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Fortney JC, Curran GM, Lyon AR, Check DK, Flum DR. Similarities and Differences Between Pragmatic Trials and Hybrid Effectiveness-Implementation Trials. J Gen Intern Med 2024; 39:1735-1743. [PMID: 38627320 PMCID: PMC11254859 DOI: 10.1007/s11606-024-08747-1] [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: 10/16/2023] [Accepted: 03/27/2024] [Indexed: 07/19/2024]
Abstract
Pragmatism in clinical trials is focused on increasing the generalizability of research findings for routine clinical care settings. Hybridism in clinical trials (i.e., assessing both clinical effectiveness and implementation success) is focused on speeding up the process by which evidence-based practices are developed and adopted into routine clinical care. Even though pragmatic trial methodologies and implementation science evolved from very different disciplines, Pragmatic Trials and Hybrid Effectiveness-Implementation Trials share many similar design features. In fact, these types of trials can easily be conflated, creating the potential for investigators to mislabel their trial type or mistakenly use the wrong trial type to answer their research question. Blurred boundaries between trial types can hamper the evaluation of grant applications, the scientific interpretation of findings, and policy-making. Acknowledging that most trials are not pure Pragmatic Trials nor pure Hybrid Effectiveness-Implementation Trials, there are key differences in these trial types and they answer very different research questions. The purpose of this paper is to clarify the similarities and differences of these trial types for funders, researchers, and policy-makers. In addition, recommendations are offered to help investigators choose, label, and operationalize the most appropriate trial type to answer their research question. These recommendations complement existing reporting guidelines for clinical effectiveness trials (TIDieR) and implementation trials (StaRI).
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Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
- Department of Veterans Affairs, Health Systems Research, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.
| | - Geoffrey M Curran
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Aaron R Lyon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Devon K Check
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - David R Flum
- Department of Surgery, School of Medicine, University of Washington, Seattle, WA, USA
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Fortney JC, Rajan S, Chen JA, Campbell SB, Nolan JP, Wong E, Sayre G, Petrova V, Simons CE, Reisinger HS, Schnurr PP. A mixed-methods evaluation of why an implementation trial failed to engage veterans with posttraumatic stress disorder in trauma-focused psychotherapy. J Trauma Stress 2023; 36:762-771. [PMID: 37370238 DOI: 10.1002/jts.22946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 06/29/2023]
Abstract
An effectiveness trial found that telemedicine collaborative care for posttraumatic stress disorder (PTSD) significantly increased engagement in trauma-focused psychotherapy (TFP) and improved PTSD symptoms. However, in a subsequent implementation trial, very few veterans enrolled in collaborative care initiated TFP. We conducted a mixed-methods evaluation to determine why veterans did not initiate TFP in the implementation trial. After conducting chart reviews of 1,071 veterans with PTSD enrolled in collaborative care, patients were categorized into four mutually exclusive TFP groups: TFP not discussed; TFP discussed, declined; TFP discussed, did not decline; and TFP initiated. We conducted semistructured interviews with 43 unique patients and 58 unique providers (i.e., care managers and mental health specialists). Almost half (48.6%) of the veterans had no documentation of discussing TFP with their care manager; another 28.9% discussed it but declined. Most veterans (77.1%) had an encounter with a mental health specialist, 36.8% of whom never discussed TFP, and 35.7% of whom discussed it but declined. Providers reported that many veterans were not able, willing, or ready to engage in TFP and that non-trauma-focused therapies were better aligned with their treatment goals. Veterans gave numerous reasons for not initiating TFP, including having bad prior experiences with TFP and wanting to avoid thinking about past traumatic experiences. Commonly cited reasons for noninitiation were providers never discussing TFP with veterans and veterans declining TFP after discussing it with their provider. Interventions, such as shared decision-making tools, may be needed to engage providers and patients in informed discussions about TFP.
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Affiliation(s)
- John C Fortney
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Suparna Rajan
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Jessica A Chen
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Sarah B Campbell
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - John P Nolan
- Independent researcher, El Dorado, Arkansas, USA
| | - Edwin Wong
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
| | - George Sayre
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
| | - Valentina Petrova
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Carol E Simons
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Heather S Reisinger
- VA Health Services Research and Development, Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Paula P Schnurr
- National Center for PTSD, VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Moise N, Bauer AM. Current and future directions in the application of implementation science to accelerate the adoption of evidence-based practices in behavioral health. Gen Hosp Psychiatry 2022; 77:88-91. [PMID: 35576715 DOI: 10.1016/j.genhosppsych.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Nathalie Moise
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
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Wong ES, Rajan S, Liu CF, Morland LA, Pyne JM, Simsek-Duran F, Reisinger HS, Moeckli J, Fortney JC. Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221116771. [PMID: 37091111 PMCID: PMC9924252 DOI: 10.1177/26334895221116771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective. Methods Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP. Results Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation. Conclusions Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.
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Affiliation(s)
- Edwin S. Wong
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Suparna Rajan
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
| | - Chuan-Fen Liu
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Leslie A. Morland
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California-San Diego, San Diego, CA
| | - Jeffrey M. Pyne
- Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Fatma Simsek-Duran
- Iowa City VA Health Care System, Iowa City, IA
- Department of Psychiatry, University of Iowa, Iowa City, IA
| | - Heather S. Reisinger
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA
- Department of Internal Medicine, University of Iowa, Iowa
City, IA
| | - Jane Moeckli
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA
| | - John C. Fortney
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
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