Implementation science communications最新文献

Background: Studies have demonstrated that standardizing labor induction (IOL), often with the use of protocols, may reduce racial inequities in obstetrics. IOL protocols are complex, multi-component interventions. To target identified implementation barriers, audit and feedback (A&F) was selected as an implementation strategy. Here, we aimed to understand the acceptability and effect of A&F on fidelity to this complex intervention through quantitative and qualitative approaches.

Methods: This secondary analysis of a type I hybrid effectiveness-implementation trial (10/2018-12/2022) compared 2 years before (PRE) to 2 years after (POST) implementation of an IOL protocol at two sites. Fidelity to each of 8 specific protocol components was collected via chart review. During the POST period, unit-aggregated A&F reports were distributed via email every 3 months to site clinicians. Reports tracked fidelity to protocol components over time. For this analysis, we compared component fidelity PRE to POST-implementation. Additionally, during the POST period, we compared fidelity by month after each A&F (Month#1 v. Month#2/3) to evaluate the effect of A&F over time. Acceptability of A&F reports was evaluated using qualitative interviews.

Results: 8509 labor inductions were included (PRE = 4214, POST = 4295). A&F reports were successfully distributed every 3 months for the 2-year POST period. PRE to POST-implementation, fidelity to 4 of the 8 components increased significantly (cervical Foley utilization, latent labor examination frequency, amniotomy timing, and intrauterine pressure catheter utilization), without change in the other 4 components. For 2 of those 4 components where improvement was noted, there was no difference in fidelity by month after A&F report; rather, there was sustained improvement across the POST-implementation period. On the other hand, for the remaining 2 components, fidelity peaked in the first month after each A&F report, with some decline in the following 2 months prior to the next A&F report. Qualitative analysis (n = 24) supported A&F acceptability, with A&F described as "motivating" and "helpful."

Conclusions: A&F was an effective implementation strategy to promote fidelity to certain components of this labor induction protocol. With some decline in effect after the first month POST-A&F report, increased A&F frequency should be considered in future work targeting obstetric outcomes, as well as health inequities.

Background: Pain management after childbirth is widely variable, increasing risk of untreated pain, opioid harms, and inequitable experiences of care. The Creating Optimal Pain Management FOR Tailoring Care (COMFORT) clinical practice guideline (CPG) seeks to promote evidence-based, equitable acute peripartum pain management in the United States. We aimed to identify contextual conditions (i.e., barriers and facilitators) and discrete implementation strategies (i.e., theory-based actions taken to routinize a clinical practice) likely to influence COMFORT CPG uptake and specify corresponding multi-component implementation interventions at the perinatal quality collaborative- and unit-level.

Methods: We conducted a qualitative study involving virtual individual interviews and focus groups. Interviews included individuals undergoing childbirth from 2018-2023, (recruited through two online registries), and actively practicing maternity clinicians and surgeons, (recruited via snowball sampling with the eDelphi panel creating the COMFORT CPG), caring for pregnant people in the United States. Focus groups included physicians, midwives, nurses, and unit-based quality improvement (QI) staff working at Michigan hospitals within the Obstetrics Initiative, a statewide perinatal quality collaborative funded by Blue Cross Blue Shield of Michigan and Blue Care Network. The Consolidated Framework for Implementation Research, Expert Recommendations for Implementing Change taxonomy, and Replicating Effective Programs framework informed data collection and analysis. Qualitative content analysis characterized influential contextual conditions, which were linked to implementation strategies and tools using principles of implementation mapping. We then specified multi-component implementation interventions for use by quality collaboratives and unit-based teams.

Results: From May-September 2023, we completed 57 semi-structured individual interviews (31 patients, 26 clinicians) and six focus groups (44 QI champions). Participants identified 10 key conditions influential for COMFORT CPG adoption. Findings enabled identification of five collaborative-level implementation strategies, 27 unit-level implementation strategies, and 12 associated tools to promote COMFORT CPG adoption including the specification of each strategy's hypothesized mechanism of action and each tool's goal and potential uses.

Conclusions: This work identifies contextual conditions and implementation strategies and tools at the perinatal quality collaborative and unit levels to promote COMFORT CPG adoption on maternity units. These findings may foster more rapid CPG implementation and thereby promote more equitable and evidence-based perinatal pain management care.

Background: Doulas, non-clinical professionals who provide support throughout the perinatal period, can positively impact patient experiences and clinical outcomes during birth. Doulas often support hospital-based births without being employed by the hospital system, resulting in varied relationships with hospitals and clinicians. Systems-level changes are needed to maximize collaboration between hospitals and doulas to ensure facilitation of, and not barriers to, doula support. We implemented and evaluated a new program, called the "Supportive Birth Collaborative," to maximize effectiveness of doula support in hospital settings.

Methods: We conducted a single-site feasibility study of the use of implementation mapping to make systemic changes to clinician-doula collaboration for labor and delivery. Implementation mapping consisted of five steps: developing a collaborative of program implementers and knowledge holders, conducting a needs assessment, developing a logic model, applying implementation strategies, and evaluating changes in outcomes. To evaluate change, process data were collected throughout, and implementation outcomes were measured in 2022 and again after one year of implementation via online surveys to all clinicians who provided labor and delivery care. Descriptive statistics were calculated and change over time was analyzed in Stata using log-binomial regression models with clustering to account for respondents who completed both surveys.

Results: The "Supportive Birth Collaborative" (SBC) was founded in November 2021. The first meeting included 19 people, who were obstetricians, anesthesiologists, nurses, doulas, students, social workers, administrators, researchers, and individuals who had given birth at the study hospital. From 2022-2023, the SBC adopted 11 implementation strategies and piloted or fully implemented 10 of them. Implementation strategies ranged from making training dynamic, to changes in the physical environment, to changes in formal policy. In 2022, 104 clinicians participated in the survey; 97 participated in 2023. There was significant improvement in clinician-reported trust in doulas (0.23, 95% CI: 0.12, 0.34) and doula-clinician communication (0.25, 95% CI: 0.12, 0.38). Clinicians had a limited understanding of the doula's role, and that understanding did not significantly improve.

Conclusions: Using implementation mapping as a guide to collaborative work can lead to meaningful health system changes. Regular review of implementation outcomes could allow for adaptation and tailoring of implementation strategies.

Background: All for Them is a theory-based and evidence-informed multilevel, multicomponent program delivered through schools to increase HPV vaccination among medically underserved youth across Texas. Given the potential logistical challenges of program implementation, understanding how to best support the implementation and sustainment of the program is critical. The overall goals of this study are twofold: 1) develop a multifaceted implementation strategy, Implementing All for Them (IM-AFT); and 2) evaluate the impact of IM-AFT on implementation outcomes for schools and healthcare providers to successfully implement All for Them in their respective settings.

Methods: This study is underpinned by a comprehensive and synergistic conceptual framework. We will use Social Cognitive Theory and the Interactive Systems Framework for Dissemination and Implementation to inform important individual and organizational factors to target as part of implementation strategy development. We will use this formative work and Implementation Mapping, a systematic, iterative process that guides the use of theories, models, and frameworks, to develop IM-AFT. The three core aims of the present study are connected to the five tasks of Implementation Mapping. For Aim 1, we will develop IM-AFT using a community-based participatory research-informed approach, including a qualitative assessment of needs and assets associated with program implementation and identification of behavioral and psychosocial objectives to determine implementation outcomes. For Aim 2, we will use a mixed-methods approach to assess user experience with the IM-AFT prototype to test its feasibility, usability, and acceptability. For Aim 3, we will use a descriptive checklist to assess the impact of IM-AFT on user fidelity of program implementation.

Discussion: This paper presents the detailed protocol for developing and evaluating IM-AFT to successfully implement All for Them, leveraging a systematic, community- and theory-based approach and user experience with the strategy prototype. This study will contribute to expanding limited scientific knowledge about using multiple sources to develop and evaluate specified implementation strategies for effective implementation of school-based vaccination programs. Theory-based IM-AFT will guide collaborations between schools and community health centers to improve HPV and other adolescent vaccination rates in underserved communities in Texas.

Background: Youth involved in the legal system have disproportionately higher rates of problematic substance use than non-involved youth. Identifying and connecting legal-involved youth to substance use intervention is critical and relies on the connection between legal and behavioral health agencies, which may be facilitated by learning health systems (LHS). We analyzed the impact of an LHS intervention on youth legal and behavioral health personnel ratings of their cross-system collaboration. We also examined organizational climate toward evidence-based practice (EBP) over and above the LHS intervention.

Methods: Data were derived from a type II hybrid effectiveness trial implementing an LHS intervention with youth legal and community mental health centers (CMHCs) in eight Indiana counties. Using a stepped wedge design, counties were randomly assigned to one of three cohorts and stepped in at nine-month intervals. Counties were in the treatment phase for 18 months, after which they were in the maintenance phase. Youth legal system and CMHC personnel completed five waves of data collection (n=307 total respondents, ranging from 108-178 per wave). Cross-system collaboration was measured via the Cultural Exchange Inventory, organizational EBP climate via the Implementation Climate Scale and Implementation Citizenship Behavior Scale, and intervention via a dummy-coded indicator variable. We conducted linear mixed models to examine: 1) the treatment indicator, and 2) the treatment indicator and organizational EBP climate variables on cross-system collaboration.

Results: The treatment indicator was not significantly associated with cross-system collaboration. When including the organizational EBP climate variables, the treatment indicator significantly predicted cross-system collaboration. Compared to the control phase, treatment (B=0.41, standard error [SE]=0.20) and maintenance (B=0.60, SE=0.29) phases were associated with greater cross-system collaboration output.

Conclusions: The analysis may have been underpowered to detect an effect; third variables may have explained variance in cross-system collaboration, and, thus, the inclusion of important covariates may have reduced residual errors and increased the estimation precision. The LHS intervention may have affected cross-system collaboration perception and offers a promising avenue of research to determine how systems work together to improve legal-involved-youth substance use outcomes. Future research is needed to replicate results among a larger sample and examine youth-level outcomes.

Trial registration: Clinicaltrials.gov identifier: NCT04499079. Registered 30 July 2020. https://clinicaltrials.gov/study/NCT04499079 .

Background: In many Asian jurisdictions, patients are required to obtain referrals from registered doctors before consulting physiotherapists. In contrast, countries such as the United States, the United Kingdom, and Australia have a direct access model for physiotherapists designed across different healthcare settings and under prescribed conditions. While research has demonstrated the benefits of direct access, issues remain on the appropriate policy design for direct access in the context of patient safety and organizational challenges in the implementation. Recently the policy to allow direct access in primary care context is being considered in Hong Kong. This study aims to examine the intervention design options for the policy of direct access to physiotherapists and identify corresponding implementation strategies, to inform the appropriate intervention design for direct access to physiotherapists and the implementation strategies.

Methods: We adopt a systematic process for developing the design of the policy and the implementation strategies using an Implementation Mapping approach informed by Consolidated Framework for Implementation Research (CFIR). We will conduct literature reviews to understand the different aspects of policy intervention design and employ qualitative in-depth interviews and focus group discussions to understand key stakeholders' perspectives related to the direct access model. The identified barriers and facilitators associated with policy implementation of an acceptable intervention design will inform the development of an effective implementation strategy tailored to the implementation context. Our approach will involve mapping the research evidence and the subsequent findings from the stakeholders' deliberations into the CFIR domains and referencing the Expert Recommendations for Implementing Change (ERIC) to develop the acceptable intervention characteristics and the corresponding implementation strategies. These insights will be further validated in a Delphi Expert Survey, for a consensus-based approach.

Discussion: This study employs a sequential mixed-method approach to explore the intervention characteristics for an acceptable intervention design in the policy formulation and the corresponding implementation strategy for direct access to physiotherapists. Integrating research insights into actionable policy recommendations and refining these recommendations in a Delphi Survey will inform the appropriate policy intervention design and implementation strategy for direct access to physiotherapy services.

Background: The Calgary Audit and Feedback Framework (CAFF) is a pragmatic, evidence-based approach for the design and implementation of in-person social learning interventions using Audit and Group Feedback (AGF). This report describes extension of CAFF into the virtual environment as part of a multifaceted intervention bundle to reduce redundant daily laboratory testing in hospitals. We evaluate the process of extending CAFF in the virtual environment and share resulting evidence of participant engagement with planning for practice change.

Methods: We describe an innovative virtually facilitated AGF intervention based on the CAFF. The AGF intervention was part of an intervention bundle which included individual physician laboratory test utilization reports and educational tools to reduce redundant daily laboratory testing in hospitals. We used data from recorded and transcribed virtual AGF sessions, post AGF session surveys and detailed field notes maintained by project team members. We used simple descriptive statistics for quantitative data and analyzed qualitative data according to the elements of CAFF.

Results: Eighty-three physicians participated over twelve virtual AGF sessions conducted across four tertiary care hospitals during the study period. We demonstrate that all prerequisite activities for CAFF (relationship building, question choice and data representation) were present in every virtual AGF session. Virtual facilitation was effective in supporting the transition of participants through different steps of CAFF in each session to lead to change talk and planning. All participants contributed to discussion during the AGF sessions. The post AGF session surveys were filled by 66% of participants (55/83), with over 90% of respondents reporting that the session helped them improve practice. 46% of participants (38/83) completed personal commitment to change forms at the end of the sessions.

Conclusions: Virtual AGF sessions, developed and implemented with fidelity to the CAFF approach, successfully engaged physicians in a group learning environment that led to change planning. Further studies are needed to determine the generalizability of our findings and to add to the literature on evidence-based virtual facilitation techniques.

Background: Acceptability, appropriateness, and feasibility are established implementation outcomes used to understand stakeholders' perceptions of an intervention. Further, they are thought to provide insight into behaviors, such as adoption. To date, measurement instruments for the three outcomes have focused on their individual assessment whilst nodding to the idea that they may interrelate. Despite this acknowledgment, there is little empirical evidence of the association among these constructs. Using the example of genetic health professionals providing additional genomic results to patients, this study aimed to examine the interrelationships among acceptability, appropriateness, and feasibility.

Methods: A sequential explanatory mixed methods approach was employed. All genetic counsellors and clinical geneticists involved in a large research program were invited to complete pre/post surveys using existing measures of acceptability, appropriateness, and feasibility. Follow-up interviews, informed by the survey results, explored clinicians' perspectives of the three outcomes in relation to providing additional genomic results to patients. To categorize interrelationships and generate feedback loops, survey data were analyzed using descriptive and correlation statistics and interpreted alongside interview data analyzed using content analysis.

Results: The survey results (pre n = 53 and post n = 40) for each outcome showed a similar midpoint mean, wide ranges, and little change post implementation (Acceptability: pre M = 3.55, range 2-5 post M = 3.56, range 1.5-5; Appropriateness: pre M = 3.35, range 1-5, post M = 3.48, range 1-5; Feasibility: pre M = 3.30, post M = 3.32; range 1.25-5). The strength of correlation among outcomes ranged from 0.54 to 0.78. Five interrelationships were categorized from analysis of interview data (n = 14) and explain how clinicians' perceptions of the intervention, positive or negative, were determined by interrelating factors of acceptability, appropriateness, and feasibility and that in different scenarios, the function and emphasis of importance among outcomes switched.

Conclusions: Rather than existing separately, our study promotes the need to consider interrelationships among acceptability, appropriateness, and feasibility to better characterize clinicians' perceptions of complex health care interventions and aid in the development of implementation strategies that have real world impact. Further, in the interest of reducing research waste, more research is needed to determine if the outcomes could serve as proxies for each other.

Background: Health care professionals often fail to adhere to evidence-based guidelines. The implementation of evidence-based methods in health care requires systematic support, but it is still unclear which strategies support professional adherence to clinical practice guidelines. Behavior change techniques can contribute to a more detailed description of implementation strategies. The aim of this scoping review was to explore the nature of studies investigating the sustainability of physiotherapists' (PTs') and occupational therapists' (OTs') clinical behavior when implementing evidence-based methods in health care. Two research questions were addressed: (1) Which implementation strategies are used in studies that have experienced sustained and unsustained changes in the clinical behavior of PTs and OTs? (2) Which behavior change techniques are used in studies involving sustained and unsustained changes in the clinical behavior of PTs and OTs?

Methods: The scoping review was carried out in accordance with recommendations and the PRISMA-ScR checklist. Six databases were searched. Studies evaluating changes in the clinical behavior of PTs or OTs before and at least 6 months after the end of an implementation intervention were included.

Results: A total of 5130 studies were screened, and 29 studies were included. Twenty-one studies reported sustained results, and 8 studies reported unsustained results. The studies reporting sustained clinical behavior used in median 7 implementation strategies, 45% used a 12-24-month implementation support period, and 86% of the interventions were theory-based. Twenty-two implementation strategies were identified among the included studies. Only two of these defined the implementation strategies in terms of behavior change techniques.

Conclusions: Studies reporting sustained results were characterized by the use of longer implementation periods, more implementation strategies, more theory-based interventions, and more behavior change techniques. Audit and feedback, resources, problem solving, and communities of practice were implementation strategies, and problem solving, demonstration of behavior, and social support were behavior change techniques that were more common in studies with sustained results of PTs' and OTs' clinical behavior. Our study also highlights the importance of well-described implementation studies.

Registration: The protocol for the scoping review has been registered in the Open Science Framework, OSF registry ( https://doi.org/10.17605/OSF.IO/DUYQM ).

Background: Prescribing cascades, which occur when a medication is used to treat the side effect of another medication, are important contributors to polypharmacy. There is an absence of studies that evaluate interventions to address them. We describe an application of the Behaviour Change Wheel (BCW) to design theory-informed interventions for addressing prescribing cascades within interprofessional primary care teams.

Methods: The BCW framework was applied to guide intervention development. This report describes the first seven steps. Three behaviours were developed based on data collected from two qualitative studies exploring why and how cascades occur across practice settings. A target behaviour was selected and the COM-B model was applied to identify relevant factors for interprofessional primary care teams. Relevant intervention types, policy options, and corresponding behaviour change techniques (BCTs) were identified, and intervention examples drafted. Prioritization of behaviours and intervention examples were guided by the APEASE criteria.

Results: The three behaviours involved supporting: (1) healthcare providers (HCPs) to ask about, investigate and manage cascades, (2) the public to ask about prescribing cascades, and (3) the public to share medication histories and experiences with HCPs. The team selected the HCP behaviour, A-I-D (ask, investigate, deprescribe), for intervention development. Psychological capability and physical opportunity were the most relevant COM-B components. Ten intervention options comprised of BCTs were developed, which are ready for further prioritization by stakeholders. These can be grouped into: provision of educational materials for use by HCPs; provision of consultation or training to support HCPs; and knowledge mobilization strategies. Through the process, the team identified that development of a practice guidance tool, which assists HCPs to investigate and manage prescribing cascades, is needed to support further intervention development.

Conclusions: The BCW framework guided the design of intervention examples to support primary HCPs practicing in interprofessional teams to address prescribing cascades. When identifying interventions for future consultation, creation of a practice guidance tool was prioritized as it underpins all proposed interventions for addressing prescribing cascades in practice. Further research is needed to determine what primary HCPs would need in this practice guidance tool and how it will be used in practice, to support its development.