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Rushlow DR, Thacher TD, Barry BA. Building Capacity for Pragmatic Trials of Digital Technology in Primary Care. Mayo Clin Proc 2024; 99:491-501. [PMID: 38432751 DOI: 10.1016/j.mayocp.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 03/05/2024]
Abstract
Frontline primary care teams face important challenges in seeking to transform the quality of care delivered to patients and to reduce clerical burden for clinicians. Digital technologies using artificial intelligence hold substantial promise to aid in this transformation. Both pragmatic clinical trials and implementation science are key tools to successfully introduce, evaluate, and sustain innovations in real-world primary care practices. Previous articles in this thematic series have provided an in-depth overview of pragmatic trials and implementation science. This paper demonstrates and provides a framework for how these concepts, together with digital transformation, can be used to solve many of the challenges facing primary care. This framework is conceived as the collaboration of frontline primary care teams with innovators in academic institutions and industry through pragmatic trials and implementation science.
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Affiliation(s)
| | | | - Barbara A Barry
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Steed L, Sheringham J, McClatchey K, Hammersley V, Marsh V, Morgan N, Jackson T, Holmes S, Taylor S, Pinnock H. IMP 2ART: development of a multi-level programme theory integrating the COM-B model and the iPARIHS framework, to enhance implementation of supported self-management of asthma in primary care. Implement Sci Commun 2023; 4:136. [PMID: 37957778 PMCID: PMC10644643 DOI: 10.1186/s43058-023-00515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/21/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Supported asthma self-management, incorporating an asthma action plan and annual clinical review, has been recommended by UK/global guidelines for over three decades. However, implementation remains poor, as only around a third of individuals receive basic asthma care, according to the UKs leading respiratory charity Asthma and Lung UK. A systematic review of implementation studies recommended that a whole systems approach targeting patients, healthcare professional education, and organisations is needed to improve implementation of supported asthma self-management in primary care. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a national Hybrid-II implementation cluster randomised controlled trial that aims to evaluate such an approach. This paper describes the development of the implementation strategy for IMP2ART with particular focus on the integration of multiple level theories. METHODS The Medical Research Council design and evaluation of complex interventions framework and the Person-Based Approach to intervention development were used as guidance for stages of strategy development. Specifically, we (i) set up a multidisciplinary team (including practicing and academic clinicians, health psychologists, public health and patient colleagues), (ii) reviewed and integrated evidence and theory, (iii) developed guiding principles, (iv) developed prototype materials, and (v) conducted a pre-pilot study before final refinement. RESULTS The implementation strategy included resources for patients, team-based and individual healthcare professional education, practice audit and feedback, and an asthma review template, as well as a facilitator role accessible to primary care practices for 12 months. The synthesis of the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) and Capability, Opportunity, Motivation and Behaviour (COM-B) frameworks led to an evolved framework bringing together important implementation and behaviour change elements which will be used as a basis for the study process evaluation. CONCLUSIONS A description of rigorous implementation strategy development for the IMP2ART study is provided along with newly theorised integration of implementation and behaviour change science which may be of benefit to others targeting implementation in primary care. TRIAL REGISTRATION ISRCTN15448074. Registered on 2nd December 2019.
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Affiliation(s)
- Liz Steed
- Wolfson Institute of Population Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jessica Sheringham
- Department of Applied Health Research, University College London, London, UK.
| | - Kirstie McClatchey
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Vicky Hammersley
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Viv Marsh
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Noelle Morgan
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Tracy Jackson
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Steve Holmes
- The Park Medical Practice, Shepton Mallet, UK
- Severn School of Primary Care, Health Education England (South West), Bristol, UK
| | - Stephanie Taylor
- Wolfson Institute of Population Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
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Shear K, Rice H, Garabedian PM, Bjarnadottir R, Lathum N, Horgas AL, Harle CA, Dykes PC, Lucero R. Management of Fall Risk Among Older Adults in Diverse Primary Care Settings. J Appl Gerontol 2023; 42:2219-2232. [PMID: 37387449 PMCID: PMC10782546 DOI: 10.1177/07334648231185757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
OBJECTIVES Falls are persistent among community-dwelling older adults despite existing prevention guidelines. We described how urban and rural primary care staff and older adults manage fall risk and factors important to integration of computerized clinical decision support (CCDS). METHODS Interviews, contextual inquiries, and workflow observations were analyzed using content analysis and synthesized into a journey map. Sociotechnical and PRISM domains were applied to identify workflow factors important to sustainable CCDS integration. RESULTS Participants valued fall prevention and described similar approaches. Available resources differed between rural and urban locations. Participants wanted evidence-based guidance integrated into workflows to bridge skills gaps. DISCUSSION Sites described similar clinical approaches with differences in resource availability. This implies that a single intervention would need to be flexible to environments with differing resources. Electronic Health Record's inherent ability to provide tailored CCDS is limited. However, CCDS middleware could integrate into different settings and increase evidence use.
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Affiliation(s)
- Kristen Shear
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, USA
- Center for Nursing Science and Clinical Inquiry, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Hannah Rice
- Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
- BWH Center for Patient Safety, Research and Practice, Boston, MA, USA
| | | | - Ragnhildur Bjarnadottir
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Nancy Lathum
- Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ann L. Horgas
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Christopher A. Harle
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Patricia C. Dykes
- Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
- BWH Center for Patient Safety, Research and Practice, Boston, MA, USA
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LaMarca A, Tse I, Keysor J. Rehabilitation Technologies for Chronic Conditions: Will We Sink or Swim? Healthcare (Basel) 2023; 11:2751. [PMID: 37893825 PMCID: PMC10606667 DOI: 10.3390/healthcare11202751] [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: 08/17/2023] [Revised: 10/08/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION Chronic conditions such as stroke, Parkinson's disease, spinal cord injury, multiple sclerosis, vestibular disorders, chronic pain, arthritis, diabetes, chronic obstructive pulmonary disease (COPD), and heart disease are leading causes of disability among middle-aged and older adults. While evidence-based treatment can optimize clinical outcomes, few people with chronic conditions engage in the recommended levels of exercise for clinical improvement and successful management of their condition. Rehabilitation technologies that can augment therapeutic care-i.e., exoskeletons, virtual/augmented reality, and remote monitoring-offer the opportunity to bring evidence-based rehabilitation into homes. Successful integration of rehabilitation techniques at home could help recovery and access and foster long term self-management. However, widespread uptake of technology in rehabilitation is still limited, leaving many technologies developed but not adopted. METHODS In this narrative review, clinical need, efficacy, and obstacles and suggestions for implementation are discussed. The use of three technologies is reviewed in the management of the most prevalent chronic diseases that utilize rehabilitation services, including common neurological, musculoskeletal, metabolic, pulmonary, and cardiac conditions. The technologies are (i) exoskeletons, (ii) virtual and augmented reality, and (iii) remote monitoring. RESULTS Effectiveness evidence backing the use of technology in rehabilitation is growing but remains limited by high heterogeneity, lack of long-term outcomes, and lack of adoption outcomes. CONCLUSION While rehabilitation technologies bring opportunities to bridge the gap between clinics and homes, there are many challenges with adoption. Hybrid effectiveness and implementation trials are a possible path to successful technology development and adoption.
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Affiliation(s)
- Amber LaMarca
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA 02129, USA;
| | - Ivy Tse
- Doctor of Physical Therapy Program, MGH Institute of Health Professions, Boston, MA 02129, USA
| | - Julie Keysor
- School of Health Care Leadership, MGH Institute of Health Professions, Boston, MA 02129, USA
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Ayton D, Pirotta S, Morello R, Rosenich E, Barton C, Lavale A, Pase MP, Maruff P, Yassi N, Brodtmann A, Lim YY, Barker A. Protocol for a Mixed-Methods Process Evaluation of BetterBrains: A Person-Centered Online Intervention to Delay Cognitive Decline in Adults at Risk of Dementia. J Alzheimers Dis 2022; 90:1689-1703. [PMID: 36314199 DOI: 10.3233/jad-220341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The BetterBrains Randomized Controlled Trial (RCT) will evaluate the effectiveness of an online, person-centered, risk factor management, coaching intervention in community-dwelling, healthy adults at risk of cognitive decline. Multi-component interventions are challenging to evaluate due to program complexity and personalization to individual needs and contexts. This paper describes a multi-level process evaluation conducted alongside the BetterBrains RCT. OBJECTIVE To understand how and why the BetterBrains intervention was effective or ineffective at reducing cognitive decline in healthy adults whilst considering the context in which it was implemented. METHODS 1,510 non cognitively-deteriorated community-dwelling adults aged 40-70 years old at risk of cognitive decline will be recruited and randomly assigned to the intervention or control group. All BetterBrains intervention participants, coaches, and the research team will be included in the evaluation. A mixed-methods design will be used, guided by The Framework for Implementation Fidelity and the program logic model. Data will be sourced from interviews, focus groups, surveys, BetterBrains coach notes, participant weekly check-in surveys, and audio recordings of intervention coaching sessions. Quantitative data will be analyzed via descriptive and inferential statistics and qualitative data will be analyzed using content and thematic analysis. RESULTS The process evaluation will provide information about contextual and influencing factors related to the implementation of BetterBrains and the RCT outcomes. CONCLUSION Understanding how BetterBrains was implemented and its associated impacts will inform the translation of the program into community and clinical settings, providing easy access to online, personalized dementia prevention services.
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Affiliation(s)
- Darshini Ayton
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Stephanie Pirotta
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Renata Morello
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Emily Rosenich
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
| | - Chris Barton
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Alexandra Lavale
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
| | - Matthew P Pase
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
| | - Paul Maruff
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Cogstate Ltd., Melbourne, VIC, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Amy Brodtmann
- Department of Neuroscience, Central Clinical School, Monash University, The Alfred Centre, Melbourne, VIC, Australia
| | - Yen Ying Lim
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
| | - Anna Barker
- Silver Chain Group, Melbourne, VIC, Australia
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Zhu X, Gray D, Brennan CS. Impact of Implementing Welcoming Clinic Space Indicators on Sexual and Gender Minority Patients' Health Care Experience. AIDS Patient Care STDS 2022; 36:127-142. [PMID: 36178404 DOI: 10.1089/apc.2022.0098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
It has been well established that those identifying as a member of the sexual and gender minority (SGM) have difficulties accessing health care services. This is strongly associated with the desire to avoid discriminatory health care practices and prejudicial providers that many SGM individuals have encountered. Implementation of specific welcoming clinic space indicators (WCSIs) has been recommended to mitigate prior health care alienation experienced by SGM individuals. The project supported three HIV clinical care sites in Louisiana to implement and maintain identified SGM WCSIs as one of its interventions to improve sexually transmitted infection screening, testing, and treatment in people with and at-risk of HIV. This project found that SGM WCSIs had a positive impact on SGM individuals and were predominately unnoticed by those that were non-SGM-identifying individuals. Further, across the entire sample, the SGM WCSIs had an extremely low (<1%) level of negative impact, eliminating the misconception that SGW WCSI implementation may offend non-SGM individuals. There were differences in the implementation of the SGM WCSIs across the three sites associated with their governance structure and priority community. Implementation of SGM WCSIs should be considered as an important component of assuring culturally competent health care for SGM individuals.
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Affiliation(s)
- Xiaodan Zhu
- Programs in Biostatistics, Louisiana State University Health New Orleans School of Public Health, New Orleans, Louisiana, USA
| | - Dana Gray
- Programs in Health Policy and System Management, Louisiana State University Health New Orleans School of Public Health, New Orleans, Louisiana, USA
| | - Christine S Brennan
- Programs in Health Policy and System Management, Louisiana State University Health New Orleans School of Public Health, New Orleans, Louisiana, USA
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[Putting prevention into practice]. Aten Primaria 2022; 54 Suppl 1:102415. [PMID: 36435586 PMCID: PMC9705220 DOI: 10.1016/j.aprim.2022.102415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Saha SK, Thursky K, Kong DCM, Mazza D. A Novel GPPAS Model: Guiding the Implementation of Antimicrobial Stewardship in Primary Care Utilising Collaboration between General Practitioners and Community Pharmacists. Antibiotics (Basel) 2022; 11:antibiotics11091158. [PMID: 36139938 PMCID: PMC9495087 DOI: 10.3390/antibiotics11091158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022] Open
Abstract
Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is central to implement antimicrobial stewardship (AMS) programmes in primary care. This study aimed to design a GP/pharmacist antimicrobial stewardship (GPPAS) model for primary care in Australia. An exploratory study design was followed that included seven studies conducted from 2017 to 2021 for the development of the GPPAS model. We generated secondary and primary evidence through a systematic review, a scoping review, a rapid review, nationwide surveys of Australian GPs and CPs including qualitative components, and a pilot study of a GPPAS submodel. All study evidence was synthesised, reviewed, merged, and triangulated to design the prototype GPPAS model using a Systems Engineering Initiative for Patient Safety theoretical framework. The secondary evidence provided effective GPPAS interventions, and the primary evidence identified GP/CP interprofessional issues, challenges, and future needs for implementing GPPAS interventions. The framework of the GPPAS model informed five GPPAS implementation submodels to foster implementation of AMS education program, antimicrobial audits, diagnostic stewardship, delayed prescribing, and routine review of antimicrobial prescriptions, through improved GP–CP collaboration. The GPPAS model could be used globally as a guide for GPs and CPs to collaboratively optimise antimicrobial use in primary care. Implementation studies on the GPPAS model and submodels are required to integrate the GPPAS model into GP/pharmacist interprofessional care models in Australia for improving AMS in routine primary care.
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Affiliation(s)
- Sajal K. Saha
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3168, Australia
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
- Public Health Unit, Geelong Centre for Emerging Infectious Disease, Barwon Health, Geelong, VIC 3220, Australia
- Correspondence: ; Tel.: +61-0452639559
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
| | - David C. M. Kong
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
- Centre for Medicine Use and Safety, Monash University, 381 Royal Parade Parkville, Melbourne, VIC 3052, Australia
- Pharmacy Department, Ballarat Health Services, Ballarat, VIC 3350, Australia
| | - Danielle Mazza
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3168, Australia
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
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