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Karki S, Shaw S, Lieberman M, Pérez A, Pincus J, Jakhmola P, Tailor A, Ogunrinde OB, Sill D, Morgan S, Alvarez M, Todd J, Smith D, Mishra N. Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study. JMIR Form Res 2024; 8:e53000. [PMID: 38621237 PMCID: PMC11058559 DOI: 10.2196/53000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP. OBJECTIVE The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record-based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic. METHODS We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility, use, and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name "X-Clinic." We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods. RESULTS Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%). CONCLUSIONS We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.
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Affiliation(s)
- Saugat Karki
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sarah Shaw
- Public Health Informatics Institute, Decatur, GA, United States
| | - Michael Lieberman
- OCHIN, Portland, OR, United States
- Oregon Health & Sciences University, Portland, OR, United States
| | - Alejandro Pérez
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Priya Jakhmola
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Amrita Tailor
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Danielle Sill
- Public Health Informatics Institute, Decatur, GA, United States
| | | | | | | | - Dawn Smith
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Ninad Mishra
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Säfström M, Löfkvist U. Employees' experiences of a large-scale implementation in a public care setting: a novel mixed-method approach to content analysis. BMC Health Serv Res 2024; 24:107. [PMID: 38238737 PMCID: PMC10797789 DOI: 10.1186/s12913-024-10560-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/04/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Research for evidence-based interventions and strategies for implementation continues. Yet there is a continued shortage of qualified health care staff while stress and burnout are common. Health care professionals' individual perceptions towards change needs to be considered to succeed in organisational change. It is therefore relevant to investigate how implementation processes affect employees within the health care sector. Challenges to implementation are especially large in the field of disability care. The present study aims to investigate employees' experiences of an ongoing large-scale implementation, and what they perceived as important to succeed in a complex clinical setting. METHODS Semi-structured focus group interviews were conducted with a self-selected sample of employees from a large and complex health care organisation responsible for public disability care in a centrally located Swedish region. A mixed-method approach adapted to content analysis was performed in a three-step process. In the first round, each unit of analysis was selected and then colour coded. In a second round, the coloured units were coded according to content analysis, and categories and concepts were compared and adjusted until the two researchers reached consensus. Finally, to further complement the content analysis, a quantitative analysis of the colour categories was made. RESULTS In general, employees experienced the implementation as being insufficient, yet opinions of the process of implementation were mixed. Most positive experiences were found in relation to the outcomes that the new method had on work effectiveness and patient care. Closely related topics like time constraints, uncertainties concerning the method and the need for supportive functions reoccurred in several concepts suggesting a relationship between differing contextual factors, implementation activities and fidelity. Also evident in the results were the strain on organisational and social work environment and the importance of managers' active leadership. CONCLUSIONS Implementation processes are experienced as challenging for employees. Key facilitators are available support functions, clear leadership and time that is sufficient and kept sacrosanct. Leaders need to communicate how and why employees may experience implementation processes differently. The impact that organisational change has on work environment should be considered.
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Affiliation(s)
- My Säfström
- Primary care and health, Uppsala County Council, Uppsala, Sweden
| | - Ulrika Löfkvist
- Primary care and health, Uppsala County Council, Uppsala, Sweden.
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
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Lennox L, Antonacci G, Harris M, Reed J. Unpacking the 'process of sustaining'-identifying threats to sustainability and the strategies used to address them: a longitudinal multiple case study. Implement Sci Commun 2023; 4:68. [PMID: 37337274 DOI: 10.1186/s43058-023-00445-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/25/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Although sustainability remains a recognised challenge for Quality Improvement (QI) initiatives, most available research continues to investigate sustainability at the end of implementation. As a result, the learning and continuous adjustments that shape sustainability outcomes are lost. With little understanding of the actions and processes that influence sustainability within QI initiatives, there is limited practical guidance and direction on how to enhance the sustainability of QI initiatives. This study aims to unpack the 'process of sustaining', by exploring threats to sustainability encountered throughout the implementation of QI Initiatives and identifying strategies used by QI teams to address these threats over time. METHODS A longitudinal multiple case study design was employed to follow 4 QI initiatives over a 3-year period. A standardised sustainability tool was used quarterly to collect perceptions of sustainability threats and actions throughout implementation. Interviews (n=38), observations (32.5 h), documentary analysis, and a focus group (n=10) were conducted to enable a greater understanding of how the process of sustaining is supported in practice. Data were analysed using the Consolidated Framework for Sustainability (CFS) to conduct thematic analysis. RESULTS Analysis identified five common threats to sustainability: workforce stability, improvement timelines, organisational priorities, capacity for improvement, and stakeholder support. Each of these threats impacted multiple sustainability constructs demonstrating the complexity of the issues encountered. In response to threats, 12 strategies to support the process of sustaining were identified under three themes: engagement (five strategies that promoted the development of relationships), integration (three strategies that supported initiatives to become embedded within local systems), and adaptation (four strategies that enhanced understanding of, and response to, emergent conditions and contextual needs). CONCLUSIONS Sustaining improvements from QI initiatives requires continuous investment in relationships, resilience to integrate improvements in local systems, and flexibility to understand emergent conditions. Findings provide practitioners, funders, and researchers with a better understanding of, and preparation for, the threats associated with sustaining improvements from QI initiatives and offer insight into specific actions that can be taken to mitigate these risks. This learning can be used to inform future initiative design and support, to optimise the sustainability of healthcare improvements. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Laura Lennox
- National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) for Northwest London, 369 Fulham Road, London, SW10 9NH, UK.
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan's Road, London, W6 8RP, UK.
| | - Grazia Antonacci
- National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) for Northwest London, 369 Fulham Road, London, SW10 9NH, UK
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, South Kensington Campus, Exhibition Rd, London, SW7 2AZ, UK
| | - Matthew Harris
- National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) for Northwest London, 369 Fulham Road, London, SW10 9NH, UK
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
| | - Julie Reed
- Julie Reed Consultancy Ltd, 27 Molasses House, London, UK
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Blecker S, Gannon M, De Leon S, Shelley D, Wu WY, Tabaei B, Magno J, Pham-Singer H. Practice facilitation for scale up of clinical decision support for hypertension management: study protocol for a cluster randomized control trial. Contemp Clin Trials 2023; 129:107177. [PMID: 37037392 PMCID: PMC10871131 DOI: 10.1016/j.cct.2023.107177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/09/2023] [Accepted: 04/04/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Only half of patients with hypertension have adequately controlled blood pressure. Clinical decision support (CDS) has the potential to overcome barriers to delivering guideline-recommended care and improve hypertension management. However, optimal strategies for scaling CDS have not been well established, particularly in small, independent primary care practices which often lack the resources to effectively change practice routines. Practice facilitation is an implementation strategy that has been shown to support process changes. Our objective is to evaluate whether practice facilitation provided with hypertension-focused CDS can lead to improvements in blood pressure control for patients seen in small primary care practices. METHODS/DESIGN We will conduct a cluster randomized control trial to compare the effect of hypertension-focused CDS plus practice facilitation on BP control, as compared to CDS alone. The practice facilitation intervention will include an initial training in the CDS and a review of current guidelines along with follow-up for coaching and integration support. We will randomize 46 small primary care practices in New York City who use the same electronic health record vendor to intervention or control. All patients with hypertension seen at these practices will be included in the evaluation. We will also assess implementation of CDS in all practices and practice facilitation in the intervention group. DISCUSSION The results of this study will inform optimal implementation of CDS into small primary care practices, where much of care delivery occurs in the U.S. Additionally, our assessment of barriers and facilitators to implementation will support future scaling of the intervention. CLINICALTRIALS gov Identifier: NCT05588466.
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Affiliation(s)
- Saul Blecker
- NYU Grossman School of Medicine, New York, NY, United States of America.
| | - Matthew Gannon
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Samantha De Leon
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Donna Shelley
- NYU School of Global Public Health, New York, NY, United States of America
| | - Winfred Y Wu
- University of Miami - Miller School of Medicine, Miami, FL, United States of America
| | - Bahman Tabaei
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Janice Magno
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
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Donnelly LJ, Cervantes PE, Guo F, Stein CR, Okparaeke E, Kuriakose S, Filton B, Havens J, Horwitz SM. Changes in Attitudes and Knowledge after Trainings in a Clinical Care Pathway for Autism Spectrum Disorder. J Autism Dev Disord 2023; 53:606-614. [PMID: 33201422 DOI: 10.1007/s10803-020-04775-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 12/12/2022]
Abstract
Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.
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Affiliation(s)
- Lauren J Donnelly
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA.
| | - Paige E Cervantes
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
| | - Fei Guo
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
- Division of Biostatistics, Department of Population Heath, NYU Langone, New York, NY, USA
| | - Cheryl R Stein
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
| | - Eugene Okparaeke
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
- Child and Adolescent Psychiatry, Bellevue Hospital Center, New York, NY, USA
| | - Sarah Kuriakose
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
- New York State Office of Mental Health, Albany, NY, USA
| | - Beryl Filton
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
- Child and Adolescent Psychiatry, Bellevue Hospital Center, New York, NY, USA
| | - Jennifer Havens
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
- Office of Behavioral Health, NYC Health and Hospitals, New York, NY, USA
| | - Sarah M Horwitz
- Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA
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Ballengee LA, Rushton S, Lewinski AA, Hwang S, Zullig LL, Ricks KAB, Ramos K, Brahmajothi MV, Moore TS, Blalock DV, Cantrell S, Kosinski AS, Gordon A, Ear B, Williams JW, Gierisch JM, Goldstein KM. Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review. J Gen Intern Med 2022; 37:885-899. [PMID: 34981354 PMCID: PMC8904663 DOI: 10.1007/s11606-021-07217-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A culture of improvement is an important feature of high-quality health care systems. However, health care teams often need support to translate quality improvement (QI) activities into practice. One method of support is consultation from a QI coach. The literature suggests that coaching interventions have a positive impact on clinical outcomes. However, the impact of coaching on specific process outcomes, like adoption of clinical care activities, is unknown. Identifying the process outcomes for which QI coaching is most effective could provide specific guidance on when to employ this strategy. METHODS We searched multiple databases from inception through July 2021. Studies that addressed the effects of QI coaching on process of care outcomes were included. Two reviewers independently extracted study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE. RESULTS We identified 1983 articles, of which 23 cluster-randomized trials met eligibility criteria. All but two took place in a primary care setting. Overall, interventions typically targeted multiple simultaneous processes of care activities. We found that coaching probably has a beneficial effect on composite process of care outcomes (n = 9) and ordering of labs and vital signs (n = 6), and possibly has a beneficial effect on changes in organizational process of care (n = 5), appropriate documentation (n = 5), and delivery of appropriate counseling (n = 3). We did not perform meta-analyses because of conceptual heterogeneity around intervention design and outcomes; rather, we synthesized the data narratively. Due to imprecision, inconsistency, and high risk of bias of the included studies, we judged the certainty of these results as low or very low. CONCLUSION QI coaching interventions may affect certain processes of care activities such as ordering of labs and vital signs. Future research that advances the identification of when QI coaching is most beneficial for health care teams seeking to implement improvement processes in pursuit of high-quality care will support efficient use of QI resources. PROTOCOL REGISTRATION This study was registered and followed a published protocol (PROSPERO: CRD42020165069).
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Affiliation(s)
- Lindsay A Ballengee
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA.
- Department of Orthopaedic Surgery, Duke University School of Medicine, Division of Physical Therapy, Duke University, Durham, NC, USA.
| | | | - Allison A Lewinski
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Leah L Zullig
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Katharine A Ball Ricks
- Cecil G. Sheps Center for Health Service Research, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Ramos
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Medicine Geriatrics, Duke University, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Mulugu V Brahmajothi
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, USA
| | - Thomasena S Moore
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Dan V Blalock
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Adelaide Gordon
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Belinda Ear
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - John W Williams
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Karen M Goldstein
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Aifah AA, Odubela O, Rakhra A, Onakomaiya D, Hu J, Nwaozuru U, Oladele DA, Odusola AO, Idigbe I, Musa AZ, Akere A, Tayo B, Ogedegbe G, Iwelunmor J, Ezechi O. Integration of a task strengthening strategy for hypertension management into HIV care in Nigeria: a cluster randomized controlled trial study protocol. Implement Sci 2021; 16:96. [PMID: 34789277 PMCID: PMC8597211 DOI: 10.1186/s13012-021-01167-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In regions with weak healthcare systems, critical shortages of the healthcare workforce, and increasing prevalence of dual disease burdens, there is an urgent need for the implementation of proven effective interventions and strategies to address these challenges. Our mixed-methods hybrid type II effectiveness-implementation study is designed to fill this evidence-to-practice gap. This study protocol describes a cluster randomized controlled trial which evaluates the effectiveness of an implementation strategy, practice facilitation (PF), on the integration, adoption, and sustainability of a task-strengthening strategy for hypertension control (TASSH) intervention within primary healthcare centers (PHCs) in Lagos State, Nigeria. DESIGN Guided by the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM), this study tests the impact of a proven effective implementation strategy to integrate hypertension management into the HIV care cascade, across 30 PHCs. The study will be conducted in three phases: (1) a pre-implementation phase that will use CFIR to develop a tailored PF intervention for integrating TASSH into HIV clinics; (2) an implementation phase that will use RE-AIM to compare the clinical effectiveness of PF vs. a self-directed condition (receipt of information on TASSH without PF) on BP reduction; and (3) a post-implementation phase that will use RE-AIM to evaluate the effect of PF vs. self-directed condition on adoption and sustainability of TASSH. The PF intervention components comprise (a) an advisory board to provide leadership support for implementing TASSH in PHCs; (b) training of the HIV nurses on TASSH protocol; and (c) training of practice facilitators, who will serve as coaches, provide support, and performance feedback to the HIV nurses. DISCUSSION This study is one of few, if any trials, to evaluate the impact of an implementation strategy for integrating hypertension management into HIV care, on clinical and implementation outcomes. Findings from this study will advance implementation science research on the effectiveness of tailoring an implementation strategy for the integration of an evidence-based, system-level hypertension control intervention into HIV care and treatment. TRIAL REGISTRATION ClinicalTrials.gov ( NCT04704336 ). Registered on 11 January 2021.
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Affiliation(s)
| | | | | | | | - Jiyuan Hu
- NYU Grossman School of Medicine, New York City, USA
| | | | | | | | - Ifeoma Idigbe
- Nigerian Institute of Medical Research, Lagos, Nigeria
| | | | | | - Bamidele Tayo
- Loyola University Parkinson School of Health Sciences and Public Health, Maywood, USA
| | - Gbenga Ogedegbe
- Institute for Excellence in Health Equity (IEHE), NYU Langone Health, New York City, USA.
| | | | - Oliver Ezechi
- Nigerian Institute of Medical Research, Lagos, Nigeria
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Lennox L, Barber S, Stillman N, Spitters S, Ward E, Marvin V, Reed JE. Conceptualising interventions to enhance spread in complex systems: a multisite comprehensive medication review case study. BMJ Qual Saf 2021; 31:31-44. [PMID: 33990462 PMCID: PMC8685660 DOI: 10.1136/bmjqs-2020-012367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 12/14/2022]
Abstract
Background Advancing the description and conceptualisation of interventions in complex systems is necessary to support spread, evaluation, attribution and reproducibility. Improvement teams can provide unique insight into how interventions are operationalised in practice. Capturing this ‘insider knowledge’ has the potential to enhance intervention descriptions. Objectives This exploratory study investigated the spread of a comprehensive medication review (CMR) intervention to (1) describe the work required from the improvement team perspective, (2) identify what stays the same and what changes between the different sites and why, and (3) critically appraise the ‘hard core’ and ‘soft periphery’ (HC/SP) construct as a way of conceptualising interventions. Design A prospective case study of a CMR initiative across five sites. Data collection included: observations, document analysis and semistructured interviews. A facilitated workshop triangulated findings and measured perceived effort invested in activities. A qualitative database was developed to conduct thematic analysis. Results Sites identified 16 intervention components. All were considered essential due to their interdependency. The function of components remained the same, but adaptations were made between and within sites. Components were categorised under four ‘spheres of operation’: Accessibility of evidence base; Process of enactment; Dependent processes and Dependent sociocultural issues. Participants reported most effort was invested on ‘dependent sociocultural issues’. None of the existing HC/SP definitions fit well with the empirical data, with inconsistent classifications of components as HC or SP. Conclusions This study advances the conceptualisation of interventions by explicitly considering how evidence-based practices are operationalised in complex systems. We propose a new conceptualisation of ‘interventions-in-systems’ which describes intervention components in relation to their: proximity to the evidence base; component interdependence; component function; component adaptation and effort.
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Affiliation(s)
- Laura Lennox
- Primary Care and Public Health, Imperial College London, London, UK.,NIHR ARC Northwest London, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Susan Barber
- Primary Care and Public Health, Imperial College London, London, UK.,NIHR ARC Northwest London, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Neil Stillman
- Primary Care and Public Health, Imperial College London, London, UK
| | - Sophie Spitters
- Primary Care and Public Health, Imperial College London, London, UK
| | - Emily Ward
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Vanessa Marvin
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Julie E Reed
- School of Health and Welfare, Halmstad University, Halmstad, Sweden .,Julie Reed Consultancy Ltd, London, UK
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Schoenthaler A, De La Calle F, Soto A, Barrett D, Cruz J, Payano L, Rosado M, Adhikari S, Ogedegbe G, Rosal M. Bridging the evidence-to-practice gap: a stepped-wedge cluster randomized controlled trial evaluating practice facilitation as a strategy to accelerate translation of a multi-level adherence intervention into safety net practices. Implement Sci Commun 2021; 2:21. [PMID: 33597041 PMCID: PMC7888171 DOI: 10.1186/s43058-021-00111-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/17/2021] [Indexed: 11/11/2022] Open
Abstract
Background Poor adherence to antihypertensive medications is a significant contributor to the racial gap in rates of blood pressure (BP) control among Latino adults, as compared to Black and White adults. While multi-level interventions (e.g., those aiming to influence practice, providers, and patients) have been efficacious in improving medication adherence in underserved patients with uncontrolled hypertension, the translation of these interventions into routine practice within “real world” safety-net primary care settings has been inadequate and slow. This study will fill this evidence-to-practice gap by evaluating the effectiveness of practice facilitation (PF) as a practical and tailored strategy for implementing Advancing Medication Adherence for Latinos with Hypertension through a Team-based Care Approach (ALTA), a multi-level approach to improving medication adherence and BP control in 10 safety-net practices in New York that serve Latino patients. Methods and design We will conduct this study in two phases: (1) a pre-implementation phase where we will refine the PF strategy, informed by the Consolidated Framework for Implementation Research, to facilitate the implementation of ALTA into routine care at the practices; and (2) an implementation phase during which we will evaluate, in a stepped-wedge cluster randomized controlled trial, the effect of the PF strategy on ALTA implementation fidelity (primary outcome), as well as on clinical outcomes (secondary outcomes) at 12 months. Implementation fidelity will be assessed using a mixed methods approach based on the five core dimensions outlined by Proctor’s Implementation Outcomes Framework. Clinical outcome measures include BP control (defined as BP< 130/80 mmHg) and medication adherence (assessed using the proportion of days covered via pharmacy records). Discussion The study protocol applies rigorous research methods to identify how implementation strategies such as PF may work to expedite the translation process for implementing evidence-based approaches into routine care at safety-net practices to improve health outcomes in Latino patients with hypertension, who suffer disproportionately from poor BP control. By examining the barriers and facilitators that affect implementation, this study will contribute knowledge that will increase the generalizability of its findings to other safety-net practices and guide effective scale-up across primary care practices nationally. Trial registration ClinicalTrials.gov NCT03713515, date of registration: October 19, 2018.
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Affiliation(s)
- Antoinette Schoenthaler
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA.
| | - Franzenith De La Calle
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Amanda Soto
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Derrel Barrett
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Jocelyn Cruz
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Leydi Payano
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Marina Rosado
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Samrachana Adhikari
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Gbenga Ogedegbe
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Milagros Rosal
- Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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10
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Dickinson WP, Nease DE, Rhyne RL, Knierim KE, Fernald DH, de la Cerda DR, Dickinson LM. Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care: From EvidenceNOW Southwest (ENSW). J Am Board Fam Med 2020; 33:675-686. [PMID: 32989062 PMCID: PMC7789932 DOI: 10.3122/jabfm.2020.05.190395] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/06/2020] [Accepted: 01/23/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To improve cardiovascular care through supporting primary care practices' adoption of evidence-based guidelines. STUDY DESIGN A cluster randomized trial compared two approaches: (1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions) and (2) standard support plus patient engagement support. METHODS Primary outcomes were cardiovascular clinical quality measures (CQMs) collected at baseline, 9 months, and 15 months. Implementation of the first 6 "Building Blocks of High-Performing Primary Care" was assessed by practice facilitators at baseline and 3, 6, and 9 months. CQMs from practices not involved in the study served as an external comparison. RESULTS A total of 211 practices completed baseline surveys. There were no differences by study arm (odds ratio [95% confidence interval]) for aspirin use (1.03 [0.99, 1.06]), blood pressure (0.98 [0.95, 1.01]), cholesterol (0.96 [0.92, 1.00]), and smoking (1.01 [0.96, 1.07]); however, there were significant improvements over time in aspirin use (1.04 [1.01, 1.07]), cholesterol (1.05 [1.03, 1.08]), and smoking (1.03 [1.01, 1.06]), but not blood pressure (1.01 [0.998, 1.03]). Improvement in enrolled practices was greater than external comparison practices across all 4 measures (all P < .05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all P < .05). Leadership and Data-Driven Improvement (P < .05) improved significantly, with no difference by arm. A greater improvement in Building Block implementation was associated with a greater improvement in blood pressure measures (P < .05). CONCLUSIONS Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices' implementation of aspects of new models of care.
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Affiliation(s)
- W Perry Dickinson
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (WPD, DEN, KEK, DHF, DRdlC, LMD); Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque (RLR).
| | - Donald E Nease
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (WPD, DEN, KEK, DHF, DRdlC, LMD); Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque (RLR)
| | - Robert L Rhyne
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (WPD, DEN, KEK, DHF, DRdlC, LMD); Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque (RLR)
| | - Kyle E Knierim
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (WPD, DEN, KEK, DHF, DRdlC, LMD); Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque (RLR)
| | - Douglas H Fernald
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (WPD, DEN, KEK, DHF, DRdlC, LMD); Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque (RLR)
| | - Dionisia R de la Cerda
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (WPD, DEN, KEK, DHF, DRdlC, LMD); Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque (RLR)
| | - L Miriam Dickinson
- From the Department of Family Medicine, University of Colorado School of Medicine, Aurora (WPD, DEN, KEK, DHF, DRdlC, LMD); Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque (RLR)
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11
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Weinberger SJ, Cowan KJ, Robinson KJ, Pellegrino CA, Frankowski BL, Chmielewski MV, Shaw JS, Harder VS. A primary care learning collaborative to improve office systems and clinical management of pediatric asthma. J Asthma 2019; 58:395-404. [PMID: 31838923 DOI: 10.1080/02770903.2019.1702199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled. METHODS The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven. RESULTS This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures. CONCLUSIONS A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.
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Affiliation(s)
- Stanley J Weinberger
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Primary Care, University of Vermont Children's Hospital, Burlington, VT, USA
| | - Kelly J Cowan
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Pulmonology, University of Vermont Children's Hospital, Burlington, VT, USA
| | - Keith J Robinson
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Pulmonology, University of Vermont Children's Hospital, Burlington, VT, USA
| | | | - Barbara L Frankowski
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Primary Care, University of Vermont Children's Hospital, Burlington, VT, USA
| | | | - Judith S Shaw
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Valerie S Harder
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
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12
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Moussa L, Garcia-Cardenas V, Benrimoj SI. Change Facilitation Strategies Used in the Implementation of Innovations in Healthcare Practice: A Systematic Review. JOURNAL OF CHANGE MANAGEMENT 2019. [DOI: 10.1080/14697017.2019.1602552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Lydia Moussa
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | | | - Shalom I. Benrimoj
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
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13
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Sustainability of a Care Pathway for Children and Adolescents with Autism Spectrum Disorder on an Inpatient Psychiatric Service. J Autism Dev Disord 2019; 49:3173-3180. [DOI: 10.1007/s10803-019-04029-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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A Cluster Randomized Trial Comparing Strategies for Translating Self-Management Support into Primary Care Practices. J Am Board Fam Med 2019; 32:341-352. [PMID: 31068398 PMCID: PMC6599532 DOI: 10.3122/jabfm.2019.03.180254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/13/2019] [Accepted: 02/15/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Self-management support (SMS) is a key factor in diabetes care, but true SMS has not been widely adopted by primary care practices. Interactive behavior-change technology (IBCT) can provide efficient methods for adoption of SMS in primary care. Practice facilitation has been effective in assisting practices in implementing complex evidence-based interventions, such as SMS. This study was designed to study the incremental impact of practice education, the Connection to Health (CTH) IBCT tool, and practice facilitation as approaches to enhance the translation of SMS for patients with diabetes in primary care practices. METHODS A cluster-randomized trial compared the effectiveness of 3 implementation strategies for enhancing SMS for patients with diabetes in 36 primary care practices: 1) SMS education (SMS-ED); 2) SMS-ED plus CTH availability (CTH); and 3) SMS-ED, CTH availability, plus brief practice facilitation (CTH + PF). Outcomes including hemoglobin A1c (HbA1c) levels and SMS activities were assessed at 18 months post study initiation in a random sample of patients through medical record reviews. RESULTS A total of 488 patients enrolled in the CTH system (141 CTH, 347 CTH + PF). In the intent-to-treat analysis of patients with medical record reviews, HbA1c slopes did not differ between study arms (CTH vs SMS-ED: P = .2243, CTH + PF vs SMS-ED: P = .8601). However, patients from practices in the CTH + PF arm who used CTH showed significantly improved HbA1c trajectories over time compared with patients from SMS-ED practices (P = .0422). SMS activities were significantly increased in CTH and CTH + PF study arms compared with SMS-ED (CTH vs SMS-ED: P = .0223, CTH + PF vs SMS-ED: P = .0013). The impact of CTH on SMS activities was a significant mediator of the impact of the CTH and CTH + PF interventions on HbA1c. CONCLUSION An interactive behavior change technology tool such as CTH can increase primary care practice SMS activities and improve patient HbA1c levels. Even brief practice facilitation assists practices in implementing SMS.
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15
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Lauria-Horner B, Beaulieu T, Knaak S, Weinerman R, Campbell H, Patten S. Controlled trial of the impact of a BC adult mental health practice support program (AMHPSP) on primary health care professionals' management of depression. BMC FAMILY PRACTICE 2018; 19:183. [PMID: 30486799 PMCID: PMC6262957 DOI: 10.1186/s12875-018-0862-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 11/05/2018] [Indexed: 01/15/2023]
Abstract
Background Depression affects over 400 million people globally. The majority are seen in primary care. Barriers in providing adequate care are not solely related to physicians’ knowledge/skills deficits, but also time constraints, lack of confidence/avoidance, which need to be addressed in mental health-care redesign. We hypothesized that family physician (FP) training in the Adult Mental Health Practice Support Program (AMHPSP) would lead to greater improvements in patient depressive symptom ratings (a priori primary outcome) compared to treatment as usual. Methods From October 2013 to May 2015, in a controlled trial 77 FP practices were stratified on the total number of physicians/practice as well as urban/rural setting, and randomized to the British Columbia AMHPSP⎯a multi-component contact-based training to enhance FPs’ comfort/skills in treating mild-moderate depression (intervention), or no training (control) by an investigator not operationally involved in the trial. FPs with a valid license to practice in NS were eligible. FPs from both groups were asked to identify 3–4 consecutive patients > 18 years old, diagnosis of depression, Patient Health Questionnaire (PHQ-9) score ≥ 10, able to read English, intact cognitive functioning. Exclusion criteria: antidepressants within 5 weeks and psychotherapy within 3 months of enrollment, and clinically judged urgent/emergent medical/psychiatric condition. Patients were assigned to the same arm as their physician. Thirty-six practices recruited patients (intervention n = 23; control n = 13). The study was prematurely terminated at 6 months of enrollment start-date due to concomitant primary health-care transformation by health-system leaders which resulted in increased in-office demands, and recruitment failure. We used the PHQ-9 to assess between-group differences at baseline, 1, 2, 3, and 6 months follow-up. Outcome collectors and assessors were blind to group assignment. Results One hundred-and-twenty-nine patients (intervention n = 72; control n = 57) were analysed. A significant improvement in depression scores among intervention group patients emerged between 3 and 6 months, time by treatment interaction, likelihood ratio test (LR) chi2(3) = 7.96, p = .047. Conclusions This novel skill-based program shows promise in translating increased FP comfort and skills managing depressed patients into improved patient clinical outcomes⎯even in absence of mental health specialists availability. Trial registration #NCT01975948. Electronic supplementary material The online version of this article (10.1186/s12875-018-0862-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Tara Beaulieu
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stephanie Knaak
- Opening Minds Anti-Stigma Initiative, Mental Health Commission of Canada, Ottawa, ON, Canada.,University of Calgary, Calgary, Alberta, Canada
| | - Rivian Weinerman
- University of Bristish Columbia, Medical Staff Honorary Status Island Health Authority, Victoria, Canada
| | - Helen Campbell
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
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16
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Wang A, Pollack T, Kadziel LA, Ross SM, McHugh M, Jordan N, Kho AN. Impact of Practice Facilitation in Primary Care on Chronic Disease Care Processes and Outcomes: a Systematic Review. J Gen Intern Med 2018; 33:1968-1977. [PMID: 30066117 PMCID: PMC6206351 DOI: 10.1007/s11606-018-4581-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/08/2018] [Accepted: 07/06/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND More than 100 million individuals in the USA have been diagnosed with a chronic disease, yet chronic disease care has remained fragmented and of inconsistent quality. Improving chronic disease management has been challenging for primary care and internal medicine practitioners. Practice facilitation provides a comprehensive approach to chronic disease care. The objective is to evaluate the impact of practice facilitation on chronic disease outcomes in the primary care setting. METHODS This systematic review examined North American studies from PubMed, EMBASE, and Web of Science (database inception to August 2017). Investigators independently extracted and assessed the quality of the data on chronic disease process and clinical outcome measures. Studies implemented practice facilitation and reported quantifiable care processes and patient outcomes for chronic disease. Each study and their evidence were assessed for risk of bias and quality according to the Cochrane Collaboration and the Grade Collaboration tool. RESULTS This systematic review included 25 studies: 12 randomized control trials and 13 prospective cohort studies. Across all studies, practices and their clinicians were aware of the implementation of practice facilitation. Improvements were observed in most studies for chronic diseases including asthma, cancer (breast, cervical, and colorectal), cardiovascular disease (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, myocardial infarction, and peripheral vascular disease), and type 2 diabetes. Mixed results were observed for chronic kidney disease and chronic illness care. DISCUSSION Overall, the results suggest that practice facilitation may improve chronic disease care measures. Across all studies, practices were aware of practice facilitation. These findings lend support for the potential expansion of practice facilitation in primary care. Future work will need to investigate potential opportunities for practice facilitation to improve chronic disease outcomes in other health care settings (e.g., specialty and multi-specialty practices) with standardized measures.
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Affiliation(s)
- Andrew Wang
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Teresa Pollack
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren A Kadziel
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Samuel M Ross
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Megan McHugh
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil Jordan
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Departments of Psychiatry & Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
| | - Abel N Kho
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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17
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Dickinson WP, Dickinson LM, Jortberg BT, Hessler DM, Fernald DH, Fisher L. A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices. BMC FAMILY PRACTICE 2018; 19:126. [PMID: 30041598 PMCID: PMC6058364 DOI: 10.1186/s12875-018-0810-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 06/27/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Advanced primary care models emphasize patient-centered care, including self-management support (SMS), but the effective use of SMS for patients with type 2 diabetes (T2DM) remains a challenge. Interactive behavior-change technology (IBCT) can facilitate the adoption of SMS interventions. To meet the need for effective SMS intervention, we have developed Connection to Health (CTH), a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients to resolve self-management problems and improve outcomes. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice facilitation has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH in diverse primary-care practices, and (b) evaluating the impact of practice facilitation to enhance implementation of the intervention. METHODS A three-arm, cluster-randomized trial will evaluate three discrete strategies for implementing SMS for patients with T2DM in diverse primary care practices. Practices will be randomly assigned to receive and implement the CTH program, the CTH program plus practice facilitation, or a SMS academic detailing educational intervention. Through this design, we will compare the effectiveness, adoption and implementation of these three SMS practice implementation strategies. Primary effectiveness outcomes including lab values and evidence of SMS will be abstracted from medical records covering baseline through 18 months post-baseline. Data from CTH assessments and action plans completed by patients enrolled in CTH will be used to evaluate practice implementation of CTH and the impact of CTH participation. Qualitative data including field notes from encounters with the practices and interviews of practice personnel will be analyzed to assess practice implementation of SMS. DISCUSSION This study will provide important information on the implementation of SMS in primary care, the effectiveness of an IBCT tool such as CTH, and the use of practice facilitation to assist implementation. TRIAL REGISTRATION Registered with ClinicalTrials.gov - ClinicalTrials.gov ID: NCT01945918 , date 08/27/2013. Modifications have been updated.
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Affiliation(s)
- W. Perry Dickinson
- Department of Family Medicine, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop F496, Aurora, CO 80045-0508 USA
| | - L. Miriam Dickinson
- Department of Family Medicine, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop F496, Aurora, CO 80045-0508 USA
| | - Bonnie T. Jortberg
- Department of Family Medicine, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop F496, Aurora, CO 80045-0508 USA
| | - Danielle M. Hessler
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Douglas H. Fernald
- Department of Family Medicine, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop F496, Aurora, CO 80045-0508 USA
| | - Lawrence Fisher
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA USA
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Abstract
Background Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models. Method A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries. Results The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals. Conclusion The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and promote their active involvement in co-design and implementation. Future research is needed to develop new chronic care models providing evidence-based and practical implications for the regional care setting.
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19
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Cardarelli R, Weatherford S, Schilling J, King D, Workman S, Rankin W, Hughes J, Piercy J, Conley-Sallaz A, Zook M, Unger K, White E, Astuto B, Stover B. Improving Chronic Pain Management Processes in Primary Care Using Practice Facilitation and Quality Improvement: The Central Appalachia Inter-Professional Pain Education Collaborative. J Patient Cent Res Rev 2017; 4:247-255. [PMID: 31413989 DOI: 10.17294/2330-0698.1457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Purpose With the increasing burden of chronic pain and opioid use, provider shortages in Eastern Kentucky and West Virginia have experienced many challenges related to chronic pain management. This study tested a practice facilitator model in both academic and community clinics that selected and implemented best practice processes to better assist patients with chronic pain and increase the use of interdisciplinary health care services. Methods Using a quasi-experimental design, a practice facilitator was assigned to each state's clinics and trained clinic teams in quality improvement methods to implement chronic pain tool(s) and workflow processes. Charts for 695 patients with chronic pain using opioids, from 8 randomly selected clinics in eastern Appalachia, were reviewed to assess for changes in clinic processes. Results Statistically significant improvements were found in 10 out of 16 chronic pain best practice process measures. These included improved workflow implementation (P<0.001), increased urine drug screen test orders (P=0.001) and increased utilization of controlled medication agreements (P=0.004). In total, 7 of 8 clinics significantly improved in at least one, if not all, selected and implemented process measures. Conclusions Our findings indicate that practice facilitation, standardization of workflows and formation of structured clinical teams can improve processes of care in chronic pain management and facilitate the use of interdisciplinary services. Future studies are needed to assess long-term patient-centered outcomes that may result from improved processes of chronic pain care.
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Affiliation(s)
- Roberto Cardarelli
- Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Sarah Weatherford
- Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Jennifer Schilling
- Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Dana King
- Department of Family Medicine, West Virginia University, Morgantown, WV
| | - Sue Workman
- Department of Family Medicine, West Virginia University, Morgantown, WV
| | - Wade Rankin
- Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Juanita Hughes
- East Kentucky Family Medicine Residency Program, University of Kentucky June Buchanan Medical Clinic, Hindman, KY
| | - Jonathan Piercy
- East Kentucky Family Residency Program, University of Kentucky North Fork Valley Community Health Center, Hazard, KY
| | - Amy Conley-Sallaz
- University of Kentucky Family Medicine Rural Track Residency Program, St. Claire Regional Medical Center, Morehead, KY
| | | | - Kendra Unger
- Department of Family Medicine, West Virginia University, Morgantown, WV
| | - Emma White
- Roane County Family Health Care, Spencer, WV
| | - Barbara Astuto
- North Fayette Family Health Clinic, New River Health Association, Fayetteville, WV
| | - Bobbi Stover
- North Fayette Family Health Clinic, New River Health Association, Fayetteville, WV
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Development and evaluation of a training workshop for lay health promoters to implement a community-based intervention program in a public low rent housing estate: The Learning Families Project in Hong Kong. PLoS One 2017; 12:e0183636. [PMID: 28841677 PMCID: PMC5571957 DOI: 10.1371/journal.pone.0183636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 06/27/2017] [Indexed: 12/03/2022] Open
Abstract
This paper presents the development and evaluation of the train-the-trainer (TTT) workshop for lay resident leaders to be lay health promoters. The TTT workshop aimed to prepare the trainees to implement and/or assist in conducting a series of community-based family well-being activities for the residents in a public low rent housing estate, entitled “Learning Families Project”, under the FAMILY project. The four-hour TTT workshop was conducted for 32 trainees (72% women, 43% aged ≥ 60, 41% ≤ elementary school education). The workshop aimed to promote trainees’ knowledge, self-efficacy, attitude and practice of incorporating the positive psychology themes into their community activities and engaging the residents to join these activities and learn with their family members. Post-training support was provided. The effectiveness of the TTT was examined by self-administered questionnaires about trainees’ reactions to training content, changes in learning and practice at three time points (baseline, and immediately and one year after training), and the difference in residents’ survey results before and after participating in the community activities delivered by the trainees. The trainees’ learning about the general concepts of family well-being, learning family, leadership skills and planning skills increased significantly with medium to large effect sizes (Cohen’s d: 0.5–1.4) immediately after the training. The effects of perceived knowledge and attitude towards practice were sustained to one year (Cohen’s d: 0.4–0.6). The application of planning skills to implement community activities was higher at one year (Cohen’s d: 0.4), compared with baseline. At one year, the residents’ survey results showed significant increases in the practice of positive communication behaviours and better neighbour cohesions after joining the family well-being activities of LFP. Qualitative feedback supported the quantitative results. Our TTT workshop could serve as a practical example of development and evaluation of training programs for lay personnel to be lay health promoters. Trial registration: ClinicalTrials.gov NCT02844244
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Davis MM, Howk S, Spurlock M, McGinnis PB, Cohen DJ, Fagnan LJ. A qualitative study of clinic and community member perspectives on intervention toolkits: "Unless the toolkit is used it won't help solve the problem". BMC Health Serv Res 2017; 17:497. [PMID: 28720092 PMCID: PMC5516321 DOI: 10.1186/s12913-017-2413-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 06/28/2017] [Indexed: 11/21/2022] Open
Abstract
Background Intervention toolkits are common products of grant-funded research in public health and primary care settings. Toolkits are designed to address the knowledge translation gap by speeding implementation and dissemination of research into practice. However, few studies describe characteristics of effective intervention toolkits and their implementation. Therefore, we conducted this study to explore what clinic and community-based users want in intervention toolkits and to identify the factors that support application in practice. Methods In this qualitative descriptive study we conducted focus groups and interviews with a purposive sample of community health coalition members, public health experts, and primary care professionals between November 2010 and January 2012. The transdisciplinary research team used thematic analysis to identify themes and a cross-case comparative analysis to explore variation by participant role and toolkit experience. Results Ninety six participants representing primary care (n = 54, 56%) and community settings (n = 42, 44%) participated in 18 sessions (13 focus groups, five key informant interviews). Participants ranged from those naïve through expert in toolkit development; many reported limited application of toolkits in actual practice. Participants wanted toolkits targeted at the right audience and demonstrated to be effective. Well organized toolkits, often with a quick start guide, with tools that were easy to tailor and apply were desired. Irrespective of perceived quality, participants experienced with practice change emphasized that leadership, staff buy-in, and facilitative support was essential for intervention toolkits to be translated into changes in clinic or public -health practice. Conclusions Given the emphasis on toolkits in supporting implementation and dissemination of research and clinical guidelines, studies are warranted to determine when and how toolkits are used. Funders, policy makers, researchers, and leaders in primary care and public health are encouraged to allocate resources to foster both toolkit development and implementation. Support, through practice facilitation and organizational leadership, are critical for translating knowledge from intervention toolkits into practice.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-based Research Network (ORPRN), School of Medicine (Department of Family Medicine), School of Public Health, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Road Mailcode: FM, Portland, OR, 97239, USA.
| | - Sonya Howk
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode: L222, Portland, OR, 97239, USA
| | - Margaret Spurlock
- Multnomah County School-Based Health Center Program, Oregon, Portland, USA
| | - Paul B McGinnis
- Greater Oregon Behavioral Health Inc, 309 East 2nd Street, The Dalles, OR, 97058, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Road Mailcode: FM, Portland, OR, 97239, USA
| | - Lyle J Fagnan
- Oregon Rural Practice-based Research Network, Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode: L222, Portland, OR, 97239, USA
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O'Connor PJ, Sperl-Hillen JM, Fazio CJ, Averbeck BM, Rank BH, Margolis KL. Outpatient diabetes clinical decision support: current status and future directions. Diabet Med 2016; 33:734-41. [PMID: 27194173 PMCID: PMC5642968 DOI: 10.1111/dme.13090] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 12/13/2022]
Abstract
Outpatient clinical decision support systems have had an inconsistent impact on key aspects of diabetes care. A principal barrier to success has been low use rates in many settings. Here, we identify key aspects of clinical decision support system design, content and implementation that are related to sustained high use rates and positive impacts on glucose, blood pressure and lipid management. Current diabetes clinical decision support systems may be improved by prioritizing care recommendations, improving communication of treatment-relevant information to patients, using such systems for care coordination and case management and integrating patient-reported information and data from remote devices into clinical decision algorithms and interfaces.
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Affiliation(s)
- P J O'Connor
- Center for Chronic Care Innovation, Minneapolis, MN, USA
- HealthPartners Institute, Minneapolis, MN, USA
| | - J M Sperl-Hillen
- Center for Chronic Care Innovation, Minneapolis, MN, USA
- HealthPartners Institute, Minneapolis, MN, USA
| | - C J Fazio
- HealthPartners, Minneapolis, MN, USA
| | | | - B H Rank
- HealthPartners, Minneapolis, MN, USA
| | - K L Margolis
- Center for Chronic Care Innovation, Minneapolis, MN, USA
- HealthPartners Institute, Minneapolis, MN, USA
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Sen A, Sinha AP. An ontological model of the practice transformation process. J Biomed Inform 2016; 61:298-318. [PMID: 27178475 DOI: 10.1016/j.jbi.2016.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 05/06/2016] [Accepted: 05/07/2016] [Indexed: 11/25/2022]
Abstract
Patient-centered medical home is defined as an approach for providing comprehensive primary care that facilitates partnerships between individual patients and their personal providers. The current state of the practice transformation process is ad hoc and no methodological basis exists for transforming a practice into a patient-centered medical home. Practices and hospitals somehow accomplish the transformation and send the transformation information to a certification agency, such as the National Committee for Quality Assurance, completely ignoring the development and maintenance of the processes that keep the medical home concept alive. Many recent studies point out that such a transformation is hard as it requires an ambitious whole-practice reengineering and redesign. As a result, the practices suffer change fatigue in getting the transformation done. In this paper, we focus on the complexities of the practice transformation process and present a robust ontological model for practice transformation. The objective of the model is to create an understanding of the practice transformation process in terms of key process areas and their activities. We describe how our ontology captures the knowledge of the practice transformation process, elicited from domain experts, and also discuss how, in the future, that knowledge could be diffused across stakeholders in a healthcare organization. Our research is the first effort in practice transformation process modeling. To build an ontological model for practice transformation, we adopt the Methontology approach. Based on the literature, we first identify the key process areas essential for a practice transformation process to achieve certification status. Next, we develop the practice transformation ontology by creating key activities and precedence relationships among the key process areas using process maturity concepts. At each step, we employ a panel of domain experts to verify the intermediate representations of the ontology. Finally, we implement a prototype of the practice transformation ontology using Protégé.
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Affiliation(s)
- Arun Sen
- Department of Information and Operations Management - Mays Business School, Texas A&M University and Texas A&M Regional Extension Center in RCHI-Texas A&M Health Sciences Center, College Station, TX 77843, USA.
| | - Atish P Sinha
- Lubar School of Business, University of Wisconsin-Milwaukee, Milwaukee, WI 53201-0742, USA.
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Thompson DS, Fazio X, Kustra E, Patrick L, Stanley D. Scoping review of complexity theory in health services research. BMC Health Serv Res 2016; 16:87. [PMID: 26968157 PMCID: PMC4788824 DOI: 10.1186/s12913-016-1343-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/09/2016] [Indexed: 11/17/2022] Open
Abstract
Background There are calls for better application of theory in health services research. Research exploring knowledge translation and interprofessional collaboration are two examples, and in both areas, complexity theory has been identified as potentially useful. However, how best to conceptualize and operationalize complexity theory in health services research is uncertain. The purpose of this scoping review was to explore how complexity theory has been incorporated in health services research focused on allied health, medicine, and nursing in order to offer guidance for future application. Given the extensiveness of how complexity theory could be conceptualized and ultimately operationalized within health services research, a scoping review of complexity theory in health services research is warranted. Methods A scoping review of published research in English was conducted using CINAHL, EMBASE, Medline, Cochrane, and Web of Science databases. We searched terms synonymous with complexity theory. Results We included 44 studies in this review: 27 were qualitative, 14 were quantitative, and 3 were mixed methods. Case study was the most common method. Long-term care was the most studied setting. The majority of research was exploratory and focused on relationships between health care workers. Authors most commonly used complexity theory as a conceptual framework for their study. Authors described complexity theory in their research in a variety of ways. The most common attributes of complexity theory used in health services research included relationships, self-organization, and diversity. A common theme across descriptions of complexity theory is that authors incorporate aspects of the theory related to how diverse relationships and communication between individuals in a system can influence change. Conclusion Complexity theory is incorporated in many ways across a variety of research designs to explore a multitude of phenomena.. Although complexity theory shows promise in health services research, particularly related to relationships and interactions, conceptual confusion and inconsistent application hinders the operationalization of this potentially important perspective. Generalizability from studies that incorporate complexity theory is, therefore, difficult. Heterogeneous conceptualization and operationalization of complexity theory in health services research suggests there is no universally agreed upon approach of how to use this theory in health services research. Future research should include clear definitions and descriptions of complexity and how it was used in studies. Clear reporting will aid in determining how best to use complexity theory in health services research.
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Affiliation(s)
- David S Thompson
- School of Nursing, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada.
| | - Xavier Fazio
- Faculty of Education, Brock University, 500 Glenridge Avenue, St. Catharines, ON, L2S 3A1, Canada
| | - Erika Kustra
- Teaching and Learning Development, University of Windsor, 401 Sunset Avenue, Windsor, ON, N9B 3P4, Canada
| | - Linda Patrick
- Faculty of Nursing, University of Windsor, 401 Sunset Avenue, Windsor, ON, N9B 3P4, Canada
| | - Darren Stanley
- Faculty of Education, University of Windsor, 401 Sunset, Avenue, Windsor, ON, N9B 3P4, Canada
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Lai AY, Mui MW, Wan A, Stewart SM, Yew C, Lam TH, Chan SS. Development and Two-Year Follow-Up Evaluation of a Training Workshop for the Large Preventive Positive Psychology Happy Family Kitchen Project in Hong Kong. PLoS One 2016; 11:e0147712. [PMID: 26808541 PMCID: PMC4726595 DOI: 10.1371/journal.pone.0147712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 01/07/2016] [Indexed: 11/18/2022] Open
Abstract
Evidence-based practice and capacity-building approaches are essential for large-scale health promotion interventions. However, there are few models in the literature to guide and evaluate training of social service workers in community settings. This paper presents the development and evaluation of the “train-the-trainer” workshop (TTT) for the first large scale, community-based, family intervention projects, entitled “Happy Family Kitchen Project” (HFK) under the FAMILY project, a Hong Kong Jockey Club Initiative for a Harmonious Society. The workshop aimed to enhance social workers’ competence and performance in applying positive psychology constructs in their family interventions under HFK to improve family well-being of the community they served. The two-day TTT was developed and implemented by a multidisciplinary team in partnership with community agencies to 50 social workers (64% women). It focused on the enhancement of knowledge, attitude, and practice of five specific positive psychology themes, which were the basis for the subsequent development of the 23 family interventions for 1419 participants. Acceptability and applicability were enhanced by completing a needs assessment prior to the training. The TTT was evaluated by trainees’ reactions to the training content and design, changes in learners (trainees) and benefits to the service organizations. Focus group interviews to evaluate the workshop at three months after the training, and questionnaire survey at pre-training, immediately after, six months, one year and two years after training were conducted. There were statistically significant increases with large to moderate effect size in perceived knowledge, self-efficacy and practice after training, which sustained to 2-year follow-up. Furthermore, there were statistically significant improvements in family communication and well-being of the participants in the HFK interventions they implemented after training. This paper offers a practical example of development, implementation and model-based evaluation of training programs, which may be helpful to others seeking to develop such programs in diverse communities.
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Affiliation(s)
- Agnes Y. Lai
- School of Public Health, The University of Hong Kong, Hong Kong, SAR, China
| | - Moses W. Mui
- The Hong Kong Council of Social Service, Hong Kong, SAR, China
| | - Alice Wan
- School of Public Health, The University of Hong Kong, Hong Kong, SAR, China
| | - Sunita M. Stewart
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, United States of America
| | - Carol Yew
- United Centre of Emotional Health and Positive Living, United Christian Nethersole Community Health Service, Hong Kong, SAR, China
| | - Tai-hing Lam
- School of Public Health, The University of Hong Kong, Hong Kong, SAR, China
- * E-mail:
| | - Sophia S. Chan
- School of Nursing, The University of Hong Kong, Hong Kong, SAR, China
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Nowalk MP, Zimmerman RK, Lin CJ, Reis EC, Huang HH, Moehling KK, Hannibal KM, Matambanadzo A, Shenouda EM, Allred NJ. Maintenance of Increased Childhood Influenza Vaccination Rates 1 Year After an Intervention in Primary Care Practices. Acad Pediatr 2016; 16:57-63. [PMID: 26767508 PMCID: PMC8311666 DOI: 10.1016/j.acap.2015.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Influenza vaccination rates among some groups of children remain below the Healthy People 2020 goal of 70%. Multistrategy interventions to increase childhood influenza vaccination have not been evaluated recently. METHODS Twenty pediatric and family medicine practices were randomly assigned to receive the intervention in either year 1 or year 2. This study focuses on influenza vaccine uptake in the 10 year 1 intervention sites during intervention and the following maintenance year. The intervention included the 4 Pillars Immunization Toolkit-a practice improvement toolkit, early delivery of donated vaccine for disadvantaged children, staff education, and feedback on progress. During the maintenance year, practices were not assisted or contacted, except to complete follow-up surveys. Student's t tests assessed vaccine uptake of children aged 6 months to 18 years, and multilevel regression modeling in repeated measures determined variables related to the likelihood of vaccination. RESULTS Influenza vaccine uptake increased 12.4 percentage points (PP; P < .01) during active intervention and uptake was sustained (+0.4 PP; P > .05) during maintenance, for an average change of 12.7 PP over all sites, increasing from 42.2% at baseline to 54.9% (P < .001) during maintenance. In regression modeling that controlled for age, race, and insurance, likelihood of vaccination was greater during intervention than baseline (odds ratio 1.47; 95% confidence interval 1.44-1.50; P < .001) and greater during maintenance than baseline (odds ratio 1.50; 95% confidence interval 1.47-1.54; P < .001). CONCLUSIONS In primary care practices, a multistrategy intervention that included the 4 Pillars Immunization Toolkit, early delivery of vaccine, and feedback was associated with significant improvements in childhood influenza vaccination rates that were maintained 1 year after active intervention.
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Affiliation(s)
- Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
| | - Richard K. Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Chyongchiou Jeng Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Evelyn Cohen Reis
- Department of Pediatrics, University of Pittsburgh School of Medicine, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Hsin-Hui Huang
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Krissy K. Moehling
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Kristin M. Hannibal
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Annamore Matambanadzo
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | | | - Norma J. Allred
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
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Kim BKE, Oesterle S, Hawkins JD, Shapiro VB. Assessing Sustained Effects of Communities That Care on Youth Protective Factors. JOURNAL OF THE SOCIETY FOR SOCIAL WORK AND RESEARCH 2015; 6:565-589. [PMID: 26951879 PMCID: PMC4778969 DOI: 10.1086/684163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE The Communities That Care (CTC) prevention system seeks to build community capacity for a science-based approach to the promotion of healthy youth development. Prior research shows the positive effects of CTC on youth protective factors during CTC implementation. This research tests sustained effects of CTC on youth protective factors 1 year after external support to communities for CTC implementation ended. METHOD Data come from a community-randomized trial of CTC in 24 communities across 7 states. A panel of 4,407 youth in CTC and control communities was surveyed annually from Grade 5 through Grade 10. Youth reported their exposure to protective factors identified in the social development model. Global test statistics are calculated to examine effects of CTC across 15 protective factors in 5 domains (community, school, family, peer, and individual) assessed in Grade 10, 1 year after study support for CTC implementation ended. Analyses also examine variation in sustained effects by gender and baseline risk levels. RESULTS Global effects of CTC on protective factors across all domains are not sustained in Grade 10. However, sustained domain-specific effects are observed in the individual domain for males, in the peer domain for females, and in the individual domain for youth with low-to-medium risk at baseline. CONCLUSIONS Greater emphasis on strengthening protective factors during high school might be needed to sustain broad effects of CTC on protective factors observed during middle school.
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Affiliation(s)
- B K Elizabeth Kim
- Center for Prevention Research in Social Welfare at the University of California, Berkeley
| | | | - J David Hawkins
- Social Work Endowed Professor of Prevention in the School of Social Work, University of Washington
| | - Valerie B Shapiro
- School of Social Welfare, University of California, Berkeley, and serves as an analyst for the Social Development Research Group as well as the Devereux Center for Resilient Children
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Sustainability of an Integrated Adventure-Based Training and Health Education Program to Enhance Quality of Life Among Chinese Childhood Cancer Survivors. Cancer Nurs 2015; 38:366-74. [DOI: 10.1097/ncc.0000000000000211] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Knowledge, attitudes, and practice patterns of recurrent urinary stones prevention in Saudi Arabia. Urolithiasis 2015; 44:135-43. [PMID: 26296383 DOI: 10.1007/s00240-015-0815-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Abstract
The purpose of this study is to assess the knowledge, attitudes, and practice patterns of urologists in Saudi Arabia regarding prevention of recurrent stone formation and how much they follow preventive stone disease management guidelines. A questionnaire about knowledge, attitudes, and practice patterns of urologists in Saudi Arabia regarding prevention of recurrent stone formation was used. The survey comprised three domains: knowledge, attitudes, and practice patterns. Data about gender, duration of experience and health care sector were also collected. Individual responses were recorded, tabulated and compared using descriptive statistics. The overall response rate was 38.8%. All respondents were male urologists. Most of them (62, 71.3%) had an experience of 5-20 years in management of stone disease patients and the majority (74, 85.1%) belonged to the governmental health care sector. A total of 51% of the respondents answered in concordance with the best practice guidelines in at least half of the questions and 40% in all of the questions. Overall, practice patterns of 58% of the respondents were in concordance with the best practice guidelines in all the questions except for the question of practices regarding stone analysis. As regards to attitude domain, a total of 58.7% respondents expressed their agreement or strong agreement with the questions. Urologists' knowledge of stone recurrence preventive programs is suboptimal. They do not apply effectively the best stone prevention practice guidelines in their daily practice as well. Efforts to increase knowledge and enforce its application in daily practice are strongly warranted.
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Kent EE, Mitchell SA, Castro KM, DeWalt DA, Kaluzny AD, Hautala JA, Grad O, Ballard RM, McCaskill-Stevens WJ, Kramer BS, Clauser SB. Cancer Care Delivery Research: Building the Evidence Base to Support Practice Change in Community Oncology. J Clin Oncol 2015; 33:2705-11. [PMID: 26195715 PMCID: PMC4559611 DOI: 10.1200/jco.2014.60.6210] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Understanding how health care system structures, processes, and available resources facilitate and/or hinder the delivery of quality cancer care is imperative, especially given the rapidly changing health care landscape. The emerging field of cancer care delivery research (CCDR) focuses on how organizational structures and processes, care delivery models, financing and reimbursement, health technologies, and health care provider and patient knowledge, attitudes, and behaviors influence cancer care quality, cost, and access and ultimately the health outcomes and well-being of patients and survivors. In this article, we describe attributes of CCDR, present examples of studies that illustrate those attributes, and discuss the potential impact of CCDR in addressing disparities in care. We conclude by emphasizing the need for collaborative research that links academic and community-based settings and serves simultaneously to accelerate the translation of CCDR results into practice. The National Cancer Institute recently launched its Community Oncology Research Program, which includes a focus on this area of research.
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Affiliation(s)
- Erin E Kent
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Sandra A Mitchell
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA.
| | - Kathleen M Castro
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Darren A DeWalt
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Arnold D Kaluzny
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Judith A Hautala
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Oren Grad
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Rachel M Ballard
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Worta J McCaskill-Stevens
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Barnett S Kramer
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
| | - Steven B Clauser
- Erin E. Kent, Sandra A. Mitchell, Kathleen M. Castro, Worta J. McCaskill-Stevens, Barnett S. Kramer, and Steven B. Clauser, National Cancer Institute, National Institutes of Health (NIH); Rachel M. Ballard, NIH Office of Disease Prevention, Bethesda, MD; Darren A. DeWalt and Arnold D. Kaluzny, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Judith A. Hautala and Oren Grad, Institute for Defense Analyses Science and Technology Policy Institute, Alexandria, VA
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Proctor E, Luke D, Calhoun A, McMillen C, Brownson R, McCrary S, Padek M. Sustainability of evidence-based healthcare: research agenda, methodological advances, and infrastructure support. Implement Sci 2015; 10:88. [PMID: 26062907 PMCID: PMC4494699 DOI: 10.1186/s13012-015-0274-5] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 05/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about how well or under what conditions health innovations are sustained and their gains maintained once they are put into practice. Implementation science typically focuses on uptake by early adopters of one healthcare innovation at a time. The later-stage challenges of scaling up and sustaining evidence-supported interventions receive too little attention. This project identifies the challenges associated with sustainability research and generates recommendations for accelerating and strengthening this work. METHODS A multi-method, multi-stage approach, was used: (1) identifying and recruiting experts in sustainability as participants, (2) conducting research on sustainability using concept mapping, (3) action planning during an intensive working conference of sustainability experts to expand the concept mapping quantitative results, and (4) consolidating results into a set of recommendations for research, methodological advances, and infrastructure building to advance understanding of sustainability. Participants comprised researchers, funders, and leaders in health, mental health, and public health with shared interest in the sustainability of evidence-based health care. RESULTS Prompted to identify important issues for sustainability research, participants generated 91 distinct statements, for which a concept mapping process produced 11 conceptually distinct clusters. During the conference, participants built upon the concept mapping clusters to generate recommendations for sustainability research. The recommendations fell into three domains: (1) pursue high priority research questions as a unified agenda on sustainability; (2) advance methods for sustainability research; (3) advance infrastructure to support sustainability research. CONCLUSIONS Implementation science needs to pursue later-stage translation research questions required for population impact. Priorities include conceptual consistency and operational clarity for measuring sustainability, developing evidence about the value of sustaining interventions over time, identifying correlates of sustainability along with strategies for sustaining evidence-supported interventions, advancing the theoretical base and research designs for sustainability research, and advancing the workforce capacity, research culture, and funding mechanisms for this important work.
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Affiliation(s)
- Enola Proctor
- George Warren Brown School of Social Work, Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO, USA.
| | - Douglas Luke
- George Warren Brown School of Social Work, Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO, USA.
| | | | - Curtis McMillen
- School of Social Service Administration, The University of Chicago, 969 E. 60th Street, Chicago, IL, USA.
| | - Ross Brownson
- George Warren Brown School of Social Work, Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO, USA.
| | - Stacey McCrary
- George Warren Brown School of Social Work, Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO, USA.
| | - Margaret Padek
- George Warren Brown School of Social Work, Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO, USA.
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Baker R, Camosso‐Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki‐Cwirko M, van Lieshout J, Jäger C. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev 2015; 2015:CD005470. [PMID: 25923419 PMCID: PMC7271646 DOI: 10.1002/14651858.cd005470.pub3] [Citation(s) in RCA: 326] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants. OBJECTIVES To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants. SEARCH METHODS We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals. SELECTION CRITERIA Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified. MAIN RESULTS We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression. AUTHORS' CONCLUSIONS Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.
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Affiliation(s)
- Richard Baker
- University of LeicesterDepartment of Health Sciences22‐28 Princess Rd WestLeicesterLeicestershireUKLE1 6TP
| | | | - Clare Gillies
- University of LeicesterUniversity Division of Medicine for the ElderlyThe Glenfield HospitalGroby RoadLeicesterUKLE5 4PW
| | - Elizabeth J Shaw
- National Institute for Health and Care Excellence (NICE)Level 1A, City PlazaPiccadilly PlazaManchesterUKM1 4BD
| | - Francine Cheater
- School of Health Sciences, University of East AngliaEdith Cavell BuildingNorwichNorfolkUK
| | - Signe Flottorp
- Norwegian Knowledge Centre for the Health ServicesBox 7004, St. Olavs plassOsloNorway0130
| | - Noelle Robertson
- Leicester UniversitySchool of Psychology (Clinical Section)104 Regent RoadLeicesterLeicestershireUKLE1 7LT
| | - Michel Wensing
- Radboud University Medical CenterRadboud Institute for Health SciencesPO Box 9101117 KWAZONijmegenNetherlands6500 HB
| | | | - Martin P Eccles
- Newcastle UniversityInstitute of Health and SocietyBadiley Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Maciek Godycki‐Cwirko
- Medical University of LodzCentre for Family and Community MedicineKopcindkiego 20LodzPoland90‐153
| | - Jan van Lieshout
- Radboud University Medical CenterScientific Institute for Quality of HealthcareP.O.Box 9101NijmegenNetherlands6500 HB
| | - Cornelia Jäger
- University Hospital of HeidelbergDepartment of General Practice and Health Services ResearchVoßstr. 2, Geb. 37HeidelbergGermany69115
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Bos D, Abara E, Parmar MS. Knowledge, attitudes, and practice patterns among healthcare providers in the prevention of recurrent kidney stones in Northern Ontario. Can Urol Assoc J 2014; 8:E795-804. [PMID: 25485006 DOI: 10.5489/cuaj.1455] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTON Kidney stone recurrence is common. Preventive measures can lead to improved quality of life and costs savings to the individual and healthcare system. Guidelines to prevent recurrent kidney stones are published by various urological societies. Adherence to guidelines amongst healthcare professionals in general is poor, while adherence to preventive management guidelines regarding stone disease is unknown. To understand this issue, we conducted an online study to assess the knowledge, attitudes, and practice patterns of healthcare practitioners in Northern Ontario. METHODS We used the database of healthcare providers affiliated with the Northern Ontario School of Medicine, in Sudbury (East Campus) and Thunder Bay (West Campus), Ontario. We designed the survey based on current best practice guidelines for the management of recurrent kidney stones. Questions covered 3 domains: knowledge, attitudes, and practice patterns. Demographic data were also collected. The survey was distributed electronically to all participants. RESULTS A total of 68 healthcare providers completed the survey. Of these, most were primary care physicians (72%). To keep uniformity, we analyzed the data of this homogenous group. A total of 70% of the respondents were aware of the current guidelines; however, only 43% applied their knowledge in clinical practice. Most participants lacked confidence while answering most items in the attitude domain. CONCLUSIONS Most primary care physician respondents were aware of the appropriate preventive measures for recurrent kidney stones; however, they do not appear to apply this knowledge effectively in clinical practice. A low response rate is a limitation of our study. Further studies involving a larger sample size may lead to information sharing and collaborative care among healthcare providers.
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Affiliation(s)
- Derek Bos
- Division of Urology, McMaster University, Hamilton, ON
| | - Emmanuel Abara
- Clinical Sciences Division, Northern Ontario School of Medicine, Sudbury, ON; and the Richmond Hill Urology Practice and Prostate Institute, Richmond Hill, ON
| | - Malvinder S Parmar
- Clinical Sciences Division, Northern Ontario School of Medicine, Sudbury, ON; and the Department of Medicine, Timmins and District Hospital, Timmins, ON
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Leykum LK, Lanham HJ, Pugh JA, Parchman M, Anderson RA, Crabtree BF, Nutting PA, Miller WL, Stange KC, McDaniel RR. Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science. Implement Sci 2014; 9:165. [PMID: 25407138 PMCID: PMC4239371 DOI: 10.1186/s13012-014-0165-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/27/2014] [Indexed: 12/02/2022] Open
Abstract
Background The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory. Methods We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results. Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease. Results We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion). Conclusions Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0165-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luci K Leykum
- South Texas Veterans Health Care System, San Antonio, TX, USA.
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Kilbourne AM, Almirall D, Eisenberg D, Waxmonsky J, Goodrich DE, Fortney JC, Kirchner JE, Solberg LI, Main D, Bauer MS, Kyle J, Murphy SA, Nord KM, Thomas MR. Protocol: Adaptive Implementation of Effective Programs Trial (ADEPT): cluster randomized SMART trial comparing a standard versus enhanced implementation strategy to improve outcomes of a mood disorders program. Implement Sci 2014; 9:132. [PMID: 25267385 PMCID: PMC4189548 DOI: 10.1186/s13012-014-0132-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/19/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months. METHODS/DESIGN This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as < 50% patients receiving ≥ 3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change. DISCUSSION This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02151331.
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Affiliation(s)
- Amy M Kilbourne
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Daniel Almirall
- />Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, 48104-2321 MI USA
| | - Daniel Eisenberg
- />Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, 48109-2029 MI USA
| | - Jeanette Waxmonsky
- />Colorado Access, 10065 E. Harvard Ave, Suite 600, Denver, 80231 CO USA
- />Department of Psychiatry, University of Colorado School of Medicine, 13199 East Montview Blvd, Mailstop F550, Suite 330, Aurora, 80045 CO USA
| | - David E Goodrich
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - John C Fortney
- />Seattle HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, 98108 WA USA
| | - JoAnn E Kirchner
- />VA Mental Health Quality Enhancement Research Initiative (MH QUERI), North Little Rock, 27114 AR USA
- />Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham, Little Rock, 72205 AR USA
| | - Leif I Solberg
- />HealthPartners Institute for Education and Research, 3311 E. Old Shakopee Road, Bloomington, 55425 MN USA
| | - Deborah Main
- />Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, 80217 CO USA
| | - Mark S Bauer
- />VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Bldg 9, Jamaica Plain Campus, 150 South Huntington Ave (152 M), Boston, 02130 MA USA
| | - Julia Kyle
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Susan A Murphy
- />Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, 48104-2321 MI USA
| | - Kristina M Nord
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Marshall R Thomas
- />Colorado Access, 10065 E. Harvard Ave, Suite 600, Denver, 80231 CO USA
- />Department of Psychiatry, University of Colorado School of Medicine, 13199 East Montview Blvd, Mailstop F550, Suite 330, Aurora, 80045 CO USA
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Meropol SB, Schiltz NK, Sattar A, Stange KC, Nevar AH, Davey C, Ferretti GA, Howell DE, Strosaker R, Vavrek P, Bader S, Ruhe MC, Cuttler L. Practice-tailored facilitation to improve pediatric preventive care delivery: a randomized trial. Pediatrics 2014; 133:e1664-75. [PMID: 24799539 PMCID: PMC4035588 DOI: 10.1542/peds.2013-1578] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services. METHODS In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods. RESULTS Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need. CONCLUSIONS Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.
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Affiliation(s)
- Sharon B. Meropol
- Departments of Pediatrics,,Epidemiology and Biostatistics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Nicholas K. Schiltz
- Epidemiology and Biostatistics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Kurt C. Stange
- Epidemiology and Biostatistics,,Family Medicine and Community Health,,Oncology,,Sociology
| | - Ann H. Nevar
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Christina Davey
- Departments of Pediatrics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Diana E. Howell
- Departments of Pediatrics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Pamela Vavrek
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Samantha Bader
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Leona Cuttler
- Departments of Pediatrics,,Bioethics, Case Western Reserve University, Cleveland, Ohio; and,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Abstract
Researchers, funders, and managers of health programs and interventions have become concerned about their long-term sustainability. However, most research about sustainability has not considered the nature of the program to be sustained. Health-related interventions may differ in their likelihood of sustainability and in the factors likely to influence continuation. I suggest a framework for analyzing the sustainability of 6 types of interventions: (1) those implemented by individual providers; (2) programs requiring coordination among multiple staff; (3) new policies, procedures, or technologies; (4) capacity or infrastructure building; (5) community partnerships or collaborations; and (6) broad-scale system change. Hypotheses for future research and strategies that program managers might use to achieve sustainability also differ by program or intervention type.
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Hunt JB, Curran G, Kramer T, Mouden S, Ward-Jones S, Owen R, Fortney J. Partnership for implementation of evidence-based mental health practices in rural federally qualified health centers: theory and methods. Prog Community Health Partnersh 2012; 6:389-98. [PMID: 22982852 DOI: 10.1353/cpr.2012.0039] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mental health and substance abuse are among the most commonly reported reasons for visits to Federally Qualified Health Centers (CHCs), yet only 6.5% of encounters are with on-site behavioral health specialists. Rural CHCs are significantly less likely to have on-site behavioral specialists than urban CHCs. Because of this lack of mental health specialists in rural areas, the most promising approach to improving mental health outcomes is to help rural primary care (PC) providers deliver evidence-based practices (EBPs). Despite the scope of these problems, no research has developed an effective implementation strategy for facilitating the adoption of mental health EBPs for rural CHCs. We sought to describe the conceptual components of an implementation partnership that focuses on the adaption and adoption of mental health EBPs by rural CHCs in Arkansas. METHODS We present a conceptual model that integrates seven separate frameworks: (1) Jones and Wells' Evidence-Based Community Partnership Model, (2) Kitson's Promoting Action on Research Implementation in Health Services (PARiHS) implementation framework, (3) Sackett's definition of evidence-based medicine, (4) Glisson's organizational social context model, (5) Rubenstein's Evidence-Based Quality Improvement (EBQI) facilitation process, (6) Glasgow's RE-AIM evaluation approach, and (7) Naylor's concept of shared decision making. CONCLUSIONS By integrating these frameworks into a meaningful conceptual model, we hope to develop a successful implementation partnership between an academic health center and small rural CHCs to improve mental health outcomes. Findings from this implementation partnership should have relevance to hundreds of clinics and millions of patients, and could help promote the sustained adoption of EBPs across rural America.
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Affiliation(s)
- Justin B Hunt
- Division of Health Services Research, Psychiatric Research Institute, University of Arkansas for Medical Sciences, USA
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Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev 2012; 10:CD009009. [PMID: 23076952 DOI: 10.1002/14651858.cd009009.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND General health checks are common elements of health care in some countries. These aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is, therefore, important to assess whether general health checks do more good than harm. OBJECTIVES We aimed to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes such as blood pressure and serum cholesterol levels. SEARCH METHODS We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility and read reference lists. One author used citation tracking (Web of Knowledge) and asked trialists about additional studies. SELECTION CRITERIA We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening general populations for more than one disease or risk factor in more than one organ system. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias in the trials. We contacted authors for additional outcomes or trial details when necessary. For mortality outcomes we analysed the results with random-effects model meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible. MAIN RESULTS We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (CI) 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), risk ratio 1.03 (95% CI 0.91 to 1.17) and eight trials on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery. AUTHORS' CONCLUSIONS General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.
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Urquhart R, Sargeant J, Porterm GA. Factors related to the implementation and use of an innovation in cancer surgery. ACTA ACUST UNITED AC 2012; 18:271-9. [PMID: 22184488 DOI: 10.3747/co.v18i6.961] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Nationally, efforts to implement an innovation in cancer surgery-a Web-based synoptic reporting tool-are ongoing in five provinces. The objective of the present study was to identify the key multilevel factors influencing implementation and early use of this innovation for breast and colorectal cancer surgery at two academic hospitals in Halifax, Nova Scotia. METHODS We used case-study methodology to examine the implementation of surgical synoptic reporting. Methods included semi-structured interviews with key informants (surgeons, implementation team members, and report end users; n = 9), nonparticipant observation, and document analysis. A thematic analysis was conducted separately for each method, followed by explanation-building to integrate the evidence and to identify the key multilevel factors influencing implementation. An audit was performed to determine use. RESULTS Key factors influencing implementation were these: Innovation-values fitFlexibility with the innovation and implementationThe innovation is not flawlessStrengthening the climate for implementationResource needs and availabilityPartner engagementSurgeon champions and involvementIn a 6-month period after implementation, 91.2% and 58.0% respectively of eligible breast and colorectal cancer surgeries were reported using the new tool. CONCLUSIONS An improved understanding of the multilevel factors influencing the implementation of innovations is critical to planning effective change interventions in health care. Further study is needed to explore differences in the use of the innovation between breast and colorectal cancer surgeons. Findings will inform the study of additional cases of synoptic reporting implementation, enabling cross-case analyses and identification of higher-level themes that may be applied in similar settings or contexts.
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Affiliation(s)
- R Urquhart
- Cancer Outcomes Research Program, Cancer Care Nova Scotia, Halifax, NS
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O'Connor P. Quality improvement collaboratives in the age of health informatics--new wine in new wineskins. BMJ Qual Saf 2012; 21:891-3. [PMID: 22822242 PMCID: PMC3594934 DOI: 10.1136/bmjqs-2012-001265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sanci L, Grabsch B, Chondros P, Shiell A, Pirkis J, Sawyer S, Hegarty K, Patterson E, Cahill H, Ozer E, Seymour J, Patton G. The prevention access and risk taking in young people (PARTY) project protocol: a cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice. BMC Public Health 2012; 12:400. [PMID: 22672481 PMCID: PMC3533834 DOI: 10.1186/1471-2458-12-400] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 04/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing. MAIN OUTCOMES clinicians' detection of risk-taking and emotional distress, young people's intention to change and reduction of risk taking. SECONDARY OUTCOMES pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol. METHODS PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff's self-perceived competency in young people's care and clinicians' detection and response to risk taking behaviours and emotional distress in 14-24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation. DISCUSSION The PARTY trial is the first to examine the effectiveness and efficiency of a psychosocial risk screening and counselling intervention for young people attending primary care. It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months. TRIAL REGISTRATION ISRCTN16059206.
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Affiliation(s)
- Lena Sanci
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, Melbourne, Australia
| | - Brenda Grabsch
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, Melbourne, Australia
| | - Patty Chondros
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, Melbourne, Australia
| | - Alan Shiell
- Centre of Excellence in Intervention and Prevention Science, Melbourne, Australia
| | - Jane Pirkis
- School of Population Health, The University of Melbourne, Melbourne, Australia
| | - Susan Sawyer
- Centre for Adolescent Health, Royal Children’s Hospital; Department of Paediatrics, Murdoch Children’s Research Institute, The University of Melbourne, Melbourne, Australia
| | - Kelsey Hegarty
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, Melbourne, Australia
| | | | - Helen Cahill
- Youth Research Centre, University of Melbourne, Melbourne, Australia
| | - Elizabeth Ozer
- Division of Adolescent & Young Adult Medicine and Office of Diversity and Outreach, University of California, San Francisco, USA
| | - Janelle Seymour
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - George Patton
- Centre for Adolescent Health, Royal Children’s Hospital; Department of Paediatrics, Murdoch Children’s Research Institute, The University of Melbourne, Melbourne, Australia
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Glasgow RE, Green LW, Taylor MV, Stange KC. An evidence integration triangle for aligning science with policy and practice. Am J Prev Med 2012; 42:646-54. [PMID: 22608384 PMCID: PMC4457385 DOI: 10.1016/j.amepre.2012.02.016] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 12/14/2011] [Accepted: 02/02/2012] [Indexed: 01/01/2023]
Abstract
Over-reliance on decontextualized, standardized implementation of efficacy evidence has contributed to slow integration of evidence-based interventions into health policy and practice. This article describes an "evidence integration triangle" (EIT) to guide translation, implementation, prevention efforts, comparative effectiveness research, funding, and policymaking. The EIT emphasizes interactions among three related components needed for effective evidence implementation: (1) practical evidence-based interventions; (2) pragmatic, longitudinal measures of progress; and (3) participatory implementation processes. At the center of the EIT is active engagement of key stakeholders and scientific evidence and attention to the context in which a program is implemented. The EIT model is a straightforward framework to guide practice, research, and policy toward greater effectiveness and is designed to be applicable across multiple levels-from individual-focused and patient-provider interventions, to health systems and policy-level change initiatives.
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Affiliation(s)
- Russell E Glasgow
- Division of Cancer Control and Population Sciences, National Cancer Institute, NIH, Rockville, MD 20852, USA.
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Fortney J, Enderle M, McDougall S, Clothier J, Otero J, Altman L, Curran G. Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics. Implement Sci 2012; 7:30. [PMID: 22494428 PMCID: PMC3353178 DOI: 10.1186/1748-5908-7-30] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Accepted: 04/11/2012] [Indexed: 01/18/2023] Open
Abstract
Background Collaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs. Methods This nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews. Results Adoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn. Conclusions Provider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs. Trial registration Clinical trial # NCT00317018.
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Affiliation(s)
- John Fortney
- Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA.
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Higgins AY, B Doubeni AR, Phillips KL, Laiyemo AO, Briesacher B, Tjia J, Doubeni CA. Self-reported colorectal cancer screening of Medicare beneficiaries in family medicine vs. internal medicine practices in the United States: a cross-sectional study. BMC Gastroenterol 2012; 12:23. [PMID: 22436107 PMCID: PMC3352176 DOI: 10.1186/1471-230x-12-23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 03/21/2012] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The benefit of screening for decreasing the risk of death from colorectal cancer (CRC) has been shown, yet many patients in primary care are still not undergoing screening according to guidelines. There are known variations in delivery of preventive health care services among primary care physicians. This study compared self-reported CRC screening rates and patient awareness of the need for CRC screening of patients receiving care from family medicine (FPs) vs. internal medicine (internists) physicians. METHODS Nationally representative sample of non-institutionalized beneficiaries who received medical care from FPs or internists in 2006 (using Medicare Current Beneficiary Survey). The main outcome was the percentage of patients screened in 2007. We also examined the percentage of patients offered screening. RESULTS Patients of FPs, compared to those of internists, were less likely to have received an FOBT kit or undergone home FOBT, even after accounting for patients' characteristics. Compared to internists, FPs' patients were more likely to have heard of colonoscopy, but were less likely to receive a screening colonoscopy recommendation (18% vs. 27%), or undergo a colonoscopy (43% vs. 46%, adjusted odds ratios [AOR], 95% confidence interval [CI]-- 0.65, 0.51-0.81) or any CRC screening (52% vs. 60%, AOR, CI--0.80, 0.68-0.94). Among subgroups examined, higher income beneficiaries receiving care from internists had the highest screening rate (68%), while disabled beneficiaries receiving care from FPs had the lowest screening rate (34%). CONCLUSION Patients cared for by FPs had a lower rate of screening compared to those cared for by internists, despite equal or higher levels of awareness; a difference that remained statistically significant after accounting for socioeconomic status and access to healthcare. Both groups of patients remained below the national goal of 70 percent.
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Affiliation(s)
- Angela Y Higgins
- Department of Family Medicine and Community Health, University of Massachusetts (UMass) Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Anna R B Doubeni
- Department of Family Medicine and Community Health, University of Massachusetts (UMass) Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Karon L Phillips
- Program on Aging and Care, Scott & White Memorial Hospital, 2401 South 31st. Street, Temple, TX 76508, USA
| | - Adeyinka O Laiyemo
- Division of Gastroenterology, Department of Medicine, Howard University College of Medicine, 2041 Georgia Avenue, NW, Washington, DC 20060, USA
| | - Becky Briesacher
- Meyers Primary Care Institute and Division of Geriatrics, UMass Medical School, 377 Plantation Street, Worcester, MA 01605, USA
| | - Jennifer Tjia
- Meyers Primary Care Institute and Division of Geriatrics, UMass Medical School, 377 Plantation Street, Worcester, MA 01605, USA
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Massachusetts (UMass) Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
- Meyers Primary Care Institute and Division of Geriatrics, UMass Medical School, 377 Plantation Street, Worcester, MA 01605, USA
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Harris R, Gamboa A, Dailey Y, Ashcroft A. One-to-one dietary interventions undertaken in a dental setting to change dietary behaviour. Cochrane Database Syst Rev 2012; 2012:CD006540. [PMID: 22419315 PMCID: PMC6464965 DOI: 10.1002/14651858.cd006540.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The dental care setting is an appropriate place to deliver dietary assessment and advice as part of patient management. However, we do not know whether this is effective in changing dietary behaviour. OBJECTIVES To assess the effectiveness of one-to-one dietary interventions for all ages carried out in a dental care setting in changing dietary behaviour. The effectiveness of these interventions in the subsequent changing of oral and general health is also assessed. SEARCH METHODS The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 24 January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1950 to 24 January 2012), EMBASE via OVID (1980 to 24 January 2012), CINAHL via EBSCO (1982 to 24 January 2012), PsycINFO via OVID (1967 to 24 January 2012), and Web of Science (1945 to 12 April 2011). We also undertook an electronic search of key conference proceedings (IADR and ORCA between 2000 and 13 July 2011). Reference lists of relevant articles, thesis publications (Dissertations Abstracts Online 1861 to 2011) were searched. The authors of eligible trials were contacted to identify any unpublished work. SELECTION CRITERIA Randomised controlled trials assessing the effectiveness of one-to-one dietary interventions delivered in a dental care setting. DATA COLLECTION AND ANALYSIS Abstract screening, eligibility screening and data extraction decisions were all carried out independently and in duplicate by two review authors. Consensus between the two opinions was achieved by discussion, or involvement of a third review author. MAIN RESULTS Five studies met the criteria for inclusion in the review. Two of these were multi-intervention studies where the dietary intervention was one component of a wider programme of prevention, but where data on dietary behaviour change were reported. One of the single intervention studies was concerned with dental caries prevention. The other two concerned general health outcomes. There were no studies concerned with dietary change aimed at preventing tooth erosion. In four out of the five included studies a significant change in dietary behaviour was found for at least one of the primary outcome variables. AUTHORS' CONCLUSIONS There is some evidence that one-to-one dietary interventions in the dental setting can change behaviour, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption. There is a need for more studies, particularly in the dental practice setting, as well as greater methodological rigour in the design, statistical analysis and reporting of such studies.
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Affiliation(s)
- Rebecca Harris
- Department of Health Services Research, University of Liverpool, Liverpool,
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Wiltsey Stirman S, Kimberly J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement Sci 2012; 7:17. [PMID: 22417162 PMCID: PMC3317864 DOI: 10.1186/1748-5908-7-17] [Citation(s) in RCA: 727] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 03/14/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research. METHODS Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized. RESULTS Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves. CONCLUSIONS Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.
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Affiliation(s)
- Shannon Wiltsey Stirman
- Women's Health Sciences Division, National Center for PTSD, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University, Boston, MA, USA
| | - John Kimberly
- Department of Healthcare Management, The Wharton School of the University of Pennsylvania, Philadelphia, PA, USA
| | - Natasha Cook
- Women's Health Sciences Division, National Center for PTSD, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Amber Calloway
- Women's Health Sciences Division, National Center for PTSD, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University, Boston, MA, USA
| | - Frank Castro
- Women's Health Sciences Division, National Center for PTSD, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University, Boston, MA, USA
| | - Martin Charns
- VA Boston Healthcare System, Boston, MA, USA
- VA Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Ogden LL, Richards CL, Shenson D. Clinical preventive services for older adults: the interface between personal health care and public health services. Am J Public Health 2012; 102:419-25. [PMID: 22390505 PMCID: PMC3487658 DOI: 10.2105/ajph.2011.300353] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2011] [Indexed: 01/13/2023]
Abstract
Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes. Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.
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Affiliation(s)
- Lydia L Ogden
- Office of Health Reform Strategy, Policy, and Coordination, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA.
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Primary care practice transformation is hard work: insights from a 15-year developmental program of research. Med Care 2012; 49 Suppl:S28-35. [PMID: 20856145 DOI: 10.1097/mlr.0b013e3181cad65c] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. METHODS Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. RESULTS A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. CONCLUSIONS It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.
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