Implementation science communications最新文献

Background: HIV pre-exposure prophylaxis (PrEP) remains underutilized in communities over-burdened by HIV. Same-day PrEP, prescribing and starting PrEP at the initial visit, may be an implementation strategy to address this gap. Federally qualified health centers (FQHC) and community-based organizations (CBO) provide healthcare to un- and under-insured populations and have the potential to increase PrEP services via same-day PrEP. This exploratory mixed methods study explored same-day PrEP program implementation strategies and determinants.

Methods: Key stakeholders, recruited from FQHC and CBO in Georgia, Texas, and Illinois, participated in virtual interviews (qualitative strand) grounded in the Consolidated Framework for Implementation Science. Thematic analysis in NVivo identified implementation strategies. Purposively sampled FQHC and CBO stakeholder focus groups (FG) rank-ordered same-day PrEP implementation strategies (quantitative strand) based on perceived effectiveness and feasibility to create meta-inferences. N = 5 individuals participated in both interviews and FG. We then calculated the mean rank order score for each implementation strategy (range = 1-12), within each state and across all three states. We calculated these mean scores separately for both perceived strategy effectiveness/impact and perceived feasibility within their respective settings.

Results: Twenty-four stakeholders completed interviews. 46% (N = 11) were clinic directors/managers, 63% (N = 15) were affiliated with a CBO, 71% (N = 17) worked in settings where same-day oral PrEP was offered. Theme 1) Medicaid expansion is a useful resource for same-day PrEP implementation; however, same-day PrEP is feasible in non-Medicaid expansion states by leveraging additional financial resources. Theme 2) Leadership buy-in and PrEP champions spearhead programs. Theme 3) Intercommunity relationships and formal evaluation are needed. The three most highly ranked strategies in terms of perceived effectiveness were: 1. Leadership buy-in (mean ranking = 2.51); 2. PrEP champion (mean ranking = 3.62); and 3. PrEP navigators (mean ranking = 4.68). Leadership buy-in first (mean ranking = 2.91), followed by the use of a PrEP champion second (mean ranking = 3.91) and consumer outreach (mean ranking = 4.81) were ranked highest in terms of perceived feasibility.

Conclusions: Diversification of funding, support from leaders, and customization of implementation strategies are consistent factors necessary for same-day PrEP programs.

Background: Better understanding of how deliverers use research and select interventions can further reduce the gap between developing and delivering effective intervention and implementation strategies, especially in the field of HIV.

Methods: We interviewed a convenience sample of Midwest health organizations and health departments who are involved with HIV treatment and/or prevention services. Using an iterative, rapid qualitative analysis, we identified key steps in the process of prioritizing health needs, selecting interventions, and disseminating or receiving information about interventions.

Results: In order to prioritize areas for interventions, organizations used community assessments, developing leaderships buy-in, considered staff capacity, accessed funding, and created partnerships. Once a priority areas was developed, interventions were usually developed by the organization or adapted from pre-existing interventions to meet local needs. Organizations preferred to receive information from trusted broker agencies or from peer organizations. There was a strong desire to evaluate and share results from home-grown interventions but evaluation capacity and funding were limiting factors.

Conclusions: There are several ways to improve dissemination and knowledge sharing between researchers and practitioners. Researchers can design flexible and adaptable interventions, with a range of dissemination materials available to broker agencies. Deliverers can partner with researchers for evaluation, while funders can specifically support evaluation and dissemination, including peer-to-peer learning.

Background: In the emergency department (ED), clinicians often make challenging, high-pressure decisions within a short time frame. Clinical decision support (CDS) tools integrated into the electronic health record can provide evidence-based support. Yet, numerous implementation barriers limit the broad use of such tools in ED settings. CDS tools could be particularly helpful for patients presenting to the ED with an acute exacerbation of heart failure (AHF), a common and costly medical condition for which patients are typically admitted to the hospital. We developed and implemented STRATIFY, a validated risk prediction model that effectively identifies AHF patients at low risk of 30-day adverse events who could potentially be discharged home from the ED.

Methods: This article describes a multi-center study to 1) develop a stakeholder-informed CDS-based implementation process for STRATIFY, 2) use novel statistical methods to overcome data integration challenges to the real-world implementation of predictive models in the ED, and 3) evaluate the implementation and effectiveness of the newly developed STRATIFY CDS at 7 EDs to guide decision-making to admit or discharge patients with AHF. The study's multi-level implementation strategy is tailored to each site and informed by site assessments (including pre-visit surveys, on-site ED visits, and virtual interviews), small group discussions with patients and caregivers, and iterative user-centered design to develop and refine the STRATIFY CDS. Overcoming data challenges for real-time predictive models involves accommodating missing risk factor data while still generating valid predictions of risk. In the evaluation of effectiveness, we will evaluate ED disposition (admit/discharge) for patients with AHF, as well as potential adverse outcomes, using an interrupted time-series design at 7 participating EDs. The study will evaluate implementation outcomes ranging from acceptability to sustainability using electronic health record data and surveys of clinicians and patients.

Discussion: This study uses a stakeholder-informed, iterative design approach to develop a tailored CDS-based process supported by a multi-level implementation strategy to incorporate a validated risk prediction tool into the care of patients with AHF in the ED. The study will advance methods to close the evidence-practice gap in the care of emergency department patients.

Background: The University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) is a complex, multilevel evidence-based intervention (EBI) aimed at enhancing access to high-quality cancer services for under-served patients. MCCAN is promising but has not been scaled beyond its original context. We aimed to adapt MCCAN, originally developed in Kentucky, to address systematic differences that threatened its implementation and effectiveness in a new context, Iowa, yielding the Iowa Cancer Affiliate Network (I-CAN).

Methods: We report our adaptation of MCCAN using the Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI) approach: (1) identify key information about MCCAN, learning about Kentucky and Iowa contexts and users; (2) adapt MCCAN's forms while leaving its core functions intact to produce I-CAN; and (3) evaluate I-CAN. Specifically, we conducted studies to identify MCCAN's forms and core functions, gathered extensive knowledge of the original and new contexts, and identified systematic differences between the two. We created a matrix to map MCCAN's core functions to its original forms, contextual differences between Kentucky and Iowa, and proposed adapted forms to produce I-CAN. We interviewed I-CAN affiliates to assess perceptions of acceptability, feasibility, and efficacy.

Results: MCCAN forms were mapped to eight intervention and 10 implementation core functions. Adaptation was required for 11 core functions, as contextual differences impacted the ability of the original forms of those core functions to be carried out in the new context. Contextual differences reflected existing relationships and referral patterns, as well as available resources (e.g., personnel and infrastructure). Lack of familiarity with the intervention process and outcomes limited the ability of I-CAN affiliates to evaluate potential adapted forms. Forms evolved as I-CAN affiliates gained practical experience in applying them and/or experienced changes in organizational structure, personnel, etc. CONCLUSIONS: We successfully adapted MCCAN, a complex, multilevel EBI designed to support community hospitals and enhance access to high-quality cancer services and programs in Kentucky to improve care for patients in Iowa affected by cancer-nearly half of whom reside in rural areas. Our application of MODIFI suggests several opportunities for refinement to advance successful EBI adaptation.

Trial registration: ClinicalTrials.gov, NCT05645328. Registered 01 December 2022, https://clinicaltrials.gov/study/NCT05645328.

Introduction: We define clinical practice guideline (CPGs) implementability as the characteristics of the guideline that reflect the extent to which it is likely to be adopted in clinical practice. Our objectives were to create a comprehensive and evidence-informed framework of guideline implementability (CFGI).

Methods: A mixed-methods approach was used. Based on a systematic literature review of six databases as the foundation, the initial version of the CFGI was created, followed by external consultations to gather feedback and natural language processing tool-assisted classification to refine the framework. To get external validation of the CFGI from expert feedback at an international conference.

Results: Fifteen studies related to guideline implementability were identified from the systematic Literature review. The first version of CFGI was compiled, including 6 domains. Feedback on the first version was received from 16 stakeholders, including clinicians, nurses, medical managers, and guideline methodologists, combined with natural language processing tool-assisted classification. The final version of the CFGI is comprised of 6 core domains, containing 21 constructs: (1) Scope and purpose; (2) Clarity and consistency of recommendations; (3) Development and evidence base; (4) Structure and Contents; (5) Development team and transparency; and (6) Implementation environment and tools. Twenty-nine experts participated in the external validation, and the results showed that CFGI had good rationality, importance, clarity, feasibility, and necessity.

Conclusions: The development of the CFGI provides a systematic theoretical basis for the development and implementation of future CPGs, which will help to enhance the implementability of guidelines and facilitate their promotion and application in different medical settings. Future research can further validate and apply the CFGI, explore its effectiveness and feasibility in actual operation.

Background: Social prescribing connects healthcare with community-based services to address social determinants of health, such as loneliness, social isolation, and low health-related quality of life. Although widely implemented in countries such as the United Kingdom and Australia, social prescribing remains underdeveloped in Denmark. The Social Prescribing Vesterbro-Sydhavnen project is the first attempt to systematically implement a general practice-embedded model of social prescribing within a tax-funded healthcare system. It aims to reduce loneliness and promote well-being among socially vulnerable adults by integrating link workers into the patient pathway, in close collaboration with general practitioners, local authorities, and voluntary organizations.

Methods: This research programme uses a Hybrid Type II effectiveness-implementation design to evaluate both clinical and implementation outcomes. The programme comprises nine interrelated work packages using mixed methods. Quantitative components include a quasi-experimental study assessing healthcare service use and patient-reported outcomes (loneliness and quality of life) among 350 referred individuals. Qualitative components include ethnographic fieldwork, semi-structured interviews, and realist evaluation to explore implementation strategies, mechanisms of change, and contextual determinants. Two programme theories guide data collection and analysis and are refined iteratively throughout the studies.

Discussion: This study addresses a gap in implementation research by investigating how a complex, socially embedded intervention can be effectively integrated into routine primary care. The use of a Hybrid Type II design enables simultaneous learning about what works and how implementation strategies interact with local contexts. Particular focus is placed on the roles of link workers, intersectoral collaboration, organizational readiness, and the fit between patient needs and community services. The research contributes to the understanding of strategy selection, adaptation, and sustainment across clinical, organizational, and community settings. Findings will inform the scale-up of social prescribing in Denmark and offer transferable insights on implementing person-centred, equity-oriented interventions in other healthcare systems.

Trial registration: The effectiveness assessment is registered prospectively at ClinicalTrials.gov (NCT07029334).

Background: Contingency management (CM) is the most effective treatment for stimulant use, but is underutilized due to implementation challenges. Digital CM platforms have shown promise in addressing barriers to implementation, but there is limited understanding of factors impacting delivery of a digital CM platform over time. The goal of this longitudinal study was to measure change in implementation determinants affecting uptake of a digital CM platform in opioid treatment programs (OTPs) for individuals who are stimulant users. The study used a novel assessment tool called the Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS) to compare implementation determinants across OTPs and measure changes in determinants over a 6-month implementation period.

Methods: Five OTPs in Rhode Island completed the IFASIS prior to and 6 months into implementation of a digital CM platform. OTP staff completed the IFASIS as a team. Twenty-seven items measuring external context, internal context, intervention factors, and recipient factors were each rated on the impact of the factor on implementation (scores 1-2 = barrier, 3 = neutral, 4-5 = facilitator) and the importance of the factor (1 = not important to 3 = very important). Teams also verbalized the rationale for their ratings. Interviews were recorded and transcribed for rapid qualitative analysis. Quantitative ratings were recorded and median scores for each item were calculated.

Results: Internal organizational factors such as leadership commitment to implementation and organizational policies were perceived as becoming greater barriers to implementation over time. Staff capacity was perceived as a stable facilitator across sites despite sites experiencing turnover and new hires from baseline to follow-up. Despite initial perceptions of recipient and intervention factors as facilitators, these factors were generally viewed as neutral or as barriers at follow-up. Staff comments revealed unanticipated challenges in referring and engaging patients that contributed to the shift in their ratings.

Discussion: Findings underscore the complex and dynamic nature of implementation determinants and highlight the importance of monitoring recipient and intervention factors when implementing digital CM platforms. Results of this study suggest the need to help OTP staff set realistic expectations about the implementation process, particularly with regard to the ease of identifying and engaging patients.

Background: Forensic mental health (FMH) serves as a critical juncture between the mental health and criminal justice systems. Factors on multiple levels - including sociopolitical, organizational, and individual- pose challenges to conducting implementation research in these settings. This hinders the uptake of evidence-based interventions and improvements to patient outcomes. This study examined implementation research conducted in FMH settings to understand its current state and inform future implementation research and practice.

Methods: We conducted a scoping review following the Joanna Briggs Institute methodology. A comprehensive literature search was performed across seven databases from their inception through April 2024, supplemented by searches in Google Scholar and six review studies, to identify relevant research. We analyzed included studies descriptively to explore determinants, strategies, and outcomes associated with the implementation of evidence-, or policy-based interventions in FMH.

Results: Of the 1327 records retrieved, 41 implementation studies were included. All studies were conducted in high-income countries and focused on interventions such as risk assessment, rehabilitation, patient support, and technology interventions, primarily using qualitative approaches. Key determinants for implementing interventions in FMH included individual characteristics (e.g., motivation, capacity) and inner setting factors (e.g., intervention compatibility with existing practices, access to knowledge and information). Various strategies, such as using evaluative and iterative strategies, training and educating stakeholders, changing infrastructure, and engaging consumers have been used to facilitate intervention uptake in FMH. Implementation outcomes primarily focused on uptake, fidelity, and acceptability.

Conclusions: There is a clear need for more implementation research using rigorous study designs in FMH. Multilevel implementation strategies should be employed to address barriers from both the inner settings and individual characteristics, thereby promoting the successful implementation of interventions in FMH. Future implementation research should incorporate a health equity lens throughout the research process to enhance inclusivity and improve reporting on implementation strategies to support replications of interventions in FMH.

Background: Financial incentives are increasingly used to achieve UNAIDS' 95-95-95 goals for ending HIV by 2030. While evidence supports their effectiveness, scaling these interventions remains challenging. This study examines the implementation successes and challenges of a financial incentive intervention in Tanzania, delivered via an mHealth application that provides automated mobile money disbursements, biometric identification, and SMS reminders.

Methods: Conducted alongside a Hybrid Type 1 Effectiveness-Implementation trial, the study evaluated financial incentives given to adults starting ART at 32 clinics. We used the Structured Assessment of Feasibility, Compatibility Beliefs in Technology (CBIT) scales, and the Program Sustainability Assessment Tool. Perspectives from 657 participants living with HIV and 90 clinic staff were collected using Proctor's implementation science framework.

Results: Clinic staff rated the mHealth system highly on CBIT subscales for perceived usefulness, ease of use, and compatibility, each scoring over 6 out of 7. Integration and applicability of the financial incentive within the mHealth system were well received, with 93.0% of staff agreeing it improved job performance. Among participants, 86.4% found SMS reminders helpful for attending appointments, and 76.7% felt the cash delivery met their expectations. Challenges included unreliable fingerprint identification and undelivered SMS reminders.

Conclusions: Despite issues with fingerprint identification and SMS delivery, the financial incentive intervention via mHealth was found to be acceptable, feasible, and potentially sustainable in resource-limited settings, with support from host governments. Future research should enhance the intervention's effectiveness and optimize biometric identification methods.

Trial registration: ClinicalTrials.gov NCT04201353. Registered 17 December 2019, https://clinicaltrials.gov/study/NCT04201353.

Background: Provision of government subsidized school meals at no charge to all students in income-eligible schools (Universal School Meals) is a critical policy approach to address food insecurity and risk for obesity in school-aged children. However, despite documented benefits, implementation challenges remain, which limit the uptake and associated impact of this provision. To ensure the longevity of this policy approach, equity-focused solutions that center the needs of those tasked with implementation and the most vulnerable Universal School Meals recipients are necessary. The aims of this study are to develop equity-focused implementation strategies and test them through a hybrid type III cluster-randomized trial to examine potential effectiveness on improving student uptake and implementation across the school system.

Methods: Aim 1 will comprise the first tasks of Implementation Mapping to co-develop implementation strategies in partnership with school implementers and recipients to ensure contextual fit within their school system. Aim 2 will comprise the final step of implementation mapping with a hybrid type III implementation-effectiveness trial to examine primary implementation and effectiveness outcomes of the applied strategies. Reach and penetration will be the primary implementation outcomes in addition to acceptability, feasibility, cost, and sustainability. Health outcomes comprise family food security, student dietary behaviors, and body mass index. Baseline, 6-month, and 12-month assessments will be recorded. A convergent (Quantitative-Qualitative) mixed methods design will be employed for analysis; exploratory hierarchical multiple regression models will be run for each behavioral outcome using students as the unit of observation and schools as the unit of analysis. Survey and interview data for implementation outcomes will be analyzed deductively according to the Exploration, Preparation, Implementation, and Sustainment and Getting to Equity frameworks then inductively to generate overarching themes across the trial period.

Discussion: This implementation mapping process will yield equity-driven strategies, which can be successfully implemented in school settings to improve uptake of USM and reduce food insecurity and obesity-related disparities in high-risk youth. This study presents a rigorous and equity-driven implementation research agenda with the potential to advance school-based obesity prevention efforts by identifying, developing, and evaluating context-specific strategies that meet the needs of vulnerable student populations.

Trial registration: ClinicalTrials.gov, NCT06579079, Registered on 11-5-2024.