Getting clinical trial results into practice: design, implementation, and process evaluation of the ALLHAT Dissemination Project

The effectiveness of interventions to disseminate the results of non-commercial randomised clinical trials to healthcare professionals: a systematic review

BACKGROUND

It is unclear how to disseminate the results of randomised controlled trials effectively to health professionals and policymakers to improve treatment, care or prevention through changing policy and practice. This systematic review examined the effectiveness of different methods of dissemination of clinical research results to professional audiences.

METHODS

We systematically reviewed the published and grey literature from 2000 to 2022 for studies assessing different approaches for disseminating clinical study results to professional audiences (health professionals, policymakers and guideline developers). Two reviewers assessed potentially relevant full texts for inclusion. We grouped studies by intervention type, synthesising findings using effect direction plots. Outcomes were grouped into out-takes (e.g. awareness, knowledge, understanding), outcomes (e.g. attitude changes) and impact (changes in policy/practice). The quality of evidence was assessed using GRADE.

RESULTS

Our search identified 13,264 unique records, of which 416 full texts were assessed for eligibility. Of 60 studies that were identified as eligible for inclusion, 20 evaluated the effectiveness of interventions to disseminate clinical research results (13 RCTs, 2 observational studies, 3 pre- and post-intervention surveys and 2 cross-sectional surveys). Studies were grouped by intervention: 7 studies that involved face-to-face meetings between the target audience and trained educators were classified as 'outreach interventions'; 5 studies that provided a summary format for systematic review findings (e.g. summary of findings tables) were grouped together. There was high certainty evidence of a small beneficial impact of outreach interventions on health and moderate certainty evidence of impact on practice (mostly prescribing). There was no evidence of impact on policy and very low certainty around benefits on outcomes and out-takes. We found no consistent benefits of summary formats for systematic review results on outcomes or out-takes (moderate quality evidence). Other interventions with less evidence are reported in the Additional Materials.

CONCLUSIONS

Outreach interventions to disseminate clinical research results can lead to changes in practice and improvements in health. However, these interventions can be resource-intensive. Investment is vital to identify and implement effective and cost-effective ways to disseminate results, so that the potential benefits of trials to patients can be realised.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), CRD42019137364.

Using Intervention Mapping to Develop a Provider Intervention to Increase HPV Vaccination in a Federally Qualified Health Center

Introduction: A healthcare provider's ability to give a strong recommendation for the HPV vaccine is of utmost importance in increasing HPV vaccination. To reduce the burden of HPV-related cancers, there is a critical need to develop and implement theory-based interventions aimed at strengthening healthcare providers' communication about the HPV vaccine. Methods: We used Intervention Mapping (IM) steps 1-5 to develop and implement a provider-level intervention that aligns with the priorities and needs of a large, urban Federally Qualified Health Center (FQHC). Results: In step 1, a diverse planning group identified barriers to HPV vaccination in clinical settings and generated process maps and a logic model of the problem. Step 2 outlined outcomes and provider performance objectives of the intervention and identified knowledge, skills, self-efficacy, outcome expectations, and normative beliefs as modifiable targets that need to change for providers to deliver strong recommendations for the HPV vaccine to parents and patients. In step 3, the planning group mapped the methods of persuasive communication, information, and modeling and skills training to behavioral targets and outlined the program practical applications (strategies) components, scope, and sequence. In steps 4 and 5, the planning group produced the intervention and planned for program implementation. The iterative and participatory process of IM resulted in modifications to the initial intervention that aligned with the needs of the FQHC. Discussion: IM provided a systematic, participatory, and iterative approach for developing a theory-based provider-level intervention aimed at strengthening healthcare providers' ability to provide a strong recommendation for the HPV vaccine to eligible patients and parents served by a large FQHC. IM assisted with the identification of behavioral targets and methods that move beyond HPV knowledge and reminders to create behavior change. IM can help researchers and planners describe the processes and rational behind developing interventions and may help to facilitate implementation in real-world clinical settings by tailoring intervention components to the needs of the population.

QuitSMART Utah: an implementation study protocol for a cluster-randomized, multi-level Sequential Multiple Assignment Randomized Trial to increase Reach and Impact of tobacco cessation treatment in Community Health Centers

BACKGROUND

Tobacco use remains the leading cause of death and disability in the USA and is disproportionately concentrated among low socioeconomic status (SES) populations. Community Health Centers (CHCs) are a key venue for reaching low SES populations with evidence-based tobacco cessation treatment such as Quitlines. Electronic health record (EHR)-based interventions at the point-of-care, text messaging (TM), and phone counseling have the potential to increase Quitline reach and are feasible to implement within CHCs. However, there is a lack of data to inform how, when, and in what combination these strategies should be implemented. The aims of this cluster-randomized trial are to evaluate multi-level implementation strategies to increase the Reach (i.e., proportion of tobacco-using patients who enroll in the Quitline) and Impact (i.e., Reach × Efficacy [efficacy is defined as the proportion of tobacco-using patients who enroll in Quitline treatment that successfully quit]) and to evaluate characteristics of healthcare system, providers, and patients that may influence tobacco-use outcomes.

METHODS

This study is a multilevel, three-phase, Sequential Multiple Assignment Randomized Trial (SMART), conducted in CHCs (N = 33 clinics; N = 6000 patients). In the first phase, clinics will be randomized to two different EHR conditions. The second and third phases are patient-level randomizations based on prior treatment response. Patients who enroll in the Quitline receive no further interventions. In phase two, patients who are non-responders (i.e., patients who do not enroll in Quitline) will be randomized to receive either TM or continued-EHR. In phase three, patients in the TM condition who are non-responders will be randomized to receive either continued-TM or TM + phone coaching.

DISCUSSION

This project will evaluate scalable, multi-level interventions to directly address strategic national priorities for reducing tobacco use and related disparities by increasing the Reach and Impact of evidence-based tobacco cessation interventions in low SES populations.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT03900767) on April 4th, 2019.

Implementation Mapping: Using Intervention Mapping to Develop Implementation Strategies

Background: The ultimate impact of a health innovation depends not only on its effectiveness but also on its reach in the population and the extent to which it is implemented with high levels of completeness and fidelity. Implementation science has emerged as the potential solution to the failure to translate evidence from research into effective practice and policy evident in many fields. Implementation scientists have developed many frameworks, theories and models, which describe implementation determinants, processes, or outcomes; yet, there is little guidance about how these can inform the development or selection of implementation strategies (methods or techniques used to improve adoption, implementation, sustainment, and scale-up of interventions) (1, 2). To move the implementation science field forward and to provide a practical tool to apply the knowledge in this field, we describe a systematic process for planning or selecting implementation strategies: Implementation Mapping. Methods: Implementation Mapping is based on Intervention Mapping (a six-step protocol that guides the design of multi-level health promotion interventions and implementation strategies) and expands on Intervention Mapping step 5. It includes insights from both the implementation science field and Intervention Mapping. Implementation Mapping involves five tasks: (1) conduct an implementation needs assessment and identify program adopters and implementers; (2) state adoption and implementation outcomes and performance objectives, identify determinants, and create matrices of change objectives; (3) choose theoretical methods (mechanisms of change) and select or design implementation strategies; (4) produce implementation protocols and materials; and (5) evaluate implementation outcomes. The tasks are iterative with the planner circling back to previous steps throughout this process to ensure all adopters and implementers, outcomes, determinants, and objectives are addressed. Discussion: Implementation Mapping provides a systematic process for developing strategies to improve the adoption, implementation, and maintenance of evidence-based interventions in real-world settings.

Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions

BACKGROUND

A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers.

METHODS

Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices.

RESULTS

Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD = 4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants.

CONCLUSIONS

The wide heterogeneity of endorsements obtained in this study's task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study's results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.

Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions

BACKGROUND

A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers.

METHODS

Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices.

RESULTS

Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD = 4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants.

CONCLUSIONS

The wide heterogeneity of endorsements obtained in this study's task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study's results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.

Engaging stakeholders in the co-development of programs or interventions using Intervention Mapping: A scoping review

BACKGROUND

Health care innovations tailored to stakeholder context are more readily adopted. This study aimed to describe how Intervention Mapping (IM) was used to design health care innovations and how stakeholders were involved.

METHODS

A scoping review was conducted. MEDLINE, EMBASE, Cochrane Library, Scopus and Science Citation Index were searched from 2008 to November 2017. English language studies that used or cited Intervention Mapping were eligible. Screening and data extraction were done in triplicate. Summary statistics were used to describe study characteristics, IM steps employed, and stakeholder involvement.

RESULTS

A total of 852 studies were identified, 449 were unique, and 333 were excluded based on title and abstracts, 116 full-text articles were considered and 61 articles representing 60 studies from 13 countries for a variety of clinical issues were included. The number of studies published per year increased since 2008 and doubled in 2016 and 2017. The majority of studies employed multiple research methods (76.7%) and all 6 IM steps (73.3%). Resulting programs/interventions were single (55.4%) or multifaceted (46.4%), and 60.7% were pilot-tested. Programs or interventions were largely educational material or meetings, and were targeted to patients (70.2%), clinicians (14.0%) or both (15.8%). Studies provided few details about current or planned evaluation. Of the 4 (9.3%) studies that reported impact or outcomes, 3 achieved positive improvements in patient or professional behaviour or patient outcomes. Many studies (28.3%) did not involve stakeholders. Those that did (71.7%) often involved a combination of patients, clinicians, and community organizations. However, less than half (48.8%) described how they were engaged. Most often stakeholders were committee members and provide feedback on program or intervention content or format.

CONCLUSIONS

It is unclear if use of IM or stakeholder engagement in IM consistently results in effective programs or interventions. Those employing IM should report how stakeholders were involved in each IM step and how involvement influenced program or intervention design. They should also report the details or absence of planned evaluation. Future research should investigate how to optimize stakeholder engagement in IM, and whether use of IM itself or stakeholder engagement in IM are positively associated with effective programs or interventions.

Planning theory- and evidence-based behavior change interventions: a conceptual review of the intervention mapping protocol

This paper discusses the Intervention Mapping (IM) protocol for planning theory- and evidence-based behavior change interventions. IM has been developed in the field of health promotion in 1998 and has mostly been applied in that field, but applications in other fields are emerging. IM can be used for any intervention that involves changing behavior. The paper discusses the protocol and its basic issues and presents in-depth examples of its use in- and outside the health promotion field: Empowerment, return to work, safety interventions, implementation, energy conservation, and academic performance. IM is characterized by three perspectives: a social ecological approach, participation of all stakeholders, and the use of theories and evidence. Through a series of six iterative steps - from needs assessment to implementation and evaluation - which are each broken down into specific tasks, correct application of the protocol is meant to produce behavior change interventions that fit into the local context and that have the best chances of effectiveness. IM helps intervention planners develop the best possible interventions targeting health behaviors, but also targeting behaviors related to other societal issues, such as environmental concerns, safety and discrimination.

Use of Intervention Mapping to Enhance Health Care Professional Practice: A Systematic Review

Background. Intervention Mapping is a planning protocol for developing behavior change interventions, the first three steps of which are intended to establish the foundations and rationales of such interventions. Aim. This systematic review aimed to identify programs that used Intervention Mapping to plan changes in health care professional practice. Specifically, it provides an analysis of the information provided by the programs in the first three steps of the protocol to determine their foundations and rationales of change. Method. A literature search was undertaken in PubMed, Scopus, SciELO, and DOAJ using “Intervention Mapping” as keyword. Key information was gathered, including theories used, determinants of practice, research methodologies, theory-based methods, and practical applications. Results. Seventeen programs aimed at changing a range of health care practices were included. The social cognitive theory and the theory of planned behavior were the most frequently used frameworks in driving change within health care practices. Programs used a large variety of research methodologies to identify determinants of practice. Specific theory-based methods (e.g., modelling and active learning) and practical applications (e.g., health care professional training and facilitation) were reported to inform the development of practice change interventions and programs. Discussion. In practice, Intervention Mapping delineates a three-step systematic, theory- and evidence-driven process for establishing the theoretical foundations and rationales underpinning change in health care professional practice. Conclusion. The use of Intervention Mapping can provide health care planners with useful guidelines for the theoretical development of practice change interventions and programs.

Use of theory to plan or evaluate guideline implementation among physicians: a scoping review

BACKGROUND

Guidelines support health care decision-making and high quality care and outcomes. However, their implementation is sub-optimal. Theory-informed, tailored implementation is associated with guideline use. Few guideline implementation studies published up to 1998 employed theory. This study aimed to describe if and how theory is now used to plan or evaluate guideline implementation among physicians.

METHODS

A scoping review was conducted. MEDLINE, EMBASE, and The Cochrane Library were searched from 2006 to April 2016. English language studies that planned or evaluated guideline implementation targeted to physicians based on explicitly named theory were eligible. Screening and data extraction were done in duplicate. Study characteristics and details about theory use were analyzed.

RESULTS

A total of 1244 published reports were identified, 891 were unique, and 716 were excluded based on title and abstract. Among 175 full-text articles, 89 planned or evaluated guideline implementation targeted to physicians; 42 (47.2%) were based on theory and included. The number of studies using theory increased yearly and represented a wide array of countries, guideline topics and types of physicians. The Theory of Planned Behavior (38.1%) and the Theoretical Domains Framework (23.8%) were used most frequently. Many studies rationalized choice of theory (83.3%), most often by stating that the theory described implementation or its determinants, but most failed to explicitly link barriers with theoretical constructs. The majority of studies used theory to inform surveys or interviews that identified barriers of guideline use as a preliminary step in implementation planning (76.2%). All studies that evaluated interventions reported positive impact on reported physician or patient outcomes.

CONCLUSIONS

While the use of theory to design or evaluate interventions appears to be increasing over time, this review found that one half of guideline implementation studies were based on theory and many of those provided scant details about how theory was used. This limits interpretation and replication of those interventions, and seems to result in multifaceted interventions, which may not be feasible outside of scientific investigation. Further research is needed to better understand how to employ theory in guideline implementation planning or evaluation.

Intervention Mapping Protocol for Developing a Theory-Based Diabetes Self-Management Education Program

Development of behavior theory–based health promotion programs is encouraged with the paradigm shift from contents to behavior outcomes. This article describes the development process of the diabetes self-management program for older Koreans (DSME-OK) using intervention mapping (IM) protocol. The IM protocol includes needs assessment, defining goals and objectives, identifying theory and determinants, developing a matrix to form change objectives, selecting strategies and methods, structuring the program, and planning for evaluation and pilot testing. The DSME-OK adopted seven behavior objectives developed by the American Association of Diabetes Educators as behavioral outcomes. The program applied an information-motivation-behavioral skills model, and interventions were targeted to 3 determinants to change health behaviors. Specific methods were selected to achieve each objective guided by IM protocol. As the final step, program evaluation was planned including a pilot test. The DSME-OK was structured as the 3 determinants of the IMB model were intervened to achieve behavior objectives in each session. The program has 12 weekly 90-min sessions tailored for older adults. Using the IM protocol in developing a theory-based self-management program was beneficial in terms of providing a systematic guide to developing theory-based and behavior outcome–focused health education programs.

ALLHAT: still providing correct answers after 7 years

PURPOSE OF REVIEW

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is re-evaluated considering information from recent subgroup and exploratory analyses, other new clinical trials, and meta-analyses. The ALLHAT analyses specifically emphasize heart failure findings, results in Black participants and those with chronic kidney disease, selection and doses of thiazide and similar diuretics, and the association of antihypertensive drug use with new-onset diabetes and its cardiovascular consequences.

RECENT FINDINGS

The initial ALLHAT conclusion, that thiazide diuretics are superior to angiotensin-converting enzyme inhibitors (ACEIs), calcium antagonists (CCBs) and alpha-blockers in preventing one or more major clinical outcomes, including heart failure and stroke, and unsurpassed in significantly preventing any cardiovascular or renal outcome, has been further validated for patients with diabetes, renal disease, and/or metabolic syndrome. The evidence is even more compelling for Black patients. New-onset diabetes associated with thiazides did not increase cardiovascular outcomes. The diuretic was superior to all in preventing heart failure with preserved left-ventricular ejection fraction (LVEF) and similar to the ACEI in preventing heart failure with impaired LVEF. It was also unsurpassed in preventing atrial fibrillation.

SUMMARY

The totality of evidence re-affirms the initial ALLHAT conclusion that thiazide and similar diuretics (at evidence-based doses) are the preferred first-step therapy in most patients with hypertension.

'Who is Helsinki?' Sex workers advise improving communication for good participatory practice in clinical trials

After premature closures in 2004 of biomedical human immunodeficiency virus (HIV) prevention trials involving sex workers in Africa and Asia, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and Global Advocacy for HIV Prevention (AVAC) undertook consultations to establish better participatory guidelines for such trials in order to address ethical concerns. This study investigated sex workers' knowledge and beliefs about research ethics and good participatory practices (GPP) and the perspectives of sex workers on research participation. A 33-question survey based on criteria identified by UNAIDS and AVAC was translated into three other languages. Participants were recruited through mailing lists and contacts with existing sex work networks. In total, 74 responses from Europe, the Americas and Asia were received. Thirty percent of respondents reported first-hand involvement in biomedical HIV prevention trials. Seventy percent indicated a lack of familiarity with codes of ethics for research. This paper focuses exclusively on communication issues described in survey responses. Communication was an important theme: the absence of clear communication between trial participants and investigators contributed to premature trial closures in at least two sites. Sex workers had recommendations for how researchers might implement GPP through improved communication, including consultation at the outset of planning, explaining procedures in non-technical terms and establishing clear channels for feedback from participants.

Primary care providers' sources and preferences for cognitive health information in the United States

In most countries, physicians and other health-care providers play key roles in promoting health. Accumulating scientific evidence suggests that providers may soon want to include cognitive health among the areas they promote. Cognitive health is the maintenance of cognitive abilities that enable social connectedness, foster a sense of purpose, promote independent living, allow recovery from illness or injury and promote effective coping with functional deficits. The US Centers for Disease Control and Prevention has established health promotion about cognitive health as a policy priority, with health providers included as one key group to participate in this effort. This study presents results from focus groups and interviews with primary care physicians (n = 28) and midlevel health-care providers (physician assistants and nurse practitioners, n = 21) in three states of the US. Providers were asked about their sources of information on cognitive health and for their ideas on how best to communicate with primary care providers about research on cognitive health. In results, providers cited online sources, popular media and continuing medical education as their most common sources of information about cognitive health. Popular media sources were used both proactively and reactively to respond to patient inquiries. Differences in sources of information were noted for physicians as compared with midlevel providers, and for rural and urban providers. Several potential ways to disseminate information about cognitive health were identified. Effective messaging is likely to require multiple strategies to reach diverse groups of primary care providers, and to include continuing medical education.

Impact of the ALLHAT/JNC7 Dissemination Project on thiazide-type diuretic use

BACKGROUND

Strategies are needed to improve the translation of clinical trial results into practice. We assessed the impact of the ALLHAT/JNC7 Dissemination Project's academic detailing component on thiazide-type diuretic prescribing (ALLHAT indicates Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; JNC7 indicates the Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure).

METHODS

We used 2 national databases available from IMS Health: a physician survey of medications reported for hypertension and a pharmacy dispensing database on antihypertensive medications. At a county level, we correlated medication data with Dissemination Project intensity. Practices before the Dissemination Project in 2004 were compared with those after its completion in 2007. We also examined 2000-2008 national trends.

RESULTS

Academic detailing reached 18 524 physicians in 1698 venues via 147 investigator-educators. We noted an association between ALLHAT/JNC7 academic detailing activities and increased prescribing of thiazide-type diuretics. Physician survey data showed that the percentage of hypertension visits where the physician recorded a thiazide-type diuretic increased the most in counties where academic detailing activity was the highest (an increase of 8.6%, from 37.9% to 46.5%) compared with counties where activity was moderate (an increase of 2%) or low (a decrease of 2%), or where there was none (an increase of 2%; P value for trend, <.05). Pharmacy dispensing data showed that thiazide-type diuretic prescribing increased by 8.7% in counties with Dissemination Project activities compared with 3.9% in those without activities (P < .001). Nationally, thiazide-type diuretic use did not increase between 2004 and 2008.

CONCLUSIONS

The ALLHAT/JNC7 Dissemination Project was associated with a small effect on thiazide-type diuretic use consistent with its small dose and the potential of external factors to diminish its impact. Academic detailing may increase physicians' implementation of clinical trial results, thereby making prescribing more consistent with evidence.