1
|
Austin EJ, Chen J, Ferro L, Saxon AJ, Fortney JC, Curran GM, Ratzliff AD, Williams EC. Are we being equitable enough? Lessons learned from sites lost in an implementation trial. IMPLEMENTATION RESEARCH AND PRACTICE 2024; 5:26334895241267023. [PMID: 39148956 PMCID: PMC11325307 DOI: 10.1177/26334895241267023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024] Open
Abstract
Background There is a growing interest in practice-based implementation research, yet too often research prioritizes and is most successful in academic settings. During a national implementation trial to evaluate the effectiveness of Collaborative Care for co-occurring opioid use and mental health disorders, we lost three of our 11 participating implementation sites, all representing community sites. Method To better understand needed supports for implementation trial participation, we conducted exit interviews (n = 5) with key staff at these community sites. Interview transcripts were double-coded and analyzed using Rapid Assessment Process. Qualitative themes were iteratively reviewed by the study team. Results Three themes emerged characterizing challenges for community sites, including that: (1) research threatens sites' most precious resource-staff; (2) staff lack comfort with and skills for research; and (3) research participation in its current form does not offer a clear return on investment. Conclusions Learnings from this work illuminate some of the barriers community sites face when trying to participate in multisite implementation research. An undercurrent of participant perspectives was the belief that community sites like theirs are just not set up to successfully participate in clinical trial research, including population-based implementation trials. Future implementation trials should consider strategies that disrupt traditional approaches, increasing the equitable inclusion of diverse practice settings in implementation research.
Collapse
Affiliation(s)
- Elizabeth J Austin
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, WA, USA
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, USA
| | - Geoffrey M Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Central Arkansas Veterans Health Care System, Little Rock, AR, USA
| | - Anna D Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, USA
| |
Collapse
|
2
|
Gabbard J, Sadarangani TR, Datta R, Fabius CD, Gettel CJ, Douglas NF, Juckett LA, Kiselica AM, Murali KP, McCarthy EP, Torke AM, Callahan CM. Career development in pragmatic clinical trials to improve care for people living with dementia. J Am Geriatr Soc 2023; 71:3554-3565. [PMID: 37736669 PMCID: PMC10810339 DOI: 10.1111/jgs.18599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 09/23/2023]
Abstract
The growing number of people living with dementia (PLWD) requires a coordinated clinical response to deliver pragmatic, evidence-based interventions in frontline care settings. However, infrastructure to support such a response is lacking. Moreover, there are too few researchers conducting rigorous embedded pragmatic clinical trials (ePCTs) to make the vision of high quality, widely accessible dementia care a reality. National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease and Related Dementias Clinical Trials (IMPACT) Collaboratory seeks to improve the pipeline of early career researchers qualified to lead ePCTs by funding career development awards. Even with support from the Collaboratory, awardees face practical and methodological challenges to success, recently exacerbated by the COVID-19 pandemic. We first describe the training opportunities and support network for the IMPACT CDA recipients. This report then describes the unique career development challenges faced by early-career researchers involved in ePCTs for dementia care. Topics addressed include challenges in establishing a laboratory, academic promotion, mentoring and professional development, and work-life balance. Concrete suggestions to address these challenges are offered for early-career investigators, their mentors, and their supporting institutions. While some of these challenges are faced by researchers in other fields, this report seeks to provide a roadmap for expanding the work of the IMPACT Collaboratory and initiating future efforts to recruit, train, and retain talented early-career researchers involved in ePCTs for dementia care.
Collapse
Affiliation(s)
- Jennifer Gabbard
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | | | - Rupak Datta
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Chanee D. Fabius
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Natalie F. Douglas
- Department of Communication Sciences and Disorders, The Herbert H. and Grace A. Dow College of Health Professions, Central Michigan University, Mt. Pleasant, Michigan
| | - Lisa A Juckett
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Andrew M. Kiselica
- Department of Health Psychology, School of Health Professions, University of Missouri, Columbia, Missouri
| | | | - Ellen P. McCarthy
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexia M. Torke
- Division of General Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Christopher M. Callahan
- Division of General Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| |
Collapse
|
3
|
Greene SM. End-to-End Integration of Pragmatic Trials Into Health Care Settings. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:45-47. [PMID: 37450522 DOI: 10.1080/15265161.2023.2217149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
|
4
|
Berger MB, Chisholm M, Miller HN, Askew S, Kay MC, Bennett GG. "We bleed for our community:" A qualitative exploration of the implementation of a pragmatic weight gain prevention trial from the perspectives of community health center professionals. BMC Public Health 2023; 23:695. [PMID: 37060053 PMCID: PMC10103522 DOI: 10.1186/s12889-023-15574-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 03/31/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Clinical trial implementation continues to shift toward pragmatic design, with the goal of increasing future adoption in clinical practice. Yet, few pragmatic trials within clinical settings have qualitatively assessed stakeholder input, especially from those most impacted by research implementation and outcomes, i.e., providers and staff. Within this context, we conducted a qualitative study of the implementation of a pragmatic digital health obesity trial with employees at a Federally qualified health center (FQHC) network in central North Carolina. METHODS Participant recruitment was conducted through purposive sampling of FQHC employees from a variety of backgrounds. Two researchers conducted semi-structured qualitative interviews and collected demographic data. Interviews were digitally recorded, professionally transcribed and double-coded by two independent researchers using NVivo 12. Coding discrepancies were reviewed by a third researcher until intercoder consensus was reached. Responses were compared within and across participants to elucidate emergent themes. RESULTS Eighteen qualitative interviews were conducted, of whom 39% provided direct medical care to patients and 44% worked at the FQHC for at least seven years. Results illuminated the challenges and successes of a pragmatically designed obesity treatment intervention within the community that serves medically vulnerable patients. Although limited time and staffing shortages may have challenged recruitment processes, respondents described early buy-in from leadership; an alignment of organizational and research goals; and consideration of patient needs as facilitators to implementation. Respondents also described the need for personnel power to sustain novel research interventions and considerations of health center resource constraints. CONCLUSIONS Results from this study contribute to the limited literature on pragmatic trials utilizing qualitative methods, particularly in community-based obesity treatment. To continue to merge the gaps between research implementation and clinical care, qualitative assessments that solicit stakeholder input are needed within pragmatic trial design. For maximum impact, researchers may wish to solicit input from a variety of professionals at trial onset and ensure that shared common goals and open collaboration between all partners is maintained throughout the trial. TRIAL REGISTRATION This trial was registered with ClinicalTrials.gov (NCT03003403) on December 28, 2016.
Collapse
Affiliation(s)
- Miriam B Berger
- Duke Digital Health Science Center, Duke University, 417 Chapel Drive Room 048, Campus Box 90086, Durham, NC, 27708-0086, USA.
| | - Miriam Chisholm
- Duke Digital Health Science Center, Duke University, 417 Chapel Drive Room 048, Campus Box 90086, Durham, NC, 27708-0086, USA
| | - Hailey N Miller
- Duke Digital Health Science Center, Duke University, 417 Chapel Drive Room 048, Campus Box 90086, Durham, NC, 27708-0086, USA
- School of Nursing, Duke University, 307 Trent Drive, Durham, NC, 27710, USA
| | - Sandy Askew
- Duke Digital Health Science Center, Duke University, 417 Chapel Drive Room 048, Campus Box 90086, Durham, NC, 27708-0086, USA
| | - Melissa C Kay
- Duke Digital Health Science Center, Duke University, 417 Chapel Drive Room 048, Campus Box 90086, Durham, NC, 27708-0086, USA
- Department of Pediatrics, Duke University, 3116 N. Duke Street, Room 1029, 27704, Durham, NC, USA
| | - Gary G Bennett
- Duke Digital Health Science Center, Duke University, 417 Chapel Drive Room 048, Campus Box 90086, Durham, NC, 27708-0086, USA
- Department of Psychology and Neuroscience, Duke University, 222 Reuben-Cooke, Durham, NC, 27708, USA
| |
Collapse
|
5
|
Baldwin LM, Tuzzio L, Cole AM, Holden E, Powell JA, Parchman ML. Tailoring Implementation Strategies for Cardiovascular Disease Risk Calculator Adoption in Primary Care Clinics. J Am Board Fam Med 2022; 35:1143-1155. [PMID: 36460353 PMCID: PMC10691203 DOI: 10.3122/jabfm.2022.210449r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/19/2022] [Accepted: 02/24/2022] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION When implementing interventions in primary care, tailoring implementation strategies to practice barriers can be effective, but additional work is needed to understand how to best select these strategies. This study sought to identify clinicians' contributions to the process of tailoring implementation strategies to barriers in clinical settings. METHODS We conducted a modified nominal group exercise involving 8 implementation scientists and 26 primary care clinicians in the WWAMI region Practice and Research Network. Each group identified implementation strategies it felt would best address barriers to using a cardiovascular disease (CVD) risk calculator previously identified across 44 primary care clinics from the Healthy Hearts Northwest pragmatic trial (2015 to 2018). These barriers had been mapped beforehand to the Consolidated Framework for Implementation Research (CFIR) domains. We examined similarities and differences in the strategies that 30% or more of each group identified (agreed-on strategies) for each barrier and for barriers in each CFIR domain. We used the results to demonstrate how strategies might be tailored to individual clinics. RESULTS Clinicians selected 23 implementation strategies to address 1 or more of the 13 barriers; implementation scientists selected 35. The 2 groups agreed on at least 1 strategy for barriers in each CFIR domain: Inner Setting, Outer Setting, Intervention Characteristics, Characteristics of Individuals, and Process. Conducting local needs assessment and assessing for readiness/identifying barriers and facilitators were the 2 most common implementation strategies chosen only by clinicians. CONCLUSIONS Clinician stakeholders identified implementation strategies that augmented those chosen by implementation scientists, suggesting that codesign of implementation processes between implementation scientists and clinicians may strengthen the process of tailoring strategies to overcome implementation barriers.
Collapse
Affiliation(s)
- Laura-Mae Baldwin
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Leah Tuzzio
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Allison M Cole
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Erika Holden
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Jennifer A Powell
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Michael L Parchman
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| |
Collapse
|
6
|
Morain SR, Mathews DJH, Geller G, Bollinger J, Weinfurt K, Jarvik JG, May E, Sugarman J. Identification and management of pragmatic clinical trial collateral findings: A current understanding and directions for future research. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100586. [PMID: 34600345 DOI: 10.1016/j.hjdsi.2021.100586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 08/26/2021] [Accepted: 09/17/2021] [Indexed: 11/29/2022]
Abstract
While the embedded nature of pragmatic clinical trials (PCTs) can improve the efficiency and relevance of research for multiple stakeholders, embedding research into ongoing clinical care can also involve ethical and regulatory challenges. An emergent challenge is the management of pragmatic clinical trial collateral findings (PCT-CFs). While PCT-CFs share some features with incidental or secondary findings that are encountered in conventional clinical trials and clinical care, the PCT context differs in ethically relevant ways that complicate PCT-CF identification and management. We report on the results of a two-year multi-method investigation of PCT-CFs. Overall, five core themes emerged: 1) the liminal nature of PCTs and the implications of this for PCT-CFs; 2) the context-specific nature of PCT-CF management; 3) the centrality of institutions; 4) the importance of prospective planning; and 5) patient expectations. Among the central lessons of this work are that prior ethics guidance from other settings cannot easily be adapted to address PCT-CFs, nor can a single approach readily accommodate all PCT-CFs. Moving forward, stakeholders, including researchers, institutions, ethics oversight bodies, and funders, should anticipate and plan for PCT-CFs in the design, conduct, and analysis of PCTs. Future scholarship is needed to examine experiences with PCT-CFs, and the practical and conceptual issues they raise for the future conduct of PCTs.
Collapse
Affiliation(s)
- Stephanie R Morain
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 310D, Houston, TX, 77030, USA; Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD, 21205, USA.
| | - Debra J H Mathews
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD, 21205, USA; Department of Genetic Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD, 21205, USA; Department of Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Juli Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD, 21205, USA
| | - Kevin Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| | - Jeffrey G Jarvik
- Departments of Radiology and Neurological Surgery and the Clinical Learning, Evidence and Research Center for Musculoskeletal Disorders, University of Washington School of Medicine, Box 359728, 325 Ninth Ave, Seattle, WA, 98104, USA
| | - Elizabeth May
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD, 21205, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD, 21205, USA; Department of Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| |
Collapse
|