward change.

CONCLUSIONS

Sustainability is an important part of organizational change efforts. Change complexity seems to influence perception about sustainability and impacts staff perceptions about the benefits of change. These perceptions seem to be driven by the information received and opportunities to participate in the change process. Further research is needed to understand how information and participation influence sustainability and affect employee commitment to change.

Recognition and treatment of mental disorders in children: considerations for pediatric health systems

General healthcare systems currently play an active role in the identification and treatment of children with mental disorders. As many as one-third of children identified and treated for mental health problems receive outpatient mental healthcare from primary care providers. Although some children do receive treatment, over half of those who need mental health care do not receive this service. Fortunately, current levels of unmet need for adequate care coincide with mounting scientific evidence to support the efficacious use of psychosocial, community-based, and pharmacological interventions. Scientific evidence indicates that the appropriate identification and treatment of mental disorders in childhood can reduce symptoms of child psychopathology, improve adaptive functioning, and sometimes serve as a buffer to further long-term impairment. However, mental health treatment can only be beneficial if it reaches those families in need, is amenable to clinical practice implementation, and is administered with an adequate dose. Future challenges lie in creating practice-relevant efficacious interventions to improve the identification of child mental health needs and to improve access to high quality, appropriate mental healthcare. Primary care settings will play an important role in this activity. Although many barriers exist, pediatric health systems will continue to play an important role in the identification and treatment of mental disorders in children. The quality of current pediatric mental healthcare could be enhanced by increased opportunities for physician training, a restructuring of current training efforts, an increased focus on patient engagement strategies, equitable care incentives and reimbursement, as well as an integrated view of physical and mental health.

A new technique for performing a laparoscopic hysterectomy using microlaparoscopy: microlaparoscopic assisted vaginal hysterectomy (mLAVH)

In an effort to further decrease patient postoperative scarring and discomfort, a new technique of microlaparoscopic assisted vaginal hysterectomy is employed. Using a 2-mm lateral port, a single infraumbilical port for the power source, and a 3-mm or 5-mm suprapubic port for aid in manipulation, seven consecutive patients underwent hysterectomy without complication and had rapid return to their daily activities.