The association between implementation strategy use and the uptake of hepatitis C treatment in a national sample

Hepatitis C Care in the Department of Veterans Affairs: Building a Foundation for Success

The Department of Veterans Affairs (VA) has made significant progress in treating hepatitis C virus, experiencing more than a 75% reduction in veterans remaining to be treated since the availability of oral direct-acting antivirals. Hepatitis C Innovation Teams use lean process improvement and system redesign, resulting in practice models that address gaps in care. The key to success is creative improvements in veteran access to providers, including expanded use of nonphysician providers, video telehealth, and electronic technologies. Population health management tools monitor and identify trends in care, helping the VA tailor care and address barriers.

Protocol for evaluating the nationwide implementation of the VA Stratification Tool for Opioid Risk Management (STORM)

BACKGROUND

Mitigating the risks of adverse outcomes from opioids is critical. Thus, the Veterans Affairs (VA) Healthcare System developed the Stratification Tool for Opioid Risk Management (STORM), a dashboard to assist clinicians with opioid risk evaluation and mitigation. Updated daily, STORM calculates a "risk score" of adverse outcomes (e.g., suicide-related events, overdoses, overdose death) from variables in the VA medical record for all patients with an opioid prescription and displays this information along with documentation of recommended risk mitigation strategies and non-opioid pain treatments. In March 2018, the VA issued a policy notice requiring VA Medical Centers (VAMCs) to complete case reviews for patients whom STORM identifies as very high-risk (i.e., top 1% of STORM risk scores). Half of VAMCs were randomly assigned notices that also stated that additional support and oversight would be required for VAMCs that failed to meet an established percentage of case reviews. Using a stepped-wedge cluster randomized design, VAMCs will be further randomized to conduct case reviews for an expanded pool of patients (top 5% of STORM risk scores vs. 1%) starting either 9 or 15 months after the notice was released, creating four natural arms. VA commissioned an evaluation to understand the implementation strategies and factors associated with case review completion rates, whose protocol is described in this report.

METHODS

This mixed-method study will include an online survey of all VAMCs to identify implementation strategies and interviews at a subset of facilities to identify implementation barriers and facilitators. The survey is based on the Expert Recommendations for Implementing Change (ERIC) project, which engaged experts to create consensus on 73 implementation strategies. We will use regression models to compare the number and types of implementation strategies across arms and their association with case review completion rates. Using questions from the Consolidated Framework for Implementation Research, we will interview stakeholders at 40 VAMCs with the highest and lowest adherence to opioid therapy guidelines.

DISCUSSION

By identifying which implementation strategies, barriers, and facilitators influence case reviews to reduce opioid-related adverse outcomes, this unique implementation evaluation will enable the VA to improve the design of future opioid safety initiatives.

TRIAL REGISTRATION

This project is registered at the ISRCTN Registry with number ISRCTN16012111 . The trial was first registered on 5/3/2017.

Intermediary/purveyor organizations for evidence-based interventions in the US child mental health: characteristics and implementation strategies

Background

Many psychosocial interventions are disseminated and supported by organizations, termed “Intermediary/Purveyor Organizations” (IPOs). Because IPOs remain largely unstudied, we lack understanding of their scale and the strategies they utilize. The role and function of organizations that link resource systems with user systems, such as IPOs, have been identified as an important but understudied issue in implementation science. The objectives of this paper are to describe features of IPOs that disseminate evidence-based interventions (EBIs) for child behavioral health and identify the strategies they use to support their implementation.

Methods

The Substance Abuse and Mental Health Services (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP) listed 119 unique IPOs for the 127 child behavioral health EBIs listed on its website. Data characterizing each organization were drawn from NREPP and GuideStar profiles. From 119 unique IPOs identified, we found contact information for 108. We sent an electronic survey to capture additional organizational information and implementation strategies the IPOs employed in spreading the EBIs; response rate was 50%. Data are presented descriptively and analyzed using ordinary least squares (OLS) regression and Latent Class Analysis (LCA).

Results

Virtually all identified EBIs had an IPO. IPOs train individuals, organizations, and communities and provide supervision for the use of EBIs. About 20% of IPOs trained at large scale, some training 500–1000+ providers annually. IPOs reported using an average of 32 distinct strategies to implement their EBIs, with most using educational, planning, and quality improvement strategies. However, there was little convergence around strategy helpfulness. The only significant predictor of number of strategies used by an IPO was the NREPP-posted implementation readiness score of the intervention. LCA revealed that IPOs either used several implementation strategies or used very few.

Conclusions

Findings add significantly to knowledge about IPO structure, scale, and function. They use numerous and varying implementation strategies but report little consensus in what works. The study advances methods for measuring and characterizing real-world implementation by demonstrating the feasibility of using a common nomenclature, per a published compilation and of LCA for data reduction in characterizing profiles of implementation approaches.

Screening and Treating Hepatitis C in the VA: Achieving Excellence Using Lean and System Redesign

The national effort to redesign care using Lean management strategies, develop local and regional teams, and centralize support allowed VA to maximize available resources to achieve higher rates of testing and treatment of patients with hepatitis C virus than that of any other health care system in the US.

A Pragmatic Approach to Guide Implementation Evaluation Research: Strategy Mapping for Complex Interventions

INTRODUCTION

Greater specification of implementation strategies is a challenge for implementation science, but there is little guidance for delineating the use of multiple strategies involved in complex interventions. The Cardiovascular (CV) Toolkit project entails implementation of a toolkit designed to reduce CV risk by increasing women's engagement in appropriate services. The CV Toolkit project follows an enhanced version of Replicating Effective Programs (REP), an evidence-based implementation strategy, to implement the CV Toolkit across four phases: pre-conditions, pre-implementation, implementation, and maintenance and evolution. Our current objective is to describe a method for mapping implementation strategies used in real time as part of the CV Toolkit project. This method supports description of the timing and content of bundled strategies and provides a structured process for developing a plan for implementation evaluation.

METHODS

We conducted a process of strategy mapping to apply Proctor and colleagues' rubric for specification of implementation strategies, constructing a matrix in which we identified each implementation strategy, its conceptual group, and the corresponding REP phase(s) in which it occurs. For each strategy, we also specified the actors involved, actions undertaken, action targets, dose of the implementation strategy, and anticipated outcome addressed. We iteratively refined the matrix with the implementation team, including use of simulation to provide initial validation.

RESULTS

Mapping revealed patterns in the timing of implementation strategies within REP phases. Most implementation strategies involving the development of stakeholder interrelationships and training and educating stakeholders were introduced during the pre-conditions or pre-implementation phases. Strategies introduced in the maintenance and evolution phase emphasized communication, re-examination, and audit and feedback. In addition to its value for producing valid and reliable process evaluation data, mapping implementation strategies has informed development of a pragmatic blueprint for implementation and longitudinal analyses and evaluation activities.

DISCUSSION

We update recent recommendations on specification of implementation strategies by considering the implications for multi-strategy frameworks and propose an approach for mapping the use of implementation strategies within complex, multi-level interventions, in support of rigorous evaluation. Developing pragmatic tools to aid in operationalizing the conduct of implementation and evaluation activities is essential to enacting sound implementation research.