Diffusion and dissemination of evidence-based dietary strategies for the prevention of cancer

Implementation strategies for knowledge products in primary healthcare: a systematic review of systematic reviews (Preprint)

Background

The underuse or overuse of knowledge products leads to waste in health care, and primary care is no exception.

Objective

This study aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.

Methods

We performed a systematic review (SR) of SRs using the Cochrane systematic approach to include eligible SRs. The inclusion criteria were any primary care contexts, health care professionals and patients, any Effective Practice and Organization of Care implementation strategies of specified knowledge products, any comparators, and any implementation outcomes based on the Proctor framework. We searched the MEDLINE, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019 without any restrictions. We searched the references of the included SRs. Pairs of reviewers independently performed selection, data extraction, and methodological quality assessment by using A Measurement Tool to Assess Systematic Reviews 2. Data extraction was informed by the Effective Practice and Organization of Care taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results by using a narrative synthesis.

Results

Of the 11,101 records identified, 81 (0.73%) SRs were included. Of these 81, a total of 47 (58%) SRs involved health care professionals alone. Moreover, 15 SRs had a high or moderate methodological quality. Most of them addressed 1 type of knowledge product (56/81, 69%), common clinical practice guidelines (26/56, 46%) or management, and behavioral or pharmacological health interventions (24/56, 43%). Mixed strategies were used for implementation (67/81, 83%), predominantly education-based (meetings in 60/81, 74%; materials distribution in 59/81, 73%; and academic detailing in 45/81, 56%), reminder (53/81, 36%), and audit and feedback (40/81, 49%) strategies. Education meetings (P=.13) and academic detailing (P=.11) seemed to be used more when the population was composed of health care professionals alone. Improvements in the adoption of knowledge products were the most commonly measured outcome (72/81, 89%). The evidence level was reported in 12% (10/81) of SRs on 62 outcomes (including 48 improvements in adoption), of which 16 (26%) outcomes were of moderate or high level.

Conclusions

Clinical practice guidelines and management and behavioral or pharmacological health interventions are the most commonly implemented knowledge products and are implemented through the mixed use of educational, reminder, and audit and feedback strategies. There is a need for a strong methodology for the SR of randomized controlled trials to explore their effectiveness and the entire cascade of implementation outcomes.

Toward optimal implementation of cancer prevention and control programs in public health: a study protocol on mis-implementation

BACKGROUND

Much of the cancer burden in the USA is preventable, through application of existing knowledge. State-level funders and public health practitioners are in ideal positions to affect programs and policies related to cancer control. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones. Greater attention to mis-implementation should lead to use of effective interventions and more efficient expenditure of resources, which in the long term, will lead to more positive cancer outcomes.

METHODS

This is a three-phase study that takes a comprehensive approach, leading to the elucidation of tactics for addressing mis-implementation. Phase 1: We assess the extent to which mis-implementation is occurring among state cancer control programs in public health. This initial phase will involve a survey of 800 practitioners representing all states. The programs represented will span the full continuum of cancer control, from primary prevention to survivorship. Phase 2: Using data from phase 1 to identify organizations in which mis-implementation is particularly high or low, the team will conduct eight comparative case studies to get a richer understanding of mis-implementation and to understand contextual differences. These case studies will highlight lessons learned about mis-implementation and identify hypothesized drivers. Phase 3: Agent-based modeling will be used to identify dynamic interactions between individual capacity, organizational capacity, use of evidence, funding, and external factors driving mis-implementation. The team will then translate and disseminate findings from phases 1 to 3 to practitioners and practice-related stakeholders to support the reduction of mis-implementation.

DISCUSSION

This study is innovative and significant because it will (1) be the first to refine and further develop reliable and valid measures of mis-implementation of public health programs; (2) bring together a strong, transdisciplinary team with significant expertise in practice-based research; (3) use agent-based modeling to address cancer control implementation; and (4) use a participatory, evidence-based, stakeholder-driven approach that will identify key leverage points for addressing mis-implementation among state public health programs. This research is expected to provide replicable computational simulation models that can identify leverage points and public health system dynamics to reduce mis-implementation in cancer control and may be of interest to other health areas.

Use of Evidence-Based Practices and Resources Among Comprehensive Cancer Control Programs

CONTEXT

While efforts to promote use of evidence-based practices (EBPs) for cancer control have increased, questions remain whether this will result in widespread adoption of EBPs (eg, Guide to Community Preventive Services interventions) by comprehensive cancer control (CCC) programs.

OBJECTIVE

To examine use of EBPs among CCC programs to develop cancer control plans and select interventions.

DESIGN

Conducted Web-based surveys of and telephone interviews with CCC program staff between March and July 2012.

SETTING

CCC programs funded by the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP).

PARTICIPANTS

Sixty-one CCC program directors.

MAIN OUTCOME MEASURES

1) Use of and knowledge/attitudes about EBPs and related resources and 2) EBP-related technical assistance needs.

RESULTS

Seventy-five percent of eligible program directors reported use of EBPs to a moderate or great extent to address program objectives. Benefits of using EBPS included their effectiveness has been proven, they are an efficient use of resources, and they lend credibility to an intervention. Challenges to using EBPs included resource limitations, lack of culturally appropriate interventions, and limited skills adapting EBPs for local use. Most respondents had heard of and used Web sites for The Guide to Community Preventive Services (95% and 91%, respectively) and Cancer Control P.L.A.N.E.T. (98% and 75%, respectively). Training needs included how to adapt an EBP and its materials for cultural appropriateness (state 78%, tribe 86%, territory 80%) and how to maintain the fidelity of an EBP (state 75%, tribe 86%, territory 60%).

CONCLUSIONS

While awareness, knowledge, and use of EBPs and related resources are high, respondents identified numerous challenges and training needs. The findings from this study may be used to enhance technical assistance provided to NCCCP grantees related to selecting and implementing EBPs.

Use of Mini-Grant to Disseminate Evidence-Based Interventions for Cancer Prevention and Control

Mini-grants are an increasingly common tool for engaging communities in evidence-based interventions for promoting public health. This article describes efforts by 4 Centers for Disease Control and Prevention/National Cancer Institute-funded Cancer Prevention and Control Research Network centers to design and implement mini-grant programs to disseminate evidence-based interventions for cancer prevention and control. This article also describes source of evidence-based interventions, funding levels, selection criteria, time frame, number and size of grants, types of organizations funded, selected accomplishments, training and technical assistance, and evaluation topics/methods. Grant size ranged from $1000 to $10 000 (median = $6250). This mini-grant opportunity was characterized by its emphasis on training and technical assistance for evidence-based programming and dissemination of interventions from National Cancer Institute's Research-Tested Intervention Programs and Centers for Disease Control and Prevention's Guide to Community Preventive Services. All projects had an evaluation component, although they varied in scope. Mini-grant processes described can serve as a model for organizations such as state health departments working to bridge the gap between research and practice.

Use of surveillance data in developing geographic dissemination strategies: a study of the diffusion of olanzapine to Michigan children insured by medicaid

OBJECTIVE

The purpose of this study was to examine the diffusion of olanzapine to urban and rural children insured by Medicaid in Michigan by identifying prescribing clusters through surveillance of claims records.

METHODS

Prescription claims records for all antipsychotic medications for 3,567 children insured by Medicaid in Michigan from 1996 through 1998 were examined through the state Medicaid database. There were 29,069 pediatric prescriptions for antipsychotic medications; 2949 were for olanzapine (576 children, 510 providers). These data were linked to the Area Resource File, Provider Enrollment File, and Rural-Urban Commuting Area codes. Patient and provider locations were geocoded by ZIP code. Mixed logistic regression analysis was performed to determine the probability of a child's being prescribed olanzapine given certain community, patient, and provider characteristics. Spatial clusters were identified through the local Moron's L statistic and empirical Bayes standardized incidence rates.

RESULTS

Rural children were more likely than urban children to be prescribed olanzapine (odds ratio [OR], 1.29; P < 0.001). There were significant differences by age and sex, with older children and girls more likely than younger children and boys to be prescribed olanzapine (OR, 1.30 and 1.37, respectively; both, P < 0.001). At the county level, the number of pediatricians per primary care physician reduced the likelihood of a child's being prescribed olanzapine (OR, 0.88; P = 0.039). The effect of the number of available mental health professionals was not significant. The global Moran's L statistic was U indicating moderate clustering of the use of olanzapine.

CONCLUSION

Graphic surveillance data may be useful for studying the delivery and use of health cue services. Further research is needed to determine how this method can be used strategically to facilitate or impede the diffusion of new medications.