Implementation salvage experiences from the Melbourne diabetes prevention study

A research agenda to advance the study of implementation mechanisms

BACKGROUND

Implementation science scholars have made significant progress identifying factors that enable or obstruct the implementation of evidence-based interventions, and testing strategies that may modify those factors. However, little research sheds light on how or why strategies work, in what contexts, and for whom. Studying implementation mechanisms-the processes responsible for change-is crucial for advancing the field of implementation science and enhancing its value in facilitating equitable policy and practice change. The Agency for Healthcare Research and Quality funded a conference series to achieve two aims: (1) develop a research agenda on implementation mechanisms, and (2) actively disseminate the research agenda to research, policy, and practice audiences. This article presents the resulting research agenda, including priorities and actions to encourage its execution.

METHOD

Building on prior concept mapping work, in a semi-structured, 3-day, in-person working meeting, 23 US-based researchers used a modified nominal group process to generate priorities and actions for addressing challenges to studying implementation mechanisms. During each of the three 120-min sessions, small groups responded to the prompt: "What actions need to be taken to move this research forward?" The groups brainstormed actions, which were then shared with the full group and discussed with the support of facilitators trained in structured group processes. Facilitators grouped critical and novel ideas into themes. Attendees voted on six themes they prioritized to discuss in a fourth, 120-min session, during which small groups operationalized prioritized actions. Subsequently, all ideas were collated, combined, and revised for clarity by a subset of the authorship team.

RESULTS

From this multistep process, 150 actions emerged across 10 priority areas, which together constitute the research agenda. Actions included discrete activities, projects, or products, and ways to shift how research is conducted to strengthen the study of implementation mechanisms.

CONCLUSIONS

This research agenda elevates actions to guide the selection, design, and evaluation of implementation mechanisms. By delineating recommended actions to address the challenges of studying implementation mechanisms, this research agenda facilitates expanding the field of implementation science, beyond studying what works to how and why strategies work, in what contexts, for whom, and with which interventions.

Implementation mapping for tobacco cessation in a federally qualified health center

Background

Implementation mapping (IM) is a promising five-step method for guiding planning, execution, and maintenance of an innovation. Case examples are valuable for implementation practitioners to understand considerations for applying IM. This pilot study aimed to determine the feasibility of using IM within a federally qualified health center (FQHC) with limited funds and a 1-year timeline.

Methods

An urban FQHC partnered with an academic team to employ IM for implementing a computerized strategy of tobacco cessation: the 5A's (Ask, Advise, Assess, Assist, Arrange). Each step of IM was supplemented with theory-driven methods and frameworks. Data collection included surveys and interviews with clinic staff, analyzed via rapid data analysis.

Results

Medical assistants and clinicians were identified as primary implementers of the 5A's intervention. Salient determinants of change included the perceived compatibility and relative priority of 5A's. Performance objectives and change objectives were derived to address these determinants, along with a suite of implementation strategies. Despite indicators of adoptability and acceptability of the 5A's, reductions in willingness to adopt the implementation package occurred over time and the intervention was not adopted by the FQHC within the study timeframe. This is likely due to the strain of the COVID-19 pandemic altering health clinic priorities.

Conclusions

Administratively, the five IM steps are feasible to conduct with FQHC staff within 1 year. However, this study did not obtain its intended outcomes. Lessons learned include the importance of re-assessing barriers over time and ensuring a longer timeframe to observe implementation outcomes.

Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels

Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Assessment of diabetes knowledge, screening and uptake of community diabetes programs in a peri-urban region in Australia

AIMS

The Wollondilly Diabetes Program (WDP) is testing ways to improve uptake of diabetes prevention services. This project evaluated the reach of WDP in diabetes promotion while assessing diabetes knowledge and risk among residents.

METHODS

A WDP member travelled in the DW weekly to community events including outreach programs between October 2016 and June 2019. Data from diabetes knowledge questionnaire (DKQ), the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), HbA1c and Random Blood Glucose (RBG) measurements obtained from participants who attended community events and road shows.

RESULTS

Over the 32 months period, WDP attended 32 community events reaching 1415 people (∼3% of the Wollondilly adult population). DKQ was completed by 154 people (52.9% females, 78% Australian born, median age 69 years), 39% had diabetes and their mean score (25.0 ± 3.1, maximum possible score = 31) was similar to those without diabetes (24.0 ± 4.6, p = 0.093). AUSDRISK assessment was completed by 166 people with 85% at intermediate or high risk of diabetes. There were 65% results above range for RBG (≥5.5 mmol/l) and/or HbA1c (≥5.7%,39 mmol/mol).

CONCLUSION

A community outreach team set up in partnership with local stakeholders that offers opportunistic diabetes screening, is an effective way of engaging with the community to increase diabetes awareness and knowledge.

Skills for Developing and Maintaining Community-Partnerships for Dissemination and Implementation Research in Children's Behavioral Health: Implications for Research Infrastructure and Training of Early Career Investigators

By engaging with community partners, dissemination and implementation scholars can enhance research relevance and translation. We illustrate the skills needed for developing and maintaining community partnerships by presenting two case studies of partnerships between early-career investigators and child welfare systems to implement mental health interventions. The cases represent two models of partnership (investigator-led and agency-led), highlighting the value and difficulty of conducting community-engaged implementation research. The experiences described feature strategies for building and managing relationships, navigating rules and regulations, adaptation, and securing resources. We offer suggestions for improving training and research infrastructures to support community-engaged implementation scholars.

Casual blood glucose and subsequent cardiovascular disease and all-cause mortality among 159 731 participants in Cohort of Norway (CONOR)

INTRODUCTION

Our aim was to assess the association between casual blood glucose level and subsequent cardiovascular disease (CVD) and mortality among community-dwelling adults without a diagnosis of diabetes.

RESEARCH DESIGN AND METHODS

In this community-based cohort study, 159 731 individuals with a measurement of casual blood glucose were followed from their participation date in Cohort of Norway (CONOR) (1994-2003) until a CVD episode, death or 31 December 2009. All analyses were done using Cox proportional hazard regression, and the results are reported as multivariable-adjusted HRs with 95% CI.

RESULTS

Compared with those with normal glucose levels (<7.8 mmol/L), participants categorized as having borderline (7.8-11.0 mmol/L) levels showed an increased risk of a stroke (HR 1.29; 95% CI 1.12 to 2.49) and cardiovascular (HR 1.29; 95% CI 1.12 to 2.48), and all-cause (HR 1.27; 95% CI 1.16 to 1.38) mortality, while participants with high glucose levels (>11.0 mmol/L) had an even more increased risk. One mmol/L increase in glucose level was associated with an increased risk of all four endpoints among participants with borderline as well as within normal glucose levels. In analyses stratified by sex and age group, the CVD risk estimates tended to be higher in women than in men and in those <65 years of age but no significant interactions were found.

CONCLUSION

An increase in casual blood glucose levels, even within the range of normal and borderline levels, was positively associated with increased risk of CVD and mortality among community-dwelling adults without a known diagnosis of diabetes.

Design of a cluster-randomized trial of the effectiveness and cost-effectiveness of metformin on prevention of type 2 diabetes among prediabetic Mexican adults (the PRuDENTE initiative of Mexico City)

INTRODUCTION

Type 2 diabetes (T2D) is a global epidemic, and nations are struggling to implement effective healthcare strategies to reduce the burden. While efficacy studies demonstrate that metformin can reduce incident T2D by half among younger, obese adults with prediabetes, its real-world effectiveness are understudied, and its use for T2D prevention in primary care is low. We describe the design of a pragmatic trial to evaluate the incremental effectiveness of metformin, as an adjunct to a simple lifestyle counseling.

METHODS

The "Prevención de la Diabetes con Ejercicio, Nutrición y Tratamiento" [Diabetes Prevention with Exercise, Nutrition and Treatment; PRuDENTE, (Spanish acronym)] is a cluster-randomized trial in Mexico City's public primary healthcare system. The study randomly assigns 51 clinics to deliver one of two interventions for 36 months: 1) lifestyle only; 2) lifestyle plus metformin, to 3060 patients ages 30-65 with impaired fasting glucose and obesity. The primary endpoint is incident T2D (fasting glucose ≥126 mg/dL, or HbA1c ≥6.5%). We will also measure a range of implementation-related process outcomes at the clinic-, clinician- and patient-levels to inform interpretations of effectiveness and enable efforts to refine, adapt, adopt and disseminate the model. We will also estimate the cost-effectiveness of metformin as an adjunct to lifestyle counseling in Mexico.

DISCUSSION

Findings from this pragmatic trial will generate new translational knowledge in Mexico and beyond, both with respect to metformin's real-world effectiveness among an 'at-risk' population, and uncovering facilitators and barriers to the reach, adoption and implementation of metformin preventive therapy in public primary care settings.

TRIAL REGISTRATION

This trial is registered at Clinicaltrials.gov (NCT03194009).

Stakeholders' perceptions and experiences of the National Health Service diabetes prevention programme in England: qualitative study with service users, intervention providers and deliverers, commissioners and referrers

BACKGROUND

The National Health Service diabetes prevention programme in England, (NHS DPP) aims to identify people at high risk of type 2 diabetes (T2D) and offer them a face-to-face, group-based, behaviour change intervention for at least 9 months. The NHS DPP was rolled out in phases. We aimed to elicit stakeholders' perceptions and experiences of the factors influencing implementation of, and participation in, the programme during the development phase.

METHODS

Individual, semi-structured telephone interviews were conducted with 50 purposively sampled stakeholders: service users (n = 20); programme commissioners (n = 7); referrers (n = 8); and intervention deliverers (n = 15). Topic guides were structured using a pragmatic, theory-informed approach. Analysis employed the framework method.

RESULTS

We identified factors that influenced participation: Risk communication at referral - stakeholders identified point of referral as a window of opportunity to offer brief advice, to provide an understanding of T2D risk and information about the programme; Perceived impact of the NHS DPP - service users highlighted the positive perceived impact on their behaviour change, the peer support provided by participating in the programme, the option to involve a relative, and the 'knock on' effect on others. Service users also voiced disappointment when blood test results still identified them at high risk after the programme; and Behavioural maintenance - participants highlighted the challenges linked to behavioural maintenance (e.g. discontinuation of active support). Factors influencing implementations were also identified: Case finding - stakeholders suggested that using community involvement to identify service users could increase reach and ensure that the workload was not solely on GP practices; Adaptability: intervention deliverers acknowledged the need to tailor advice to service users' preferences and needs; Accountability - the need to acknowledge who was responsible for what at different stages of the NHS DPP pathway; and Fidelity - stakeholders described procedures involved in monitoring service users' satisfaction, outcome data collection and quality assurance assessments.

CONCLUSIONS

The NHS DPP offers an evidence-informed behavioural intervention for T2D prevention. Better risk communication specification could ensure consistency at the referral stage and improve participation in the NHS DPP intervention. Cultural adaptations and outreach strategies could ensure the NHS DPP contributes to reducing health inequalities.

Getting a clinical innovation into practice: An introduction to implementation strategies

Just as there is a robust science that supports development and rigorous testing of clinical innovations, the emerging field of implementation science is developing new theory-based knowledge regarding a growing portfolio of meticulously tested implementation strategies that seek to improve uptake of evidence-based practices by targeting barriers at multiple levels within health care settings. Studying and documenting implementation strategies associated with uptake during the development and trial of a clinical innovation could subsequently position the researcher for a more seamless transition and handoff of the innovation to clinical and operational leaders. The objective of this manuscript is to introduce the concept of implementation strategies: what they are; the rigor with which they are defined and applied to address barriers to clinical innovation adoption; how strategy selection may vary based on contextual, innovation, and recipient factors; how to document the application of strategies over the course of an implementation study; and how testing their effectiveness is the focus of implementation research trials.

Enhancing the Impact of Implementation Strategies in Healthcare: A Research Agenda

The field of implementation science was developed to better understand the factors that facilitate or impede implementation and generate evidence for implementation strategies. In this article, we briefly review progress in implementation science, and suggest five priorities for enhancing the impact of implementation strategies. Specifically, we suggest the need to: (1) enhance methods for designing and tailoring implementation strategies; (2) specify and test mechanisms of change; (3) conduct more effectiveness research on discrete, multi-faceted, and tailored implementation strategies; (4) increase economic evaluations of implementation strategies; and (5) improve the tracking and reporting of implementation strategies. We believe that pursuing these priorities will advance implementation science by helping us to understand when, where, why, and how implementation strategies improve implementation effectiveness and subsequent health outcomes.

Challenges of diabetes prevention in the real world: results and lessons from the Melbourne Diabetes Prevention Study

OBJECTIVE

To assess effectiveness and implementability of the public health programme Life! Taking action on diabetes in Australian people at risk of developing type 2 diabetes.

RESEARCH DESIGN AND METHODS

Melbourne Diabetes Prevention Study (MDPS) was a unique study assessing effectiveness of Life! that used a randomized controlled trial design. Intervention participants with AUSDRISK score ≥15 received 1 individual and 5 structured 90 min group sessions. Controls received usual care. Outcome measures were obtained for all participants at baseline and 12 months and, additionally, for intervention participants at 3 months. Per protocol set (PPS) and intention to treat (ITT) analyses were performed.

RESULTS

PPS analyses were considered more informative from our study. In PPS analyses, intervention participants significantly improved in weight (-1.13 kg, p=0.016), waist circumference (-1.35 cm, p=0.044), systolic (-5.2 mm Hg, p=0.028) and diastolic blood pressure (-3.2 mm Hg, p=0.030) compared with controls. Based on observed weight change, estimated risk of developing diabetes reduced by 9.6% in the intervention and increased by 3.3% in control participants. Absolute 5-year cardiovascular disease (CVD) risk reduced significantly for intervention participants by 0.97 percentage points from 9.35% (10.4% relative risk reduction). In control participants, the risk increased by 0.11 percentage points (1.3% relative risk increase). The net effect for the change in CVD risk was -1.08 percentage points of absolute risk (p=0.013).

CONCLUSIONS

MDPS effectively reduced the risk of diabetes and CVD, but the intervention effect on weight and waist reduction was modest due to the challenges in recruiting high-risk individuals and the abbreviated intervention.

Diabetes prevention and treatment strategies: are we doing enough?

OBJECTIVE

Effective interventions to prevent, delay, or remit diabetes are currently available. However, their impact on the prevalence of diabetes at the population level is unknown. This study aimed to estimate the impact of a range of diabetes interventions on the population prevalence of diabetes for Australian adults between 2010 and 2025.

RESEARCH DESIGN AND METHODS

We used the Australian Diabetes Projection Model to estimate the impact of a population-wide strategy, high-risk prevention, surgical diabetes treatment, and a combination strategy on the future population prevalence of diabetes and to estimate the number of diabetes cases that could be potentially prevented in the year 2025.

RESULTS

We estimate that a population-wide strategy would reduce the number of diabetes cases by 60,000-85,000 in 2025 from an estimated 2 million cases under the status quo scenario. A high-risk prevention strategy would result in 106,000 to 150,000 fewer cases of diabetes in 2025, and surgically induced weight loss would result in 3,000-6,000 fewer cases. No single intervention, or combination of interventions, reversed the increasing trend in diabetes prevalence over the next 15 years.

CONCLUSIONS

To reverse upward trends in diabetes prevalence in future years, it is essential that current approaches to diabetes prevention and treatment are optimized and implemented and that alternative approaches to reduce the prevalence of diabetes at a population level are developed.