Use of RE-AIM to develop a multi-media facilitation tool for the patient-centered medical home

A mixed-methods observational study of strategies for success in implementation science: overcoming emergency departments hurdles

BACKGROUND

Heart failure is a major public health concern, affecting 6.7 million Americans. An estimated 16% of emergency department (ED) patients with acute heart failure (AHF) are discharged home. Our Get with the Guidelines in Emergency Department Patients with Heart Failure (GUIDED-HF) toolkit aims to improve AHF self-care and facilitate safer transitions in care for these patients. We describe implementation barriers and facilitators, and the selection and refinement of implementation strategies, to facilitate future GUIDED-HF implementation.

METHODS

A mixed-methods cross-sectional observational study was conducted in four United States EDs in two diverse healthcare systems in the Pacific West and Midwest. Data were collected using a survey and interviews with ED providers, nurses, and leaders. The survey assessed the ED context using the context scale of the Organizational Readiness to Change Assessment (ORCA). The Consolidated Framework for Implementation Research informed interviews. Quantitative data were summarized using medians (interquartile ranges) or percentages (frequencies). Wilcoxon rank-sum tests and Kruskal-Wallis tests were used to assess differences in the healthcare system and profession. Qualitative data were analyzed and summarized using rapid qualitative analysis. Convergence of quantitative and qualitative data was used to inform specific refining of implementation strategies to the local context (e.g., who should serve as champions, how best practice alerts should be implemented).

RESULTS

Participants were predominately white (76%) with median (IQR) age 37.0 (32.0, 41.0). ED leaders/administrators, providers, and nurses comprised 15%, 55%, and 29% of participants, respectively. Sites reported an ORCA context scale score of 3.7 [3.4, 4.0] (scale of 1 = strongly disagree to 5 = strongly agree). Comparison of scores by profession showed a significant difference in the context score among providers (3.9 [3.5, 4.0]), leaders (3.7 [3.5, 4.0]), and nurses (3.6 [3.0, 3.9]) (p = 0.048). Qualitative data indicated implementation barriers (e.g., resource limitations, patient health literacy), facilitators (e.g., GUIDED-HF is patient-centric; site and intervention congruent values, norms, and goals), and site-specific needs due to contextual factors (e.g., education needs, feedback mechanisms, champions).

CONCLUSIONS

Specific determinants of implementation exist in ED settings and require the refining of implementation strategies to overcome site-specific barriers and enhance facilitators.

TRIAL REGISTRATION

n/a.

Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland

BACKGROUND

Cisgender women account for 1 of every 5 new US HIV diagnoses, with most cases (85%) attributed to heterosexual contact. HIV preexposure prophylaxis is an effective prevention strategy; however, preexposure prophylaxis awareness and prescriptions among women are low.

OBJECTIVE

This study aimed to increase preexposure prophylaxis counseling and uptake among cisgender women attending obstetrics and gynecology clinics.

STUDY DESIGN

The study included 3 obstetrics and gynecology clinics within a single health system in a high HIV prevalence region. There were 3 phases: baseline (the 3-month period before the clinical trial that included provider education and training of a registered nurse about preexposure prophylaxis), clinical trial (the 3-month period during which eligible patients were randomized to an active control or preexposure prophylaxis registered nurse intervention), and maintenance (the 3-month period after the trial ended). Electronic medical record clinical decision support tools were available to both arms during the clinical trial, which included best practice alerts, order sets, progress note templates, and written and video preexposure prophylaxis educational materials for patients. In the intervention arm, a preexposure prophylaxis nurse contacted and counseled patients and was equipped to prescribe preexposure prophylaxis. Moreover, this study evaluated the phases through the "reach, effectiveness, adoption, implementation, and maintenance" framework. The primary outcome of the study was effectiveness (eg, percentage of eligible patients with documented HIV prevention counseling in the electronic medical record or preexposure prophylaxis prescriptions). The secondary outcomes included reach (eg, percentage of best practice alerts that providers acted on or the percentage of eligible patients who spoke with the preexposure prophylaxis registered nurse), adoption (eg, percentage of eligible patients with a best practice alert that triggered or the percentage of eligible patients the preexposure prophylaxis registered nurse attempted to contact), and maintenance (eg, percentage of patients with documented HIV prevention counseling or preexposure prophylaxis prescriptions during the maintenance phase).

RESULTS

There were 904 unique patients in all phases with a mean age of 28.8±7.7 years, and 416 patients (46%) were pregnant; moreover, 436 patients were randomized in the clinical trial phase. Concerning reach and adoption, best practice alerts were triggered for 100% of eligible encounters; however, the providers acted on 52% of them. The preexposure prophylaxis nurse attempted to contact every patient and successfully spoke with 81.2% of them in the preexposure prophylaxis registered nurse arm. Concerning effectiveness, there were significantly more patients counseled about preexposure prophylaxis in the preexposure prophylaxis registered nurse group than in the active control group (66.5% vs 12.3%, respectively; P<.001), although preexposure prophylaxis prescriptions were equivalent (P=1.0). Among the subgroup of patients who were counseled about preexposure prophylaxis, 18.5% of patients in the active control arm and 3.4% in the preexposure prophylaxis registered nurse arm were prescribed preexposure prophylaxis (P=.02). Concerning maintenance, clinical decision support tools alone resulted in preexposure prophylaxis counseling of 1.0% of patients during the maintenance phase vs 0.6% of patients during the baseline phase and 11.2% of patients during the clinical trial phase (P<.001). Preexposure prophylaxis prescriptions were not statistically different among the 3 phases (P=.096).

CONCLUSION

A preexposure prophylaxis nurse effectively increased HIV prevention discussions but did not lead to more preexposure prophylaxis prescriptions than the preexposure prophylaxis-focused clinical decision support tools used by providers. The decrease in preexposure prophylaxis counseling after the trial phase suggests that persistent interventions are needed to maintain effects.

Clinical Integration of Digital Patient-Reported Outcome Measures in Primary Health Care for Chronic Disease Management: Protocol for a Systematic Review

BACKGROUND

Health measurement guides policies and health care decisions are necessary to describe and attain the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. In the primary care setting, patient-reported outcome measurement allows outcome comparisons within and across settings and helps improve the clinical management of patients. However, these digital patient-reported outcome measures (PROMs) are still not adapted to the clinical context of primary health care, which is an indication of the complexity of integrating these tools in this context. We must then gather evidence of their impact on chronic disease management in primary health care and understand the characteristics of effective implementation.

OBJECTIVE

We will conduct a systematic review to identify and assess the impact of electronic PROMs (ePROMs) implementation in primary health care for chronic disease management. Our specific objectives are to (1) determine the impact of ePROMs in primary health care for chronic disease management and (2) compare and contrast characteristics of effective ePROMs' implementation strategies.

METHODS

We will conduct a systematic review of the literature in accordance with the guidelines of the Cochrane Methods Group and in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for its reporting. A specific search strategy was developed for relevant databases to identify studies. Two reviewers will independently apply the inclusion criteria using full texts and will extract the data. We will use a 2-phase sequential mixed methods synthesis design by conducting a qualitative synthesis first, and use its results to perform a quantitative synthesis.

RESULTS

This study was initiated in June 2022 by assembling the research team and the knowledge transfer committee. The preliminary search strategy will be developed and completed in September 2022. The main search strategy, data collection, study selection, and application of inclusion criteria were completed between October and December 2022.

CONCLUSIONS

Results from this review will help support implementation efforts to accelerate innovations and digital adoption for primary health care and will be relevant for improving clinical management of chronic diseases and health care services and policies.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022333513; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=333513.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48155.

Evaluation of a systems ergonomics-based incident reporting system

INTRODUCTION

Incident reporting and learning systems are a fundamental component of safety management. The purpose of this study was to evaluate a novel incident reporting system specific to the Australian Led Outdoor Activity (LOA) sector. The Understanding and Preventing Led Outdoor Accidents Data System (UPLOADS), is a recently introduced systems thinking-based incident reporting and learning system that utilises contemporary safety theory and methods.

METHOD

The implementation of UPLOADS was evaluated using the RE-AIM framework based on the following dimensions: Reach, Efficacy, Adoption, Implementation, and Maintenance. A pragmatic evaluation approach was used in which evaluation data were collected through the triangulation of multiple sources including different LOA stakeholders from both the individual organisational level (LOA providers) and LOA sector governance level (LOA industry representatives), incident data collected through the UPLOADS National Incident Dataset, and the online and physical presence of UPLOADS.

RESULTS

The findings show that a key strength of UPLOADS is its effectiveness as incident reporting tool for improving safety in the LOA sector. However, a weakness of UPLOADS is that it is not being implemented appropriately by the LOA providers.

CONCLUSION

Overall, the current findings suggest that UPLOADS incident reporting tool is perceived by SMEs as an effective tool for improving safety in LOA. However, further work is required for UPLOADS to have a greater impact on the LOA sector. Specifically, Implementation of the UPLOADS system requires improvement, as well as additional training and education may be required to upskill and empower LOA providers to improve reporting and enhance the value placed on safety by LOA stakeholders. The RE-AIM framework was an appropriate evaluation framework for understanding the effectiveness of UPLOADS as a LOA sector specific incident reporting and learning system.

PRACTICAL APPLICATIONS

The current findings have practical implications for ergonomics researchers applying evaluation frameworks in the real world, and LOA providers for implementing safety interventions. Lastly, contemporary systems-based incident reporting and learning systems have the capability to enhance the safety practices of the LOA sector.

Mbarara University Research Training Initiative: Experiences and Accomplishments of the MEPI Junior D43 TW010128 Award in Uganda

OBJECTIVE

In 2015, Mbarara University of Science and Technology was awarded the Mbarara University Research Training Initiative (MURTI) under grant number D43 TW010128 to build capacity of junior faculty to become the next generation of researchers in Africa. In this paper, we document the experiences and achievements of the research capacity building efforts at MUST.

METHODS

We conducted a descriptive evaluation study which involved document review and in-depth interviews. We used "Reach" and 'Effectiveness' from the RE-AIM framework to guide the document review, and the organizational theory of implementation effectiveness to guide the in-depth interviews.

RESULTS

In the MURTI program, we conducted 17 short courses between August 2015 and July 2021, a total of 6597 attendances were recorded. The most attended courses were responsible conduct of research (n = 826), qualitative research methods (n = 744), and data management (n = 613). Thirty-three fellows were recruited and funded to conduct mentored research leading to 48 publications and 14 extramural grant applications were yielded. From the in-depth interviews, the participants appreciated the research training program, the enhanced research skills attained, and the institutional capacity built. They attributed the success of the program to the training approach of using short courses, readiness of the junior faculty to change, and the supportive environment by the mentors and trainers in the program.

CONCLUSION

The D43 TW010128 research training grant-built capacity for the junior faculty at MUST, enhanced their research skills, promoted research capacity institutionally and provided career development for the junior faculty. This was possible due to the positive attitude of the junior faculty (organizational readiness) to change and the supportive environment (mentors and trainers) during implementation of the grant. These two factors provided a favorable institutional climate that guaranteed success of the funding goals.

Feasibility and Acceptability of a Digital Patient-Reported Outcome Tool in Routine Outpatient Diabetes Care: Mixed Methods Formative Pilot Study

Background

Improvements in the digital capabilities of health systems provide new opportunities for the integration of patient-reported outcome (PRO) solutions in routine care, which can facilitate the delivery of person-centered diabetes care. We undertook this study as part of our development of a new digital PRO diabetes questionnaire and clinical dialog support tool for use by people with diabetes and their health care professionals (HCPs) to improve person-centered diabetes care quality and outcomes.

Objective

This study evaluates the feasibility, acceptability, and perceived benefits and impacts of using a digital PRO diabetes tool, DiaProfil, in routine outpatient diabetes care.

Methods

Overall, 12 people with diabetes scheduled for routine medical diabetes visits at the outpatient clinic were recruited. Purposive sampling was used to optimize heterogeneity regarding age, gender, duration, type of diabetes, treatment modality, and disease severity. Participants filled out a PRO diabetes questionnaire 2 to 5 days before their visit. During the visit, HCPs used a digital PRO tool to review PRO data with the person with diabetes for collaborative care planning. Participants completed evaluation forms before and after the visit and were interviewed for 30 to 45 minutes after the visit. HCPs completed the evaluation questionnaires after each visit. All visits were audio-recorded and transcribed for analysis. Data were analyzed using quantitative, qualitative, and mixed methods analyses.

Results

People with diabetes found the PRO diabetes questionnaire to be relevant, acceptable, and feasible to complete from home. People with diabetes and HCPs found the digital PRO tool to be feasible and acceptable for use during the diabetes visit and would like to continue using it. HCPs were able to use the tool in a person-centered manner, as intended. For several people with diabetes, completion of the questionnaire facilitated positive reflection and better preparation for the visit. The use of the PRO tool primarily improved the quality of the dialog by improving the identification and focus on the issues most important to the person with diabetes. People with diabetes did not report any negative aspects of the PRO tool, whereas HCPs highlighted that it was demanding when the person with diabetes had many PRO issues that required attention within the predefined time allocated for a visit.

Conclusions

The Danish PRO diabetes questionnaire and the digital tool, DiaProfil, are feasible and acceptable solutions for routine diabetes visits, and this tool may generate important benefits related to advancement of person-centered care. Further research is now required to corroborate and expand these formative insights on a larger scale and in diverse health care settings. The results of this study are therefore being used to define research hypotheses and finalize real-world PRO evaluation tools for a forthcoming large-scale multisector implementation study in Denmark.

Transforming Health and Resiliency Through Integration of Values-based Experiences: Implementation of an Electronic Evidence-based Whole Health Clinical Program

BACKGROUND

Complementary and integrative health (CIH) is the foundation of the Department of Veterans Affairs (VA) Whole Health System program (WH), including Transforming Health and Resiliency through Integration of Values-based Experiences (THRIVE). The global COVID-19 pandemic prompted an urgent need to provide services such as THRIVE while following guidelines for social distancing.

OBJECTIVE

The objective of this paper was to describe the systematic implementation of THRIVE using an electronic delivery model.

METHODS

The study involved an observational clinical program implementation project using the RE-AIM framework to contextualize the implementation strategies and results, and then the implementation of an electronically delivered CIH group medical appointment program (eTHRIVE).

RESULTS

Clinical staff transitioned to 100% electronic delivery of the THRIVE curriculum using the new eTHRIVE delivery model. The current electronic delivery model, eTHRIVE, has effectively enrolled 10-12 veterans per cohort, with 8 cohorts, totaling 87 veterans to date. eTHRIVE attrition has been 6% (5/87) since initiation.

CONCLUSIONS

The current climate of the VA WH programmatic initiative combined with the public health needs during a global pandemic prompted the move of THRIVE program into an electronic format to broaden scalability and reach.

An Implementation Approach Comparison of a Child Care Center-Based Obesity Prevention Program

OBJECTIVE

To compare the effectiveness of the Healthy Caregivers-Healthy Children (HC2) phase 1 (2011-2014) and 2 (2015-2018) child care center (CCC)-based obesity prevention intervention(s) on child dietary practices and body mass index percentile (PBMI) outcomes over 2 years. Phase 1 was implemented via a university-based research team, and phase 2 was delivered via a train-the-trainers approach (university-based research team trains preschool-based coaches, who in turn train CCC teachers to implement and disseminate HC2).

METHODS

Phase 1 and 2 were both cluster randomized controlled trials of the HC2 obesity prevention intervention. Phase 1 was composed of 1224 children in 28 CCCs (12 intervention and 16 control). Phase 2 was composed of 825 children in 24 CCCs (12 intervention and 12 control). Both phases included CCCs serving low-resource, predominantly ethnic minority families.

RESULTS

The mean rate of weekly fruit consumption significantly increased (β = 0.16, p = 0.001) in phase 1, whereas vegetable intake significantly increased (β = 0.16, p = 0.002) in phase 2 intervention CCCs. Fried (β = -0.36, p < 0.001), fast (β = -0.16, p = 0.001), and other unhealthy food (β = -0.57, p < 0.001) consumption significantly decreased in phase 1 only. The mean rate of snack food consumption significantly decreased in phase 2 (β = -0.97, p < 0.001). Mean child PBMI remained in the healthy range over 2 years for all groups in both study phases.

CONCLUSION

A university-based research team implementation and dissemination approach seemed to be more effective than a train-the-trainers implementation method in improving dietary intake patterns. This finding suggests that CCCs may need robust educational support beyond their existing internal resources for long-term positive dietary intake pattern changes.

PRimary Care Opioid Use Disorders treatment (PROUD) trial protocol: a pragmatic, cluster-randomized implementation trial in primary care for opioid use disorder treatment

Background

Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here.

Methods

PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16–90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims (“electronic health records,” [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization.

Discussion

The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings.

Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&rank=1

I am ready to see you now, Doctor! A mixed-method study of the Let's Discuss Health website implementation in Primary Care

Background

Let's Discuss Health (LDH) is a website that encourages patients to prepare their health‐care encounters by providing communication training, review of topics and questions that are important to them.

Objective

To describe LDH implementation during primary care (PC) visits for chronic illnesses.

Methods

Design: Descriptive mixed‐method study. Setting: 6 PC clinics. Participants: 156 patients and 51 health‐care providers (HCP). Intervention: LDH website implementation. Outcome Measures: Perceived quality and usefulness of LDH; perceived quality of HCP‐patient communication; patient activation; LDH integration in routine PC practices and barriers to its use.

Results

Patients reported a positive perception of the website in that it helped them to adopt an active role in the encounters; recall their visit agenda and reduce encounter‐related stress; feel more confident to ask questions, feel more motivated to prepare their future medical visits and improve their chronic illness management. However, a certain disconnect emerged between HCP and patient perceptions as to the value of LDH in promoting a sense of partnership and collaboration. The main barriers to the use of LDH are HCP lack of interest, limited access to technology, lack of time and language barriers.

Conclusion

Our findings indicate that it is advantageous for patients to prepare their medical encounters. However, the study needs to be replicated in other medical environments using larger and more diverse samples.

Patient and Public Contribution

Patient partners were involved in the conduct of this study.

Leveraging implementation science to improve implementation outcomes in precision medicine

BACKGROUND AND PURPOSE

Introduction of omics technologies in clinical practice means increased use of validated biomarkers, through precision medicine (PM). Although implementation science (IS) affords an array of theoretical approaches that can potentially explain PM intervention uptake, their relevance and applicability in PM implementation has not been empirically tested. This article identifies and examines existing implementation frameworks for their applicability in PM, demonstrating how different IS theories can be used to generate testable implementation hypotheses in PM.

METHODS

A three-step methodology was employed to search and select implementation models: a scoping search in Google Scholar produced 15 commonly used models in healthcare; a systematic search in PUBMED and Web of Science using the names of each model as keywords in search strings produced 290 publications for screening and abstraction; finally, a citation frequency search in the 3 databases produced most cited models that were included in the narrative synthesis.

RESULTS

Main concepts and constructs associated with each of the 15 models were identified. Four most cited frameworks in healthcare were: REAIM, CFIR, PRISM and PARiHS. Corresponding constructs were mapped and examined for potential congruence to PM. A generalized PM implementation conceptual framework was developed showing how omics biomarker uptake relates to their evidence base, patient and provider engagement and Big data capabilities of involved organizations.

CONCLUSION

We demonstrated how implementation complexities in PM can be addressed by explicit use of implementation theories. The work here may provide a reference for further research of empirically testing and refining the identified implementation constructs.

A Lower Leg Physical Activity Intervention for Individuals With Chronic Venous Leg Ulcers: Randomized Controlled Trial

BACKGROUND

Individuals with venous leg ulcers (VLUs) suffer disproportionately with multiple chronic conditions, are often physically deconditioned, and demonstrate high levels of physical inactivity.

OBJECTIVE

The primary objective of this randomized controlled trial was to establish the feasibility of a mobile health (mHealth) physical activity exercise app for individuals with VLUs to improve lower leg function.

METHODS

In a 6-week study, adults with VLUs were recruited from 2 wound centers in South Carolina, United States, and enrolled if they were aged 18 years or older with impaired functional mobility and an ankle-brachial index between 0.8 and 1.3. Participants were randomized 1:1 to receive evidence-based, phased, nonexertive physical conditioning activities for lower leg function (FOOTFIT) or FOOTFIT+ with an added patient-provider communication feature. The mHealth Conditioning Activities for Lower Leg Function app also provided automated educational and motivational messages and user reports. Foot movement on the VLU-affected leg was tracked by a Bluetooth-enabled triaxial accelerometer. The study was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the feasibility of reach, adherence, acceptability, implementation, and maintenance.

RESULTS

A total of 24 patients were recruited, enrolled, and randomized in the study. Most patients reported difficulty following the protocol for exercising and using the accelerometer and mobile phone and did not use the provider contact feature. However, all patients were adherent to the 6-week exercise program more than 85% of the time for duration, whereas 33% (8/24) of patients adhered more than 85% for the frequency of performing the exercises. Across the three exercise levels, adherence did not differ between the two groups. Confidence limits around the difference in proportions ranged from -0.4 to 0.7. Providers in FOOTFIT+ were inconsistent in checking participant progress reports because of lack of time from competing work commitments. The technology became outdated quickly, making maintenance problematic. Participants said they would continue to exercise their foot and legs and liked being able to follow along with the demonstrations of each level of exercise provided through the app.

CONCLUSIONS

The findings of this study suggest that despite initial interest in using the app, several components of the program as originally designed had limited acceptability and feasibility. Future refinements should include the use of more modern technology including smaller wearable accelerometers, mobile phones or tablets with larger screens, an app designed with larger graphics, automated reporting for providers, and more engaging user features.

TRIAL REGISTRATION

ClinicalTrials.gov NTC02632695; https://clinicaltrials.gov/ct2/show/NCT02632695.

Utilizing the RE-AIM framework to determine effectiveness of a preschool intervention program on social-emotional outcomes

Social-emotional issues in preschoolers continue to be an area of concern across the nation. Models to determine effective implementation practices are needed. The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework is one model that can be used to evaluate program implementation in preschool settings. The Jump Start program provided short-term intervention to children in low-income preschools from multiethnic backgrounds. The goal was to promote prosocial behaviors while minimizing problem behaviors. Various evidenced-based practices (i.e., I Can Problem Solve, play therapy, Pyramid Model) were utilized. 305 children from 73 childcare centers participated in the program. The majority of participants were from ethnic minority backgrounds and resided in high-poverty areas of the county. The RE-AIM framework was utilized to determine program outcomes. Results showed successes on each level of RE-AIM with an at-risk population. The Jump Start program significantly increased positive behaviors and decreased challenging behaviors in preschool-aged children. Results indicated medium to large effect sizes. One year following program participation, the majority of children who participated in the program were at decreased risk of special education services and expulsion.

Interventions to Enhance Patient and Family Engagement Among Adults With Multiple Chronic Conditions: A Systematic Scoping Review

PURPOSE

In the United States, 42% of adults, and 81% of adults over 65 years of age live with multiple chronic condition (MCC). Current interventions to facilitate engagement in care focus primarily on the patient; however, many individuals with MCC manage and live with their conditions within the context of their family. This review sought to identify interventions used to facilitate patient and/or family engagement among adults with MCC.

METHODS

We adhered as closely as possible to PRISMA guidelines and conducted a systematic scoping review using a modified approach by Arksey and O'Malley. We searched PubMed, Web of Science, and Scopus using terms related to MCC, patient and family engagement, and intervention. We included articles that: (1) were published in English; (2) were peer-reviewed; (3) described an engagement intervention (with or without a comparator); and (4) targeted individuals with MCC. We abstracted data from included articles and classified them using the Multidimensional Framework for Patient and Family Engagement in Health and Health Care, and the Classification Model of Patient Engagement.

RESULTS

We identified 21 discrete interventions. Six (29%) were classified as having the highest degree of engagement. Eighteen (85%) focused on engagement at the direct care level. Only one was specifically designed to engage families.

CONCLUSIONS

Many engagement interventions currently exist for adults with MCC. Few of these interventions foster the highest degree of engagement; most focus on engagement at the level of direct care and do not specifically target family member involvement.

Application and effectiveness of eHealth strategies for metabolic and bariatric surgery patients: A systematic review

OBJECTIVE

To date the application of eHealth strategies among adults and adolescents undergoing metabolic and bariatric surgery (MBS) has not been systematically reviewed. This study comprehensively examines eHealth intervention studies among MBS patients within the RE-AIM framework to assess reach, effectiveness, adoption, implementation and maintenance of these efforts.

METHODS

A search was conducted using PubMed, EMBASE, CINAHL, PsycNET and SCOPUS of original research relating to eHealth strategies for MBS patients published in peer-reviewed journals and revealed 38 published articles between 2011 and 2019.

RESULTS

Studies varied widely in terms of design (qualitative to randomized controlled trials) and eHealth delivery method (telemedicine to blog post content) with a balance of pre- or post-MBS use. No studies included adolescents and very few reported (1) a conceptual framework to support study design/outcomes; and (2) race/ethnicity composition.

CONCLUSIONS

Although some studies report that eHealth strategies/interventions are effective in producing post-MBS weight loss and other positive health outcomes, most are pilot studies or have study design limitations. There is an opportunity for development of (1) tailored eHealth interventions to support pre- and post-MBS sustained behavior change and improved outcomes; and (2) rigorous studies that employ robust conceptual frameworks so dissemination and implementation efforts can be mapped to construct-driven outcomes.

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease

Background:

As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians.

Objective:

To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD.

Design:

This is a sequential, mixed methods study that will be conducted in 3 phases.

Setting:

The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]).

Patients:

Patients suffering from CKD will be included in the study.

Measurements:

We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Methods:

The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Results:

We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult.

Limitations:

Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task.

Conclusions:

Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents.

Trial registration:

Not required.

Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and a Case Study

PURPOSE OF REVIEW

In recent years, the recommendation for and use of patient-reported outcome measures (PROMs) in routine diabetes care has significantly increased. We review recent evidence and highlight key opportunities and challenges related to the active clinical use of PROMs to support person-centered diabetes care and focus areas for future research in the area.

RECENT FINDINGS

Recent pragmatic studies support that integration of multi-dimensional PROMs for diabetes in clinical care as part of a care improvement strategy can be acceptable for and valued by people with diabetes (PWD) and healthcare professionals (HCPs) and may improve multiple aspects of quality of care, including screening, medical care monitoring and decision support, individualization of self-management support and goal-setting, and broader benefits related to active patient participation and person-centred diabetes care. We identify multiple intervention, individual, and care setting characteristics, which influence acceptability, feasibility, implementation, and effectiveness of PROMs in routine care. Recent clinical PROM studies highlight the value of mixed methods research and systematic involvement of PWD, clinicians, and other stakeholders in the design and implementation of questionnaires for patient input in routine diabetes care. We identified a new significant trend towards participatory development of multi-dimensional PROMs with the aim of IT-enabled integration into routine diabetes care to facilitate multiple components of person-centered diabetes care and better clinical, quality of life, and cost outcomes. While results from large-scale randomized controlled studies are still limited, a growing number of pragmatic implementation studies support that user-centric PROM interventions have the potential to facilitate significant improvements in care for PWD.

Closed-loop electronic referral to SmokefreeTXT for smoking cessation support: a demonstration project in outpatient care

Too few smokers who present for outpatient healthcare receive evidence-based interventions to stop smoking. Referral to nationally available smoking cessation support may enhance tobacco intervention reach during healthcare visits. This study evaluated the feasibility of outpatient electronic health record (EHR)-enabled, closed-loop referral (eReferral) to SmokefreeTXT, a National Cancer Institute text message smoking cessation program. SmokefreeTXT eReferral for adult patients who smoke was implemented in a family medicine clinic and an allergy and asthma clinic in an integrated Midwestern healthcare system. Interoperable, HIPAA-compliant eReferral returned referral outcomes to the EHR. In Phase 1 of implementation, clinicians were responsible for eReferral; in Phase 2 this responsibility shifted to Medical Assistants and/or nurses. EHR data were extracted to compute eReferral rates among adult smokers and compare demographics among those eReferred versus not referred. SmokefreeTXT data were used to compute SmokefreeTXT enrollment rates among those eReferred. Descriptive analyses of clinic staff surveys assessed implementation context and staff attitudes toward and adaptations of eReferral processes. During clinician implementation, 43 of 299 adult smokers (14.4%) were eReferred. During medical assistant (MA) implementation, 36 of 401 adult smokers (9.0%) were eReferred. Overall, among those eReferred, 25.7% completed SmokefreeTXT enrollment (3.1% of patients eligible for eReferral). Staff survey responses indicated that eReferral was efficient and easy. eReferral rates and relevant attitudes varied meaningfully by clinic. Thus, interoperable eReferral via outpatient EHR to SmokefreeTXT is feasible and acceptable to clinic staff and enrolls roughly 3.0% of smokers. Clinic context and implementation approach may influence reach.

A Cluster Randomized Trial Comparing Strategies for Translating Self-Management Support into Primary Care Practices

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.

Measuring the Implementation of Behavioral Intervention Technologies: Recharacterization of Established Outcomes

Behavioral intervention technologies (BITs) are websites, software, mobile apps, and sensors designed to help users address or change behaviors, cognitions, and emotional states. BITs have the potential to transform health care delivery, and early research has produced promising findings of efficacy. BITs also favor new models of health care delivery and provide novel data sources for measurement. However, there are few examples of successful BIT implementation and a lack of consensus on as well as inadequate descriptions of BIT implementation measurement. The aim of this viewpoint paper is to provide an overview and characterization of implementation outcomes for the study of BIT use in routine practice settings. Eight outcomes for the evaluation of implementation have been previously described: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. In a proposed recharacterization of these outcomes with respect to BIT implementation, definitions are clarified, expansions to the level of analysis are identified, and unique measurement characteristics are discussed. Differences between BIT development and implementation, an increased focus on consumer-level outcomes, the expansion of providers who support BIT use, and the blending of BITs with traditional health care services are specifically discussed. BITs have the potential to transform health care delivery. Realizing this potential, however, will hinge on high-quality research that consistently and accurately measures how well such technologies have been integrated into health services. This overview and characterization of implementation outcomes support BIT research by identifying and proposing solutions for key theoretical and practical measurement challenges.

A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices

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.

Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies

BACKGROUND

Information communication technology (ICT) is a critical enabler of integrated models of community-based primary health care; however, little is known about how existing technologies have been used to support new models of integrated care. To address this gap, we draw on data from an international study of integrated models, exploring how ICT is used to support activities of integrated care and the organizational and environmental barriers and enablers to its adoption.

METHODS

We take an embedded comparative multiple-case study approach using data from a study of implementation of nine models of integrated community-based primary health care, the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. Six cases from Canada, three each in Ontario and Quebec, and three in New Zealand, were studied. As part of the case studies, interviews were conducted with managers and front-line health care providers from February 2015 to March 2017. A qualitative descriptive approach was used to code data from 137 interviews and generate word tables to guide analysis.

RESULTS

Despite different models and contexts, we found strikingly similar accounts of the types of activities supported through ICT systems in each of the cases. ICT systems were used most frequently to support activities like care coordination by inter-professional teams through information sharing. However, providers were limited in their ability to efficiently share patient data due to data access issues across organizational and professional boundaries and due to system functionality limitations, such as a lack of interoperability.

CONCLUSIONS

Even in innovative models of care, managers and providers in our cases mainly use technology to enable traditional ways of working. Technology limitations prevent more innovative uses of technology that could support disruption necessary to improve care delivery. We argue the barriers to more innovative use of technology are linked to three factors: (1) information access barriers, (2) limited functionality of available technology, and (3) organizational and provider inertia.

Patient and provider perspectives on the design and implementation of an electronic consultation system for kidney care delivery in Canada: a focus group study

OBJECTIVES

We assessed stakeholder perceptions on the use of an electronic consultation system (e-Consult) to improve the delivery of kidney care in Alberta. We aim to identify acceptability, barriers and facilitators to the use of an e-Consult system for ambulatory kidney care delivery.

METHODS

This was a qualitative focus group study using a thematic analysis design. Eight focus groups were held in four locations in the province of Alberta, Canada. In total, there were 72 participants in two broad stakeholder categories: patients (including patients' relatives) and providers (including primary care physicians, nephrologists, other care providers and policymakers).

FINDINGS

The e-Consult system was generally acceptable across all stakeholder groups. The key barriers identified were length of time required for referring physicians to complete the e-Consult due to lack of integration with current electronic medical records, and concerns that increased numbers of requests might overwhelm nephrologists and lead to a delayed response or an unsustainable system. The key facilitators identified were potential improvement of care coordination, dissemination of best practice through an educational platform, comprehensive data to make decisions without the need for face-to-face consultation, timely feedback to primary care providers, timeliness/reduced delays for patients' rapid triage and identification of cases needing urgent care and improved access to information to facilitate decision-making in patient care.

CONCLUSIONS

Stakeholder perceptions regarding the e-Consult system were favourable, and the key barriers and facilitators identified will be considered in design and implementation of an acceptable and sustainable electronic consultation system for kidney care delivery.

Implementation and evolution of a regional chronic disease self-management program

OBJECTIVE

To establish a comprehensive, community-based program to improve and sustain self-management support for individuals with chronic diseases and complement office-based strategies to support behaviour change.

PARTICIPANTS

Health service delivery organizations.

SETTING

The Champlain Local Health Integration Network (LHIN), a health district in Eastern Ontario.

INTERVENTION

We created Living Healthy Champlain (LHC), a regional organization providing peer leader training and coordination for the group Stanford Chronic Disease Self-Management Program (CDSMP); skills training and mentorship in behaviour change approaches for health care providers; and support to organizations to integrate self-management support into routine practice. We used the RE-AIM framework to evaluate the overall program's impact by exploring its reach, effectiveness, adoption, implementation and maintenance.

OUTCOME

A total of 232 Stanford CDSMP sessions (63 during the pilot project and 169 post-pilot) have been held at 127 locations in 24 cities across the Champlain LHIN, reaching approximately 4,000 patients. The effectiveness of the service was established through ongoing evidence reviews, a focus group and a pre-post utilization study of the pilot. LHC trained over 300 peer volunteers to provide the Stanford CDSMP sessions, 98 of whom continue to activelyhost workshops. An additional 1,327 providers have been trained in other models of self-management support, such as Health Coaching and Motivational Interviewing. Over the study period, LHC grew from a small pilot project to a regional initiative with sustainable provincial funding and was adopted by the province as a model for similar service delivery across Ontario.

CONCLUSION

A community-based self-management program working in partnership with primary care can be effectively and broadly implemented in support of patients living with chronic conditions.

Reducing childhood obesity through coordinated care: Development of a park prescription program

Major hindrances to controlling the current childhood obesity epidemic include access to prevention and/or treatment programs that are affordable, provide minimal barriers for participation, and are available to the general public. Moreover, successful childhood obesity prevention efforts will require coordinated partnerships in multiple sectors such as government, health care, school/afterschool, and the community but very few documented sustainable programs currently exist. Effective, community-based health and wellness programs with a focus on maintaining healthy weight via physical activity and healthy eating have the potential to be a powerful referral resource for pediatricians and other healthcare professionals who have young patients who are overweight/obese. The Miami Dade County Department of Parks, Recreation and Open Spaces in partnership with the University of Miami UHealth Systems have created a "Park Prescription Program (Parks Rx 4Health(TM))" that formally coordinates pediatricians, families, parents, caregivers, and child/adolescents to provide daily obesity-prevention activities. This Parks Rx 4Health(TM) program that we describe here allows UHealth pediatricians to seamlessly refer their overweight and obese patients to Fit2Play(TM), an evidence-based, park-based afterschool health and wellness program. Measurable outcomes that include body mass index, blood pressure, fitness, and nutrition knowledge are being collected at baseline and at 3-and 6-mo after referral to document patient progress. Results are then shared with the referring physician so they can follow up with the patient if necessary. Identifying successful models that integrate primary care, public health, and community-based efforts is important to accelerating progress in preventing childhood obesity. Effective, community-based health and wellness programs with a focus on physical activity and nutrition education could be a powerful referral resource for pediatricians who have obese patients.

Implementation of health risk assessments with family health history: barriers and benefits

Health risk assessments provide an opportunity to emphasise health promotion and disease prevention for individuals and populations at large. A key component of health risk assessments is the detailed collection of family health history information. This information is helpful in determining risk both for common chronic conditions and more rare diseases as well. While the concept of health risk assessments has been around since the Framingham Heart Study was launched in the 1950s, and such assessments are commonly performed in the workplace today, the US healthcare system has been slow to embrace them and the emphasis on prevention that they represent. Before wider implementation of health risk assessments within healthcare can be seen, several concerns must be addressed: (1) provider impact, (2) patient impact, (3) validity of patient-entered data and (4) health outcomes effect. Here, we describe recent developments in health risk assessment design that are helping to address these issues.

Bridging the gap between research and practice: an assessment of external validity of community-based physical activity programs in Bogotá, Colombia, and Recife, Brazil

For more than a decade, physical activity classes have been offered in public places at no cost to the participants in some Latin American cities, however, internal and external validity evidence of these programs is limited. The goals of this study were to assess, report, and compare the external validity of the Recreovia program (RCP) in Colombia, and the Academia da Cidade program (ACP) in Brazil. Interviews to assess external validity of the RCP and ACP were conducted in 2012. The interview guide was developed based on the RE-AIM framework. Seventeen key informants were selected to participate in the study. Interviews were recorded and transcribed verbatim. Transcripts were analyzed using a constant comparative qualitative method and experts validated common themes. RCP and ACP key informants reported that both programs reach underserved population. There is no information available about effectiveness. Both programs take place in public spaces (e.g., parks and plazas), which are selected for adoption mainly based on community demand. RCP and ACP offer free physical activity classes with educational and cultural components, have a strong organizational structure for implementation, and differ on schedule and content of classes. Funding sources were reported to play an important role on long-term maintenance. Facilitators and barriers were identified. Programs are similar in the reach and adoption elements; the main differences were found on implementation and maintenance, whereas information on effectiveness was not found. Reporting external validity of these programs is useful to bridge the gap between research and practice.

Bringing life course home: a pilot to reduce pregnancy risk through housing access and family support

Proponents of life course comment that while the theory is persuasive, translating theory to practice is daunting. This paper speaks to the challenges and possibilities of intervention based on life course theory. It describes Healthy Start in Housing (HSiH), a partnership between the Boston Public Health Commission (BPHC) and the Boston Housing Authority (BHA) to reduce stress due to housing insecurity among low-income, pregnant women. HSiH seeks improved birth outcomes and long term health of mothers and infants. BHA goals are improved quality of life for participants, greater public housing stability and enhanced impact of housing on community well-being. HSiH is a 1 year pilot offering 75 housing units to pregnant women at risk of adverse birth outcomes and homelessness. BHA provides housing and expedites processing of HSiH applications; BPHC staff oversee enrollment, guide women through the application process, and provide enhanced, long-term case management. Of 130 women referred to HSiH to date, 53 were ineligible, 59 have submitted applications, 13 are preparing applications and 5 dropped out. Nineteen women have been housed. Among eligible women, 58 % had medical conditions, 56 % mental health conditions, and 14 % prior adverse outcomes; 30 % had multiple risks. Standardized assessments reflected high levels of depressive symptoms; 41 % had symptoms consistent with post-traumatic stress disorder. Life course theory provides both the framework and the rationale for HSiH. HSiH experience confirms the salience of daily social experience to women's health and the importance of addressing stressors and stress in women's lives.

What does it mean to be pragmatic? Pragmatic methods, measures, and models to facilitate research translation

BACKGROUND

One of the reasons for the slow and uncertain translation of research into practice is likely due to the emphasis in science on explanatory models and efficacy designs rather than more pragmatic approaches.

METHODS

Following a brief definition of what constitutes a pragmatic approach, I provide examples of pragmatic methods, measures, and models and how they have been applied.

RESULTS

Descriptions are provided of pragmatic trials and related designs, practical measures including patient-reported items for the electronic health record, and the Evidence Integration Triangle and RE-AIM practical models, each of which can help increase the relevance of research to policy makers, practitioners, and patients/consumers.

CONCLUSIONS

By focusing on the perspective of stakeholders and the context for application of scientific findings, pragmatic approaches can accelerate the integration of research, policy, and practice. Progress has been made, especially in pragmatic trials but even more opportunities remain.

Considering context in quality improvement interventions and implementation: concepts, frameworks, and application

Growing consensus within the health care field suggests that context matters and needs more concerted study for helping those who implement and conduct research on quality improvement interventions. Health care delivery system decision makers require information about whether an intervention tested in one context will work in another with some differences from the original site. We aimed to define key terms, enumerate candidate domains for the study of context, provide examples from the pediatric quality improvement literature, and identify potential measures for selected contexts. Key sources include the organizational literature, broad evaluation frameworks, and a recent project in the patient safety area on context sensitivity. The article concludes with limitations and next steps for developments in this area.

Developing a framework to generate evidence of health outcomes from social media use in chronic disease management

Background

While there is an abundance of evidence-based practice (EBP) recommendations guiding management of various chronic diseases, evidence suggesting best practice for using social media to improve health outcomes is inadequate. The variety of social media platforms, multiple potential uses, inconsistent definitions, and paucity of rigorous studies, make it difficult to measure health outcomes reliably in chronic disease management. Most published investigations report on an earlier generation of online tools, which are not as user-centered, participatory, engaging, or collaborative, and thus may work differently for health self-management.

Objective

The challenge to establish a sound evidence base for social media use in chronic disease starts with the need to define criteria and methods to generate and evaluate evidence. The authors’ key objective is to develop a framework for research and practice that addresses this challenge.

Methods

This paper forms part of a larger research project that presents a conceptual framework of how evidence of health outcomes can be generated from social media use, allowing social media to be utilized in chronic disease management more effectively. Using mixed methods incorporating a qualitative literature review, a survey and a pilot intervention, the research closely examines the therapeutic affordances of social media, people with chronic pain (PWCP) as a subset of chronic disease management, valid outcome measurement of patient-reported (health) outcomes (PRO), the individual needs of people living with chronic disease, and finally translation of the combined results to improve evidence-based decision making about social media use in this context.

Results

Extensive review highlights various affordances of social media that may prove valuable to understanding social media’s effect on individual health outcomes. However, without standardized PRO instruments, we are unable to definitively investigate these effects. The proposed framework that we offer outlines how therapeutic affordances of social media coupled with valid and reliable PRO measurement may be used to generate evidence of improvements in health outcomes, as well as guide evidence-based decision making in the future about social media use as part of chronic disease self-management.

Conclusions

The results will (1) inform a framework for conducting research into health outcomes from social media use in chronic disease, as well as support translating the findings into evidence of improved health outcomes, and (2) inform a set of recommendations for evidence-based decision making about social media use as part of chronic disease self-management. These outcomes will fill a gap in the knowledge and resources available to individuals managing a chronic disease, their clinicians and other researchers in chronic disease and the field of medicine 2.0.

Implementation science approaches for integrating eHealth research into practice and policy

PURPOSE

To summarize key issues in the eHealth field from an implementation science perspective and to highlight illustrative processes, examples and key directions to help more rapidly integrate research, policy and practice.

METHODS

We present background on implementation science models and emerging principles; discuss implications for eHealth research; provide examples of practical designs, measures and exemplar studies that address key implementation science issues; and make recommendations for ways to more rapidly develop and test eHealth interventions as well as future research, policy and practice.

RESULTS

The pace of eHealth research has generally not kept up with technological advances, and many of our designs, methods and funding mechanisms are incapable of providing the types of rapid and relevant information needed. Although there has been substantial eHealth research conducted with positive short-term results, several key implementation and dissemination issues such as representativeness, cost, unintended consequences, impact on health inequities, and sustainability have not been addressed or reported. Examples of studies in several of these areas are summarized to demonstrate this is possible.

CONCLUSIONS

eHealth research that is intended to translate into policy and practice should be more contextual, report more on setting factors, employ more responsive and pragmatic designs and report results more transparently on issues important to potential adopting patients, clinicians and organizational decision makers. We outline an alternative development and assessment model, summarize implementation science findings that can help focus attention, and call for different types of more rapid and relevant research and funding mechanisms.

The RE-AIM framework: a systematic review of use over time

We provided a synthesis of use, summarized key issues in applying, and highlighted exemplary applications in the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We articulated key RE-AIM criteria by reviewing the published literature from 1999 to 2010 in several databases to describe the application and reporting on various RE-AIM dimensions. After excluding nonempirical articles, case studies, and commentaries, 71 articles were identified. The most frequent publications were on physical activity, obesity, and disease management. Four articles reported solely on 1 dimension compared with 44 articles that reported on all 5 dimensions of the framework. RE-AIM was broadly applied, but several criteria were not reported consistently.

Web 2.0 chronic disease self-management for older adults: a systematic review

Background

Participatory Web 2.0 interventions promote collaboration to support chronic disease self-management. Growth in Web 2.0 interventions has led to the emergence of e-patient communication tools that enable older adults to (1) locate and share disease management information and (2) receive interactive healthcare advice. The evolution of older e-patients contributing to Web 2.0 health and medical forums has led to greater opportunities for achieving better chronic disease outcomes. To date, there are no review articles investigating the planning, implementation, and evaluation of Web 2.0 chronic disease self-management interventions for older adults.

Objective

To review the planning, implementation, and overall effectiveness of Web 2.0 self-management interventions for older adults (mean age ≥ 50) with one or more chronic disease(s).

Methods

A systematic literature search was conducted using six popular health science databases. The RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) model was used to organize findings and compute a study quality score (SQS) for 15 reviewed articles.

Results

Most interventions were adopted for delivery by multidisciplinary healthcare teams and tested among small samples of white females with diabetes. Studies indicated that Web 2.0 participants felt greater self-efficacy for managing their disease(s) and benefitted from communicating with health care providers and/or website moderators to receive feedback and social support. Participants noted asynchronous communication tools (eg, email, discussion boards) and progress tracking features (eg, graphical displays of uploaded personal data) as being particularly useful for self-management support. Despite high attrition being noted as problematic, this review suggests that greater Web 2.0 engagement may be associated with improvements in health behaviors (eg, physical activity) and health status (eg, HRQoL). However, few studies indicated statistically significant improvements in medication adherence, biological outcomes, or health care utilization. Mean SQS scores were notably low (mean=63%, SD 18%). Studies were judged to be weakest on the Maintenance dimension of RE-AIM; 13 reviewed studies (87%) did not describe any measures taken to sustain Web 2.0 effects past designated study time periods. Detailed process and impact evaluation frameworks were also missing in almost half (n=7) of the reviewed interventions.

Conclusions

There is need for a greater understanding of the costs and benefits associated with using patient-centered Web 2.0 technologies for chronic disease self-management. More research is needed to determine whether the long-term effectiveness of these programs is sustainable among larger, more diverse samples of chronically ill patients. The effective translation of new knowledge, social technologies, and engagement techniques will likely result in novel approaches for empowering, engaging, and educating older adults with chronic disease.

The highest attainable standard of evidence (HASTE) for HIV/AIDS interventions: toward a public health approach to defining evidence

OBJECTIVES

Evidence-driven decisions have become a standard for health interventions, policy, and programs. While randomized controlled trials (RCTs) are encouraged for public health interventions, there are limitations with RCTs as the gold standard of evidence for HIV interventions. We developed a novel system of evaluating evidence for assessing HIV preventive interventions termed the Highest Attainable Standard of Evidence (HASTE).

METHODS

The HASTE system focuses on triangulation of three distinct categories of evidence: efficacy data, implementation data, and plausibility. We conducted systematic reviews, including experimental and observational data, to assess all available interventions for men who have sex with men (MSM). We collected implementation and programmatic data using a global electronic consultation, Internet searches, and in-person consultations. We assessed plausibility with expert analyses of both biological and public health evidence.

RESULTS

HASTE includes four grades of evidence: Strong (Grade 1), Conditional (Grade 2), Insufficient (Grade 3), and Inappropriate (Grade 4). We used the HASTE system to evaluate the evidence for HIV interventions for MSM in low- and middle-income countries. Several differences emerged in the strength of recommendation with the use of the HASTE system, including strong recommendations for voluntary counseling and testing and for structural interventions.

CONCLUSIONS

The HASTE system addresses a need for an evidence evaluation tool that is specific for HIV interventions and facilitates an evaluation of biomedical, behavioral, and structural approaches using the highest standard of attainable evidence. HASTE represents a tool that balances scientific integrity and practicality in assessing the quality of evidence of preventive interventions targeting the most-at-risk populations for HIV.

Patient-reported measures of psychosocial issues and health behavior should be added to electronic health records

Recent legislation and delivery system reform efforts are greatly expanding the use of electronic health records. For these efforts to reach their full potential, they must actively involve patients and include patient-reported information about such topics as health behavior, preferences, and psychosocial functioning. We offer a plan for including standardized, practical patient-reported measures as part of electronic health records, quality and performance indexes, the primary care medical home, and research collaborations. These measures must meet certain criteria, including being valid, reliable, sensitive to change, and available in multiple languages. Clinicians, patients, and policy makers also must be able to understand the measures and take action based on them. Including more patient-reported items in electronic health records would enhance health, patient-centered care, and the capacity to undertake population-based research.