Implementation science communications最新文献

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.

Background: Health disparities lead to negative COVID-19 outcomes for Hispanic/Latino communities. Rapid antigen testing was an important mitigation tool for protecting schools and their communities as in-person learning resumed. Within the context of a 3-middle-school non-inferiority trial we assessed acceptability and appropriateness of at-home and school-based COVID-19 antigen testing and implementation barriers and facilitators to facilitate district-wide scale up.

Methods: Guided by the Consolidated Framework for Implementation Research (CFIR) and acceptability and appropriateness implementation outcomes, we collected post-implementation qualitative (n = 30) and quantitative (n = 454) data in English and Spanish from trial participants, in-depth feedback sessions among program implementers (n = 19) and coded 137 project meeting minutes. Verbatim transcripts were thematically analyzed. We used multivariate linear models to evaluate program acceptability and appropriateness by COVID-19 testing modality and mixed qualitative and quantitative findings for interpretation.

Results: Questionnaire respondents closely matched school demographics (> 80% Hispanic/Latino and 8% Filipino/Asian Pacific Islander). While both testing modalities were rated as highly acceptable and appropriate, at-home testing was consistently favorable. Qualitative findings provided actionable areas for at-home testing program refinement, guiding district-wide scale up including: maintaining a learning climate to accommodate modifications as guidelines changed, needs of the school community, and implementation challenges; ensuring an engaged school leadership and sufficient human resources; improving educational communication about COVID-19 and technology ease of use; and increased time for pre-implementation planning and engagement.

Conclusions: Results underscore the value of the CFIR to inform program implementation, particularly programs to reduce disparities during a public health emergency. Results support optimal testing implementation strategies centering the needs and perspectives of Hispanic/Latinos.

Background: Implementation strategies can help support the adoption and implementation of health interventions that are appropriate for a local context and acceptable to decision makers and community members. Implementation strategies should be designed to handle the complexity of the multi-level, dynamic contexts in which interventions are implemented. Systems science theories and methods explicitly attend to complexity and can be valuable for specifying implementation strategies. Group Model Building (GMB) combines research partner engagement strategies with systems science to support researchers' and partners' learning about complex problems and to identify solutions through consensus. This paper specifies how GMB can operationalize implementation strategies - methods for supporting evidence implementation in real-world practice - and describes how GMB can aid in selecting and tailoring both health interventions and implementation strategies. A case study in child maltreatment prevention planning is provided to illustrate how GMB was used to specify the "actions" - strategy activities - for three implementation strategies (conduct local consensus discussions; build a coalition; model and simulate change) during the earliest implementation phases, with the goal of supporting intervention selection decisions. Examples are provided of generalizable research products that can be produced concurrently through GMB, in addition to contextually-driven implementation support.

Methods: Participants (n = 8) were engaged over four sessions using tailored GMB activities. Participants generated a qualitative system dynamics model that described their theory of change for how to prevent child maltreatment in their communities. This theory of change reflected a dynamic understanding of the interconnected determinants of child maltreatment.

Results: GMB was acceptable to participants and resulted in products that could be used for implementation planning (e.g., to model and simulate change) and future research. GMB fostered trust and idea sharing between participants.

Conclusion: GMB can facilitate learning about which outcomes are (or are not) impacted by interventions, which resources and approaches are required for quality implementation (e.g., implementation strategies), and tradeoffs in outcomes and resources between interventions. GMB also provides a structured, effective process to generate a shared implementation vision amongst participants. Lessons learned include methods for developing trust with and between participants, and the need for researchers to tailor GMB actions for participant and project needs.

Background: Familial hypercholesterolemia (FH) is an autosomal dominant genetic condition that carries increased risk for premature atherosclerotic cardiovascular disease, cardiovascular events, and death. Due to low uptake of evidence-based practices, up to 80% of FH patients remain undiagnosed and most are undertreated. This project aimed to understand patient and clinician perceptions across the care pathway of evidence-based diagnosis and treatment of FH, to inform implementation strategy design for two clinical trials seeking to increase evidence-based care.

Methods: With input from FH experts, we identified key points along the FH care pathway that might be targeted with broad-scale implementation efforts, including: (a) identification of the need for screening; (b) completion of screening test(s); (c) diagnosis; (d) connection to treatment; and (e) family cascade screening (a process used to identify and screen relatives of individuals diagnosed with FH). Then, we conducted qualitative interviews with patients who had participated in a prior FH quality improvement initiative and with clinicians who treat high cholesterol. We analyzed data using thematic analysis.

Results: We interviewed 21 patients and 17 clinicians. Patient themes offered insights related to the impact of family history, reactions to a diagnosis of high cholesterol and/or FH, experiences with FH treatment and clinical care, perceptions of tools to diagnose FH, motivations and preferences for FH screening efforts, and reactions to family screening. Clinician themes offered insights into the perceived value of FH screening and diagnosis, current FH-related practice and context, and attitudes toward tools to aid clinical practice. In both sets of interviews, confusion and misconceptions about what makes FH unique and its clinical implications were common, as were concerns about logistics and competing priorities.

Conclusion: Qualitative inquiry generated insights into several modifiable patient and clinician determinants of engagement with evidence-based implementation along the FH care pathway, many of which can be targeted with behavioral economics strategies that simplify complex decisions and by addressing informational and emotional needs. These findings offer actionable insights to inform future implementation research that seeks to close the evidence-to-practice gap in diagnosis and delivery of evidence-based care for FH.

Background: Positive pressure ventilation (PPV) is an essential component of neonatal resuscitation. Meta-analytic evidence suggests that, among late preterm and term newborn infants who require resuscitation after birth, a supraglottic airway (SA) device is more effective than a face mask at reducing the probability of PPV failure and reducing the need for endotracheal intubation. However, SA devices are rarely used in routine practice in hospital delivery room settings within the United States.

Methods: In preparation for a pragmatic hybrid effectiveness-implementation trial, we used implementation mapping to identify barriers and facilitators to SA use; develop a logic model; identify and operationalize implementation strategies targeting key barriers and facilitators; and refine strategies based on iterative feedback from clinicians and administrators (e.g., physicians, nurse practitioners, nurse managers, and respiratory therapists). We used the Consolidated Framework for Implementation Research (CFIR) to organize barriers and implementation strategies.

Results: Across open-ended survey responses and focus groups, identified barriers included: (1) mixed perceptions of the advantages or disadvantages of SA compared to alternatives; (2) insufficient education and training in SA use; and (3) lack of perceived need for an alternative to intubation as a standard practice. The research team's understanding of these barriers and selection of implementation strategies to address them were refined throughout the iterative implementation mapping process, which resulted in the selection of two sets of implementation strategies to be tested in a hybrid trial.

Conclusions: The implementation mapping process described in this paper provides an exemplar of a systematic and partner-engaged process to identify and select implementation strategies for the purpose of hybrid trial design.

Background: Neovascular age-related macular degeneration (nAMD) is one of the largest single-disease contributors to hospital outpatient appointments. Challenges in finding the clinical capacity to meet this demand can lead to sight-threatening delays in the macular services that provide treatment. Clinical artificial intelligence (AI) technologies pose one opportunity to rebalance demand and capacity in macular services. However, there is a lack of evidence to guide early-adopters seeking to use AI as a solution to demand-capacity imbalance. This study aims to provide guidance for these early adopters on how AI-enabled macular services may best be implemented by exploring what will influence the outcome of AI implementation and why.

Methods: Thirty-six semi-structured interviews were conducted with participants. Data were analysed with the Nonadoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to identify factors likely to influence implementation outcomes. These factors and the primary data then underwent a secondary analysis using the Fit between Individuals, Technology and Task (FITT) framework to propose an actionable intervention.

Results: nAMD treatment should be initiated at face-to-face appointments with clinicians who recommend year-long periods of AI-enabled scheduling of treatments. This aims to maintain or enhance the quality of patient communication, whilst reducing consultation frequency. Appropriately trained photographers should take on the additional roles of inputting retinal imaging into the AI device and overseeing its communication to clinical colleagues, while ophthalmologists assume clinical oversight and consultation roles. Interoperability to facilitate this intervention would best be served by imaging equipment that can send images to the cloud securely for analysis by AI tools. Picture Archiving and Communication Software (PACS) should have the capability to output directly into electronic medical records (EMR) familiar to clinical and administrative staff.

Conclusion: There are many enablers to implementation and few of the remaining barriers relate directly to the AI technology itself. The proposed intervention requires local tailoring and prospective evaluation but can support early adopters in optimising the chances of success from initial efforts to implement AI-enabled macular services.

Protocol registration: Hogg HDJ, Brittain K, Teare D, Talks J, Balaskas K, Keane P, Maniatopoulos G. Safety and efficacy of an artificial intelligence-enabled decision tool for treatment decisions in neovascular age-related macular degeneration and an exploration of clinical pathway integration and implementation: protocol for a multi-methods validation study. BMJ Open. 2023 Feb 1;13(2):e069443. https://doi.org/10.1136/bmjopen-2022-069443 . PMID: 36725098; PMCID: PMC9896175.