Refining a taxonomy for guideline implementation: results of an exercise in abstract classification

Stimulating implementation of clinical practice guidelines in hospital care from a central guideline organization perspective: A systematic review

BACKGROUND

The uptake of guidelines in care is inconsistent. This review focuses on guideline implementation strategies used by guideline organizations (governmental agencies, scientific/professional societies and other umbrella organizations), experienced implementation barriers and facilitators and impact of their implementation efforts.

METHODS

We searched PUBMED, EMBASE and CINAHL and conducted snowballing. Eligibility criteria included guidelines focused on hospital care and OECD countries. Study quality was assessed using the Mixed Methods Appraisal Tool. We used framework analysis, narrative synthesis and summary statistics.

RESULTS

Twenty-six articles were included. Sixty-two implementation strategies were reported, used in different combinations and ranged between 1 and 16 strategies per initiative. Most frequently reported strategies were educational session(s) and implementation supporting materials. The most commonly reported barrier and facilitator were respectively insufficient healthcare professionals' time and resources; and guideline's credibility, evidence base and relevance. Eighty-five percent of initiatives that measured impact achieved improvements in adoption, knowledge, behavior and/or clinical outcomes. No clear optimal approach for improving guideline uptake and impact was found. However, we found indications that employing multiple active implementation strategies and involving external organizations and hospital staff were associated with improvements.

CONCLUSION

Guideline organizations employ diverse implementation strategies and encounter multiple barriers and facilitators. Our study uncovered potential effective implementation practices. However, further research is needed on effective tailoring of implementation approaches to increase uptake and impact of guidelines.

A streamlined approach to classifying and tailoring implementation strategies: recommendations to speed the translation of research to practice

BACKGROUND

Implementation science emerged from the recognized need to speed the translation of effective interventions into practice. In the US, the science has evolved to place an ever-increasing focus on implementation strategies. The long list of implementation strategies, terminology used to name strategies, and time required to tailor strategies all may contribute to delays in translating evidence-based interventions (EBIs) into practice. To speed EBI translation, we propose a streamlined approach to classifying and tailoring implementation strategies.

MAIN TEXT

A multidisciplinary team of eight scholars conducted an exercise to sort the Expert Recommendations for Implementing Change (ERIC) strategies into three classes: implementation processes (n = 25), capacity-building strategies (n = 20), and integration strategies (n = 28). Implementation processes comprise best practices that apply across EBIs and throughout the phases of implementation from exploration through sustainment (e.g., conduct local needs assessment). Capacity-building strategies target either general or EBI-specific knowledge and skills (e.g., conduct educational meetings). Integration strategies include "methods and techniques" that target barriers or facilitators to implementation of a specific EBI beyond those targeted by capacity building. Building on these three classes, the team collaboratively developed recommendations for a pragmatic, five-step approach that begins with the implementation processes and capacity-building strategies practice-settings are already using prior to tailoring integration strategies. A case study is provided to illustrate use of the five-step approach to tailor the strategies needed to implement a transitional care intervention in skilled nursing facilities.

CONCLUSIONS

Our proposed approach streamlines the formative work required prior to implementing an EBI by building on practice partner preferences, expertise, and infrastructure while also making the most of prior research findings.

Health-care organization characteristics in cancer care delivery: an integrated conceptual framework with content validation

Context can influence cancer-related outcomes. For example, health-care organization characteristics, including ownership, leadership, and culture, can affect care access, communication, and patient outcomes. Health-care organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming health-care organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-level, organization-level, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in health care delivery-and their dynamics is an important yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. The field lacks conceptual grounding, however, to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Underreporting of implementation strategies and barriers in physical activity interventions for young people at risk of problematic substance use: a brief report

BACKGROUND

Several studies have assessed whether physical activity interventions can reduce substance use in young people at risk of problematic substance use. This report identifies and describes the reporting of implementation characteristics within published studies of physical activity interventions for young people at risk of problematic substance use and provides recommendations for future reporting.

METHODS

Reported implementation strategies (including intervention manualization), barriers, implementation fidelity, and personnel acceptance were extracted from studies of physical activity interventions for young people aged 12-25 years at risk of problematic substance use that were included in a previous systematic review of intervention efficacy.

RESULTS

Implementation strategies were reported in less than half of the included studies (42.9%), implementation barriers in only 10.7% of studies, intervention fidelity in 21.4%, and personnel acceptance in a single study (3.6%).

CONCLUSIONS

Results indicate insufficient reporting of implementation strategies, barriers, fidelity, and personnel acceptance. Consideration of implementation characteristics is essential for implementing physical activity interventions in practice. Inadequate or limited reporting of these characteristics may contribute to delayed uptake and adoption of evidence-based interventions in clinical practice. Recommendations to improve the reporting of implementation information include integrating standards for reporting implementation characteristics into existing reporting guidelines, developing an international taxonomy of implementation strategies, and upskilling intervention researchers in the fundamentals of implementation science.

Moving toward the Development and Effective Implementation of High-Quality Guidelines in Pediatric Surgery: A Review of the Literature

Applying evidence-based guidelines can enhance the quality of patient care. While robust guideline development methodology ensures credibility and validity, methodological variations can impact guideline quality. Besides methodological rigor, effective implementation is crucial for achieving improved health outcomes. This review provides an overview of recent literature pertaining to the development and implementation of guidelines in pediatric surgery. Literature was reviewed to provide an overview of sound guideline development methodologies and approaches to promote effective guideline implementation. Challenges specific to pediatric surgery were highlighted. A search was performed to identify published guidelines relevant to pediatric surgery from 2018 to June 2023, and their quality was collectively appraised using the AGREE II instrument. High-quality guideline development can be promoted by using methodologically sound tools such as the Guidelines 2.0 checklist, the GRADE system, and the AGREE II instrument. While implementation can be promoted during guideline development and post-publication, its effectiveness may be influenced by various factors. Challenges pertinent to pediatric surgery, such as limited evidence and difficulties with outcome selection and heterogeneity, may impact guideline quality and effective implementation. Fifteen guidelines were identified and collectively appraised as suboptimal, with a mean overall AGREE II score of 58%, with applicability being the lowest scoring domain. There are identified challenges and barriers to the development and effective implementation of high-quality guidelines in pediatric surgery. It is valuable to prioritize the identification of adapted, innovative methodological strategies and the use of implementation science to understand and achieve effective guideline implementation.

Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol

INTRODUCTION

Early sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood culture, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L and vasopressors for hypotension during/after fluid resuscitation within 1 hour of sepsis recognition) is low across healthcare settings. Delays in sepsis recognition and a lack of high-quality evidence hinder its implementation. We propose a novel sepsis care model (National Early Warning Score, NEWS-1 care), in which the SSC Hour-1 Bundle is triggered objectively by a high NEWS-2 (≥5). This study aims to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial on the NEWS-1 care in multiple EDs.

METHODS AND ANALYSIS

We will conduct a pilot type 1 hybrid trial and prospectively recruit 200 patients from 4 public EDs in Hong Kong cluster randomised in a stepped wedge design over 10 months. All study sites will start with an initial period of standard care and switch in random order at 2-month intervals to the NEWS-1 care unidirectionally. The implementation evaluation will employ mixed methods guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, which includes qualitative and quantitative data from focus group interviews, staff survey and clinical record reviews. We will analyse the 14 feasibility outcomes as progression criteria to a full-scale trial, including trial acceptability to patients and staff, patient and staff recruitment rates, accuracy of sepsis screening, protocol adherence, accessibility to follow-up data, safety and preliminary clinical impacts of the NEWS1 care, using descriptive statistics.

ETHICS AND DISSEMINATION

The institutional review boards of all study sites approved this study. This study will establish the feasibility of a full-scale hybrid trial. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities.

TRIAL REGISTRATION NUMBER

NCT05731349.

Protocol for a cluster randomised trial of a goal-oriented care approach for multimorbidity patients supported by a digital platform

INTRODUCTION

Health information systems represent an opportunity to improve the care provided to people with multimorbidity. There is a pressing need to assess their impact on clinical outcomes to validate this intervention. Our study will determine whether using a digital platform (Multimorbidity Management Health Information System, METHIS) to manage multimorbidity improves health-related quality of life (HR-QoL).

METHODS AND ANALYSIS

A superiority, cluster randomised trial will be conducted at primary healthcare practices (1:1 allocation ratio). All public practices in the Lisbon and Tagus Valley (LVT) Region, Portugal, not involved in a previous pilot trial, will be eligible. At the participant level, eligible patients will be people with complex multimorbidity, aged 50 years or older, with access to an internet connection and a communication technology device. Participants who cannot sign/read/write and who do not have access to an email account will not be included in the study. The intervention combines a training programme and a customised information system (METHIS). Both are designed to help clinicians adopt a goal-oriented care model approach and to encourage patients and carers to play a more active role in autonomous healthcare. The primary outcome is HR-QoL, measured at 12 months with the physical component scale of the 12-item Short Form questionnaire (SF-12). Secondary outcomes will also be measured at 12 months and include mental health (mental component Scale SF-12, Hospital Anxiety and Depression Scale). We will also assess serious adverse events during the trial, including hospitalisation and emergency services. Finally, at 18 months, we will ask the general practitioners for any potentially missed diagnoses.

ETHICS AND DISSEMINATION

The Research and Ethics Committee (LVT Region) approved the trial protocol. Clinicians and patients will sign an informed consent. A data management officer will handle all data, and the publication of several scientific papers and presentations at relevant conferences/workshops is envisaged.

TRIAL REGISTRATION NUMBER

NCT05593835.

Barriers and facilitators for implementing lifestyle-related treatment modalities in osteoarthritis: A cross-sectional study among primary and secondary healthcare professionals

PURPOSE

To identify barriers and facilitators as perceived by primary and secondary healthcare professionals (HCPs) when implementing lifestyle-related treatment modalities (LRTMs) in patients with hip/knee osteoarthritis (OA).

METHODS

A cross-sectional study. A Dutch online survey was distributed among eight different disciplines of primary and secondary HCPs. Potential barriers and facilitators were identified based on participants' responses to 32 research-derived statements on implementing LRTMs, and presented as factors with "major agreement" (≥75%), "minor agreement" (60-75%) or "no agreement" (<60%).

RESULTS

213 participants completed the survey. Seven "barriers" and 20 "facilitators" were identified. There were three "major agreement barriers": organization of Dutch healthcare system, audits within organization, and lifestyle climate in Dutch society. The top three "major agreement facilitators" were: health effects on patients, safety of increasing physical activity, and personal attitude. The total number of "barriers" differed per HCP discipline, with the highest number (12) among orthopedic surgeons (or in-training) and the lowest number (4) among dieticians, physiotherapists, and lifestyle counselors.

CONCLUSIONS

The findings suggest that implementing LRTMs within OA care could be improved by focusing on societal rather than individual HCP factors. National preventive policies on health promotion could counteract the expected increase in healthcare demand and costs due to OA and other chronic diseases. Future research is needed to match relevant implementation strategies to all barriers identified.

Systematic development of a set of implementation strategies for transitional care innovations in long-term care

BACKGROUND

Numerous transitional care innovations (TCIs) are being developed and implemented to optimize care continuity for older persons when transferring between multiple care settings, help meet their care needs, and ultimately improve their quality of life. Although the implementation of TCIs is influenced by contextual factors, the use of effective implementation strategies is largely lacking. Thus, to improve the implementation of TCIs targeting older persons receiving long-term care services, we systematically developed a set of viable strategies selected to address the influencing factors.

METHODS

As part of the TRANS-SENIOR research network, a stepwise approach following Implementation Mapping (steps 1 to 3) was applied to select implementation strategies. Building on the findings of previous studies, existing TCIs and factors influencing their implementation were identified. A combination of four taxonomies and overviews of change methods as well as relevant evidence on their effectiveness were used to select the implementation strategies targeting each of the relevant factors. Subsequently, individual consultations with scientific experts were performed for further validation of the process of mapping strategies to implementation factors and for capturing alternative ideas on relevant implementation strategies.

RESULTS

Twenty TCIs were identified and 12 influencing factors (mapped to the Consolidated Framework for Implementation Research) were designated as priority factors to be addressed with implementation strategies. A total of 40 strategies were selected. The majority of these target factors at the organizational level, e.g., by using structural redesign, public commitment, changing staffing models, conducting local consensus discussions, and organizational diagnosis and feedback. Strategies at the level of individuals included active learning, belief selection, and guided practice. Each strategy was operationalized into practical applications.

CONCLUSIONS

This project developed a set of theory and evidence-based implementation strategies to address the influencing factors, along further tailoring for each context, and enhance the implementation of TCIs in daily practice settings. Such work is critical to advance the use of implementation science methods to implement innovations in long-term care successfully.

Creation of a theoretically rooted workbook to support implementers in the practice of knowledge translation

BACKGROUND

Few training opportunities or resources for non-expert implementers focus on the "practice" as opposed to the "science" of knowledge translation (KT). As a guide for novice implementers, we present an open-access, fillable workbook combining KT theories, models, and frameworks (TMFs) that are commonly used to support the implementation of evidence-based practices. We describe the process of creating and operationalizing our workbook.

METHODS

Our team has supported more than 1000 KT projects and 300 teams globally to implement evidence-based interventions. Our stakeholders have consistently highlighted their need for guidance on how to operationalize various KT TMFs to support novice implementers in "practising" KT. In direct response to these requests, we created a pragmatic, fillable KT workbook. The workbook was designed by KT scientists and experts in the fields of adult education, graphic design, and usability and was piloted with novice implementers. It is rooted in an integrated KT approach and applies an intersectionality lens, which prompts implementers to consider user needs in the design of implementation efforts.

RESULTS

The workbook is framed according to the knowledge-to-action model and operationalizes each stage of the model using appropriate theories or frameworks. This approach removes guesswork in selecting appropriate TMFs to support implementation efforts. Implementers are prompted to complete fillable worksheets that are informed by the Theoretical Domains Framework, the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, the Effective Practice and Organization of Care framework, Proctor's operationalization framework, the Durlak and DuPre process indicators, and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. As they complete the worksheets, users are guided to apply theoretically rooted approaches in planning the implementation and evaluation of their evidence-based practice.

CONCLUSIONS

This workbook aims to support non-expert implementers to use KT TMFs to select and operationalize implementation strategies to facilitate the implementation of evidence-based practices. It provides an accessible option for novice implementers who wish to use KT methods to guide their work.

Assessing Barriers and Facilitators for Implementing Clinical Practice Guidelines in Middle Eastern and North African Region: Delphi Study

BACKGROUND

Clinical practice guidelines (CPGs) improve clinical decision making and patient outcomes, but CPG implementation is poor. The success of CPGs is influenced by several factors related to barriers and facilitators. For this reason, it can be extremely useful to explore key barriers and facilitators of CPG implementation in the Middle East and North Africa (MENA).

METHODS

A three-round Delphi study was performed using the input of 30 experts involved in the clinical practice guidelines. In the first two rounds, participants were asked to score each statement relevant to barriers or facilitators for CPG implementation on a five-point Likert scale. These statements were identified from existing systematic reviews and expert input. In round three, participants ranked the most important barriers and facilitators identified from rounds one and two. A descriptive analysis was conducted on the barrier and facilitators statements using frequencies, percentages, and medians to summarize the variables collected.

RESULTS

We identified 10 unique barriers and 13 unique facilitators to CPG implementation within the MENA region. The two highest-ranked barriers related to communications and available research and skills. The most important facilitator was the availability of training courses for healthcare professionals.

CONCLUSIONS

Key barriers and facilitators to the implementation of clinical practice guidelines seem to exist in professional, organizational, and external contexts, which should all be taken into account in order to increase implementation success within MENA region. The results of this study are useful in the design of future implementation strategies aimed at overcoming the barriers and leveraging the facilitators.

An external facilitation intervention to increase uptake of an adverse drug event reporting intervention

Background

Adverse drug events (ADEs) are a leading cause of emergency department visits and hospital admissions in Canada. ActionADE prevents repeat ADEs by enabling clinicians to document and communicate standardized ADE information across care settings. We used an external facilitation intervention to promote the uptake of ActionADE in four hospitals in British Columbia, Canada. This study examined whether, how and in what context external facilitation influenced the uptake of ActionADE.

Methods

In this convergent-parallel mixed-methods study, an external facilitator used a four-step iterative process to support site champions using context-specific implementation strategies to increase the ADE reporting rate at their sites. We extracted archival data to assess implementation determinants before and after the implementation of the external facilitation and implementation strategies. We also retrieved data on the mean monthly counts of reported ADEs for each user from the ActionADE server. Zero-inflated Poisson models were used to examine changes in mean monthly counts of reported ADEs per user between pre-intervention (June 2021 to October 2021) and intervention (November 2021 to March 2022) periods.

Results

The external facilitator and site champions co-created three functions: (1) educate pharmacists about what and how to report in ActionADE, (2) educate pharmacists about the impact of ActionADE on patient outcomes, and (3) provide social support for pharmacists to integrate ADE reporting into clinical workflows. Site champions used eight forms to address the three functions. Peer support and reporting competition were the two common strategies used by all sites. Sites' responses to external facilitation varied. The rate of mean monthly counts of reported ADEs per user significantly increased during the intervention period compared to the pre-intervention period at LGH (RR: 3.74, 95% CI 2.78 to 5.01) and RH (RR: 1.43, 95% CI 1.23 to 1.94), but did not change at SPH (RR: 0.68, 95% CI: 0.43 to 1.09) and VGH (RR: 1.17, 95% CI 0.92 to 1.49). Leave of absence of the clinical pharmacist champion and failure to address all identified functions were implementation determinants that influenced the effectiveness of external facilitation.

Conclusion

External facilitation effectively supported researchers and stakeholders to co-create context-specific implementation strategies. It increased ADE reporting at sites where clinical pharmacist champions were available, and where all functions were addressed.

Scaling up an intervention to protect preterm infants from neurodevelopmental disabilities - findings from a qualitative process evaluation comparing standard with enhanced quality improvement support packages for maternity units in England

BACKGROUND

A quality improvement strategy (PReCePT) was used in a standard and enhanced format to scale up a clinical intervention (administering magnesium sulphate to women in preterm labour) across all maternity units in England to protect prematurely born infants from neurodevelopmental disabilities. Formal evaluations reported the effectiveness of the standard package alone in increasing the administration of magnesium sulphate. In this paper, we focus on the findings of the process evaluations, using normalisation process theory to explain how different implementation contexts generated the observed outcomes relating to normative and relational restructuring and sustainment.

METHODS

Interviews were conducted with key individuals in implementation of leadership positions nationally and locally. Interviews were analysed initially using the framework method. We then engaged recursively with NPT constructs to generate generalisable insights with pragmatic applicability in other settings.

RESULTS

In total, 72 interviews were conducted with good representation from units across England and staff from the National Academic Health Science Network. We found that all units irrespective of whether they received a standard or enhanced QI package were successful in the 'normative restructuring' of their setting to enable magnesium sulphate to be administered. This suggests that this implementation outcome is necessary to achieve improvements. However, it may not be sufficient to sustain the changes once additional resources have been withdrawn. Sustainment, our findings suggest, required 'relational restructuring' to accommodate altered workflows and facilitate the sharing of responsibilities and tasks in daily practice. Relational restructuring was more likely to have been achieved units receiving enhanced QI support but also happened in units with standard QI support, especially in those where perinatal team working was already well established.

CONCLUSION

Unlike other large QI-focused spread-and-scale programmes which failed to show any impact on outcomes, the PReCePT programme in both the enhanced and standard support packages led to improvements in the uptake of magnesium sulphate. The findings suggest that QI programmes interact with the enabling factors, such as strong interprofessional team working, already present in the setting. A standard package with minimal support was therefore sufficient in settings with enabling factors, but enhanced support was required in units where these were absent.

The effectiveness of clinical guideline implementation strategies in oncology-a systematic review

IMPORTANCE

Guideline recommendations do not necessarily translate into changes in clinical practice behaviour or better patient outcomes.

OBJECTIVE

This systematic review aims to identify recent clinical guideline implementation strategies in oncology and to determine their effect primarily on patient-relevant outcomes and secondarily on healthcare professionals' adherence.

METHODS

A systematic search of five electronic databases (PubMed, Web of Science, GIN, CENTRAL, CINAHL) was conducted on 16 december 2022. Randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) assessing the effectiveness of guideline implementation strategies on patient-relevant outcomes (overall survival, quality of life, adverse events) and healthcare professionals' adherence outcomes (screening, referral, prescribing, attitudes, knowledge) in the oncological setting were targeted. The Cochrane risk-of-bias tool and the ROBINS-I tool were used for assessing the risk of bias. Certainty in the evidence was evaluated according to GRADE recommendations. This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number CRD42021268593.

FINDINGS

Of 1326 records identified, nine studies, five cluster RCTs and four controlled before-and after studies, were included in the narrative synthesis. All nine studies assess the effect of multi-component interventions in 3577 cancer patients and more than 450 oncologists, nurses and medical staff.

PATIENT-LEVEL

Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain.

PROVIDER-LEVEL

Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.

CONCLUSIONS AND RELEVANCE

Knowledge and skill accumulation through team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched guideline implementation strategies in oncology recently. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.

Utilisation and application of implementation science in complex suicide prevention interventions: A systematic review

OBJECTIVES

Little is known about how complex, multilevel, and multicomponent suicide prevention interventions work in real life settings. Understanding the methods used to systematically adopt, deliver, and sustain these interventions could ensure that they have the best chance of unfolding their full effect. This systematic review aimed to examine the application and extent of utilisation of implementation science in understanding and evaluating complex suicide prevention interventions.

METHODS

The review adhered to updated PRISMA guidelines and was prospectively registered with PROSPERO (CRD42021247950). PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL were searched. All English-language records (1990-2022) with suicide and/or self-harm as the primary aims or targets of intervention were eligible. A forward citation search and a reference search further bolstered the search strategy. Interventions were considered complex if they consisted of three or more components and were implemented across two or more levels of socio-ecology or levels of prevention.

RESULTS

One hundred thirty-nine records describing 19 complex interventions were identified. In 13 interventions, use of implementation science approaches, primarily process evaluations, was explicitly stated. However, extent of utilisation of implementation science approaches was found to be inconsistent and incomprehensive.

LIMITATIONS

The inclusion criteria, along with a narrow definition of complex interventions may have limited our findings.

CONCLUSION

Understanding the implementation of complex interventions is crucial for unlocking key questions about theory-practice knowledge translation. Inconsistent reporting and inadequate understanding of implementation processes can lead to loss of critical, experiential knowledge related to what works to prevent suicide in real world settings.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective

As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

Design and methods

We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.

Results

Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.

Conclusions

IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Trends in guideline implementation: an updated scoping review

Background

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

Methods

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

Results

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01223-6.

Tracking, naming, specifying, and comparing implementation strategies for person-centred care in a real-world setting: a case study with seven embedded units

BACKGROUND

The implementation of person-centred care (PCC) is advocated worldwide. Stakeholders in charge of implementing PCC as a broad-scale change across the health care sector face two intertwined and complex challenges. First, making sense of PCC as an intervention with complex innovation characteristics and second, staging implementation of PCC by choosing appropriate implementation strategies. We aimed to explore one of these challenges by tracking, naming, specifying, and comparing which strategies and how strategies were enacted to support the implementation of more PCC in a real-world setting represented by one health care region in Sweden.

METHODS

A case study with seven embedded units at two organisational levels within a health care region was conducted from 2016 to 2019. Data were collected from three sources: activity logs, interviews, and written documents. Strategies were identified from all sources and triangulated deductively by name, definition, and cluster in line with the taxonomy Expert Recommendations for Implementing Change (ERIC) and specified according to recommendations by Proctor and colleagues as actor, action, action target, temporality, dose, outcome, and justification.

RESULTS

Four hundred thirteen activities were reported in logs, representing 43 discrete strategies identified in ERIC (n = 38), elsewhere (n = 1), or as emerging strategies (n = 4). The highest reported frequencies of discrete strategies were identified as belonging to two clusters: Train and educate stakeholders (40%) and Develop stakeholder interrelationships (38%). We identified a limited number of strategies belonging to the cluster Use evaluative and iterative strategies (4.6%) and an even smaller number of strategies targeting information to patients about the change initiative (0.8%). Most of the total dose of 11,076 person-hours in the 7 units was spent on strategies targeting health care professionals who provide PCC (81.5%) while the dose of strategies targeting support functions was 18.5%.

CONCLUSIONS

Our findings show both challenges and merits when strategies for implementation of PCC are conducted in a real-world setting. The results can be used to support and guide both scientists and practitioners in future implementation initiatives.

Do the Expert Recommendations for Implementing Change (ERIC) strategies adequately address sustainment?

Background

Sustainability science is an emerging area within implementation science. There is limited evidence regarding strategies to best support the continued delivery and sustained impact of evidence-based interventions (EBIs). To build such evidence, clear definitions, and ways to operationalize strategies specific and/or relevant to sustainment are required. Taxonomies and compilations such as the Expert Recommendations for Implementing Change (ERIC) were developed to describe and organize implementation strategies. This study aimed to adapt, refine, and extend the ERIC compilation to incorporate an explicit focus on sustainment. We also sought to classify the specific phase(s) of implementation when the ERIC strategies could be considered and applied.

Methods

We used a two-phase iterative approach to adapt the ERIC. This involved: (1) adapting through consensus (ERIC strategies were mapped against barriers to sustainment as identified via the literature to identify if existing implementation strategies were sufficient to address sustainment, needed wording changes, or if new strategies were required) and; (2) preliminary application of this sustainment-explicit ERIC glossary (strategies described in published sustainment interventions were coded against the glossary to identify if any further amendments were needed). All team members independently reviewed changes and provided feedback for subsequent iterations until consensus was reached. Following this, and utilizing the same consensus process, the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework was applied to identify when each strategy may be best employed across phases.

Results

Surface level changes were made to the definitions of 41 of the 73 ERIC strategies to explicitly address sustainment. Four additional strategies received deeper changes in their definitions. One new strategy was identified: Communicate with stakeholders the continued impact of the evidence-based practice. Application of the EPIS identified that at least three-quarters of strategies should be considered during preparation and implementation phases as they are likely to impact sustainment.

Conclusion

A sustainment-explicit ERIC glossary is provided to help researchers and practitioners develop, test, or apply strategies to improve the sustainment of EBIs in real-world settings. Whilst most ERIC strategies only needed minor changes, their impact on sustainment needs to be tested empirically which may require significant refinement or additions in the future.

Strategies to adapt and implement health system guidelines and recommendations: a scoping review

BACKGROUND

Evidence-based health system guidelines are pivotal tools to help outline the important financial, policy and service components recommended to achieve a sustainable and resilient health system. However, not all guidelines are readily translatable into practice and/or policy without effective and tailored implementation and adaptation techniques. This scoping review mapped the evidence related to the adaptation and implementation of health system guidelines in low- and middle-income countries.

METHODS

We conducted a scoping review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was implemented in MEDLINE (Ovid), Embase, CINAHL, LILACS (VHL Regional Portal), and Web of Science databases in late August 2020. We also searched sources of grey literature and reference lists of potentially relevant reviews. All findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

A total of 41 studies were included in the final set of papers. Common strategies were identified for adapting and implementing health system guidelines, related barriers and enablers, and indicators of success. The most common types of implementation strategies included education, clinical supervision, training and the formation of advisory groups. A paucity of reported information was also identified related to adaptation initiatives. Barriers to and enablers of implementation and adaptation were reported across studies, including the need for financial sustainability. Common approaches to evaluation were identified and included outcomes of interest at both the patient and health system level.

CONCLUSIONS

The findings from this review suggest several themes in the literature and identify a need for future research to strengthen the evidence base for improving the implementation and adaptation of health system guidelines in low- and middle-income countries. The findings can serve as a future resource for researchers seeking to evaluate implementation and adaptation of health system guidelines. Our findings also suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local contexts and health system arrangements in low- and middle-income countries.

Dissemination and implementation strategies for physical activity guidelines among adults with disability, chronic conditions, and pregnancy: a systematic scoping review

BACKGROUND

Physical activity guidelines for adults with disability, chronic conditions, and pregnancy (i.e., specific populations) have been developed to provide guidance for engaging in physical activity. However, specific populations remain considerably less physically active compared to the general population, presenting a knowledge-practice gap.

PURPOSE

The purpose of this systematic scoping review was to identify and evaluate strategies for disseminating and implementing physical activity guidelines among specific populations and/or stakeholders (e.g., healthcare professionals) in Canada.

METHODS

Five search approaches (peer-reviewed literature databases, grey literature database, custom Google search engines, targeted web-based searches, and content expert consultation) identified records documenting and/or evaluating strategies that had been used to disseminate or implement guidelines from a predetermined list. Systematic and scoping review protocols were followed. Risk of bias assessments were conducted for all studies that evaluated strategies.

RESULTS

Eighty-one records reported dissemination strategies (n = 42), implementation strategies (n = 28), or both (n = 11). Twenty-two studies reporting on 29 evaluated strategies were deemed "serious" or "high" risk of bias. Common guideline dissemination and implementation strategies are deliberated and recommendations for future practice are made.

CONCLUSIONS

Findings may inform future dissemination and implementation efforts for physical activity guidelines in Canada or similar countries.

Framework for identification and measurement of spillover effects in policy implementation: intended non-intended targeted non-targeted spillovers (INTENTS)

BACKGROUND

There is increasing awareness among researchers and policymakers of the potential for healthcare interventions to have consequences beyond those initially intended. These unintended consequences or "spillover effects" result from the complex features of healthcare organisation and delivery and can either increase or decrease overall effectiveness. Their potential influence has important consequences for the design and evaluation of implementation strategies and for decision-making. However, consideration of spillovers remains partial and unsystematic. We develop a comprehensive framework for the identification and measurement of spillover effects resulting from changes to the way in which healthcare services are organised and delivered.

METHODS

We conducted a scoping review to map the existing literature on spillover effects in health and healthcare interventions and used the findings of this review to develop a comprehensive framework to identify and measure spillover effects.

RESULTS

The scoping review identified a wide range of different spillover effects, either experienced by agents not intentionally targeted by an intervention or representing unintended effects for targeted agents. Our scoping review revealed that spillover effects tend to be discussed in papers only when they are found to be statistically significant or might account for unexpected findings, rather than as a pre-specified feature of evaluation studies. This hinders the ability to assess all potential implications of a given policy or intervention. We propose a taxonomy of spillover effects, classified based on the outcome and the unit experiencing the effect: within-unit, between-unit, and diagonal spillover effects. We then present the INTENTS framework: Intended Non-intended TargEted Non-Targeted Spillovers. The INTENTS framework considers the units and outcomes which may be affected by an intervention and the mechanisms by which spillover effects are generated.

CONCLUSIONS

The INTENTS framework provides a structured guide for researchers and policymakers when considering the potential effects that implementation strategies may generate, and the steps to take when designing and evaluating such interventions. Application of the INTENTS framework will enable spillover effects to be addressed appropriately in future evaluations and decision-making, ensuring that the full range of costs and benefits of interventions are correctly identified.

Adoption of change in endodontic practice after an educational program: A qualitative study

Objectives

The aim was to define the characteristics of successful implementation of new clinical endodontic routines within a public dental health organization, following an educational program.

Materials and Methods

Fifteen staff members were strategically selected for the interview. All had completed a theoretical educational intervention including a complementary endodontic treatment strategy and, for the dentists, comprising training in the nickel‐titanium‐rotary‐technique. All experienced the successful acceptance of new clinical routines. Two thematic in‐depth audiotaped interviews were conducted, wherein the informants described the implementation process in their own words. The interviews were transcribed verbatim and analyzed according to Qualitative Content Analysis.

Results

A theme was identified: A multiple flexible process with governance support and gradual reinforcement of motivation, with the following main categories: Firstly, contextual facilitation, with two subcategories (i) a multifaceted organizational foundation and (ii) a tolerance of flexibility. Secondly, emotional facilitation, with two subcategories (i) an experience of simplification and (ii) an experience of improvement.

Conclusion

The results improve the understanding of a multifaceted process underlying the acceptance of changes to clinical endodontic procedures by dentists in a public dental health organization. Important contributing factors identified were governance support, a committed resource person with contextual knowledge, tolerance of flexibility in implementation, and permissive informal communication channels within the local workplace. These findings might be a valuable contribution to an evidence base, facilitating the selection of the most appropriate educational strategy and structure for a specified purpose.

Implementation Science in Pediatric Rheumatology: A Path to Health Equity

Implementation science is the study of processes that promote reliable uptake of evidence-based practices into clinical care. The integration of implementation science and health disparities research approaches has been proposed as a method to reduce health inequity through detection, understanding, and implementation of health equity-focused interventions. In this review, we provide an argument for the study of implementation science in pediatric rheumatology in light of previously observed health disparities, present a framework for the study of health equity and implementation science in pediatric rheumatology, and propose next steps to accelerate action.

De-implementation and substitution of clinical care processes: stakeholder perspectives on the transition to primary human papillomavirus (HPV) testing for cervical cancer screening

Background

New cervical cancer screening guidelines recommend primary human papillomavirus (HPV) testing for women age 30–65 years. Healthcare organizations are preparing to de-implement the previous recommended strategies of Pap testing or co-testing (Pap plus HPV test) and substitute primary HPV testing. However, there may be significant challenges to the replacement of this entrenched clinical practice, even with an evidence-based substitution. We sought to identify stakeholder-perceived barriers and facilitators to this substitution within a large healthcare system, Kaiser Permanente Southern California.

Methods

We conducted semi-structured qualitative interviews with clinician, administrative, and patient stakeholders regarding (a) acceptability and feasibility of the planned substitution; (b) perceptions of barriers and facilitators, with an emphasis on those related to the de-implementation/implementation cycle of substitution; and (c) perceived readiness to change. Our interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Using a team coding approach, we developed an initial coding structure refined during iterative analysis; the data were subsequently organized thematically into domains, key themes, and sub-themes using thematic analysis, followed by framework analysis informed by CFIR.

Results

We conducted 23 interviews: 5 patient and 18 clinical/administrative. Clinicians perceived that patients feel more tests equals better care, and clinicians and patients expressed fear of missed cancers (“…it’ll be more challenging convincing the patient that only one test is…good enough to detect cancer.”). Patients perceived practice changes resulting in “less care” are driven by the desire to cut costs. In contrast, clinicians/administrators viewed changing from two tests to one as acceptable and a workflow efficiency (“…It’s very easy and half the work.”). Stakeholder-recommended strategies included focusing on the increased efficacy of primary HPV testing and developing clinician talking points incorporating national guidelines to assuage “cost-cutting” fears.

Conclusions

Substitution to replace an entrenched clinical practice is complex. Leveraging available facilitators is key to ease the process for clinical and administrative stakeholders—e.g., emphasizing the efficiency of going from two tests to one. Identifying and addressing clinician and patient fears regarding cost-cutting and perceived poorer quality of care is critical for substitution. Multicomponent and multilevel strategies for engagement and education will be required.

Trial registration

ClinicalTrials.gov, #NCT04371887

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00211-z.

Trends in guideline implementation: an updated scoping review protocol

OBJECTIVE

The objective of the review is to assess trends in guideline implementation, including the interventions used, rationale provided, and the impact on patient or health care professional knowledge, behavior or outcomes.

INTRODUCTION

Guidelines must be actively implemented to promote use and achieve beneficial outcomes. A review published in 2015 found that studies of guideline implementation did not employ a range of implementation planning approaches to select and tailor interventions, resulting in inconsistent impact. This study will update the 2015 review and elaborate beyond the four diseases originally covered to assess if more recent efforts to implement guidelines were informed by best implementation practices.

INCLUSION CRITERIA

We will include published studies that describe the implementation of guidelines on any clinical topic relevant to primary, secondary, or tertiary care using interventions targeted to patients, families/caregivers, or health care professionals.

METHODS

We will search MEDLINE, Embase, AMED, CINAHL, Scopus, and the Cochrane Library from 2014 (search date in 2015 review) to the present. Two or more persons will screen titles and full-text articles, and extract data from included studies. We will use summary statistics, tables, and a narrative summary to describe study characteristics, guideline implementation interventions, the rationale for intervention selection and tailoring (pre-identified barriers, patient or stakeholder preferences, theory), and intervention impact.

Dissemination and implementation of national physical activity, sedentary behaviour, and/or sleep guidelines among community-dwelling adults aged 18 years and older: a systematic scoping review and suggestions for future reporting and research

Strategies for dissemination (purposive distribution of a guideline to specific audiences) and implementation (actions to support the general public in meeting guideline recommendations/behavioural benchmarks) of national movement guidelines (physical activity (PA), sedentary behaviour, and sleep) have yet to be synthesized. The purpose of this systematic scoping review was to identify strategies for dissemination and implementation of national PA, sedentary behaviour, and/or sleep guidelines among community-dwelling adults (aged >18 years) and/or stakeholders in Canada and analogous countries. Five search approaches (e.g., published literature, grey literature, targeted web-based, custom Google, and content expert consultation) identified records (e.g., empirical studies, organizational reports, website pages, or guideline messages) that discussed and/or evaluated dissemination or implementation strategies for a prespecified list of guidelines. A modified strategy classification system was developed to chart the data. Forty-seven reports met inclusion criteria. Dissemination strategies (n = 42) were more frequently reported than implementation strategies (n = 24). Implementation strategies were more frequently evaluated (n = 13 vs. 7 dissemination strategies) and associated with positive outcomes. The 13 studies that evaluated strategies were at high or serious risk of bias. We identified limited information about the dissemination and implementation of national movement guidelines and identified strategies were rarely evaluated. Greater efforts are required to increase the impact of guidelines among the general public and stakeholders and to build the evidence base in this field. (Open Science Framework registration: https://osf.io/4tyw3.) Novelty An adapted movement guideline dissemination and implementation strategy classification framework is provided. Knowledge translation efforts should be documented and evaluated to advance science and practice in the movement guideline field.

The role of dissemination and implementation science in global breast cancer control programs: Frameworks, methods, and examples

Global disparities in breast cancer outcomes are attributable to a sizable gap between evidence and practice in breast cancer control and management. Dissemination and implementation science (D&IS) seeks to understand how to promote the systematic uptake of evidence-based interventions and/or practices into real-world contexts. D&IS methods are useful for selecting strategies to implement evidence-based interventions, adapting their implementation to new settings, and evaluating the implementation process as well as its outcomes to determine success and failure, and adjust accordingly. Process models, explanatory theories, and evaluation frameworks are used in D&IS to develop implementation strategies, identify implementation outcomes, and design studies to evaluate these outcomes. In breast cancer control and management, research has been translated into evidence-based, resource-stratified guidelines by the Breast Health Global Initiative and others. D&IS should be leveraged to optimize the implementation of these guidelines, and other evidence-based interventions, into practice across the breast cancer care continuum, from optimizing public education to promoting early detection, increasing guideline-concordant clinical practice among providers, and analyzing and addressing barriers and facilitators in health care systems. Stakeholder engagement through processes such as co-creation is critical. In this article, the authors have provided a primer on the contribution of D&IS to phased implementation of global breast cancer control programs, provided 2 case examples of ongoing D&IS research projects in Tanzania, and concluded with recommendations for best practices for researchers undertaking this work.

Developing National and International Guidelines

Food allergy (FA) is considered an emerging public health problem. The development of evidence-based guidelines aims to help health care professionals in an accurate diagnosis and management of such diseases. It is proven that there are differences in the factors that determine FA in the different regions of the world. It is necessary to encourage standardization processes of guidelines development. Nevertheless, in the future it will be necessary to take into consideration not only a methodologically correct analysis of the evidence but also the socio-economic realities where the guidelines will be applied.

"What Is the Right Decision for Me?" Integrating Patient Perspectives Through Shared Decision-Making for Valvular Heart Disease Therapy

Innovations in the treatment of valvular heart disease have transformed treatment options for people with valvular heart disease. In this rapidly evolving environment, the integration of patients' perspectives is essential to close the potential gap between what can be done and what patients want. Shared decision-making (SDM) and the measurement of patient-reported outcomes (PROs) are two strategies that are in keeping with this aim and gaining significant momentum in clinical practice, research, and health policy. SDM is a process that involves an individualised, intentional, and bidirectional exchange among patients, family, and health care providers that integrates patients' preferences, values, and priorities to reach a high-quality consensus treatment decision. SDM is widely endorsed by international valvular heart disease guidelines and increasingly integrated in health policy. Patient decision aids are evidence-based tools that facilitate SDM. The measurement of PROs-an umbrella term that refers to the standardised reporting of symptoms, health status, and other domains of health-related quality of life-provides unique data that come directly from patients to inform clinical practice and augment the reporting of quality of care. Sensitive and validated instruments are available to capture generic, dimensional, and disease-specific PROs in patients with valvular heart disease. The integration of PROs in clinical care presents significant opportunities to help guide treatment decision and monitor health status. The integration of patients' perspectives promotes the shift to patient-centred care and optimal outcomes, and contributes to transforming the way we care for patients with valvular heart disease.

Context counts: a qualitative study exploring the interplay between context and implementation success

PURPOSE

Implementing change in healthcare is difficult to accomplish due to the unpredictability associated with challenging the status quo. Adapting the intervention/practice/program being implemented to better fit the complex context is an important aspect of implementation success. Despite the acknowledged influence of context, the concept continues to receive insufficient attention at the team-level within implementation research. Using two heterogeneous multidisciplinary healthcare teams as implementation case studies, this study evaluates the interplay between context and implementation and highlights the ways in which context influences the introduction of a collective leadership intervention in routine practice.

DESIGN/METHODOLOGY/APPROACH

The multiple case study design adopted, employed a triangulation of qualitative research methods which involved observation (Case A = 16 h, Case B = 15 h) and interview data (Case A = 13 participants, Case B = 12 participants). Using an inductive approach, an in-depth thematic analysis of the data outlined the relationship between team-level contextual factors and implementation success.

FINDINGS

Themes are presented under the headings: (1) adapting to the everyday realities, a key determinant for implementation success and (2) implementation stimulating change in context. The findings demonstrate a dynamic relationship between context and implementation. The challenges of engaging busy healthcare professionals emphasised that mapping the contextual complexity of a site and adapting implementation accordingly is essential to enhance the likelihood of successful implementation. However, implementation also altered the surrounding context, stimulating changes within both teams.

ORIGINALITY/VALUE

By exposing the reciprocal relationship between team-level contextual factors and implementation, this research supports the improved design of implementation strategies through better understanding the interplay and mutual evolution of evidence-based healthcare interventions within different contexts.

Even High-Quality CPGs Seldom Include Implementation Strategies

Background: Implementation is a key step in ensuring that high-quality clinical practice guideline (CPG) recommendations are followed and have a positive impact. This step must be planned during CPG development. This study aims to inform professionals tasked with developing and implementing CPGs regarding implementation strategies and tools reported in high-quality CPGs for chronic non-communicable diseases (NCDs).

Methods: NCD guidelines were selected based on Appraisal of Guideline Research and Evaluation (AGREE) II assessment. CPGs with a score of ≥60% in AGREE II domains 3 (rigor of development), 5 (applicability), and 6 (editorial independence), were considered high quality. The content related to implementation was extracted from CPG full texts and complementary materials. Implementation strategies and tools were assessed and classified using Mazza taxonomy.

Results: Twenty high-quality CPGs were selected, most of which were developed by government institutions (16; 80%) with public funding (16; 80%); almost half (9; 45%) addressed the treatment of cardiovascular diseases. The countries with the most high-quality CPGs were the UK (6; 30%) and Colombia (5; 25%). These countries also had the highest average number of strategies, Colombia with 28 (SD = 1) distributed in all levels, and the UK with 15 (SD = 7), concentrating on professional and organizational levels. Although the content of the Colombian CPGs was similar regardless the disease, the CPGs from the UK were specific and contained data-based feedback reports and information on CPG compliance. Implementation strategies most frequently identified were at the professional level, such as distributing reference material (18; 80%) and educating groups of healthcare professionals (18; 80%). At the organizational level, the most frequent strategies involve changes in structure (15; 75%) and service delivery method (13; 65%).

Conclusion: Countries with established CPG programs, such as the UK and Colombia, where identified as having the highest number of high-quality CPGs, although CPG implementation content had significant differences. Among high-quality CPGs, the most common implementation strategies were at the professional and organizational levels. There is still room for improvement regarding the implementation strategies report, even among high-quality CPGs, especially concerning monitoring of implementation outcomes and selection of strategies based on relevant implementation barriers.

Consensus on strategies for implementing high priority mental health care practices within the US Department of Veterans Affairs

Background

Identifying feasible and effective implementation strategies remains a significant challenge. At present, there is a gap between the number of strategies prospectively included in implementation trials, typically four or fewer, and the number of strategies utilized retrospectively, often 20 or more. This gap points to the need for developing a better understanding of the range of implementation strategies that should be considered in implementation science and practice.

Methods

This study elicited expert recommendations to identify which of 73 discrete implementation strategies were considered essential for implementing three mental health care high priority practices (HPPs) in the US Department of Veterans Affairs: depression outcome monitoring in primary care mental health (n = 20), prolonged exposure therapy for treating posttraumatic stress disorder (n = 22), and metabolic safety monitoring for patients taking antipsychotic medications (n = 20). Participants had expertise in implementation science, the specific HPP, or both. A highly structured recommendation process was used to obtain recommendations for each HPP.

Results

Majority consensus was identified for 26 or more strategies as absolutely essential; 53 or more strategies were identified as either likely essential or absolutely essential across the three HPPs.

Conclusions

The large number of strategies identified as essential starkly contrasts with existing research that largely focuses on application of single strategies to support implementation. Systematic investigation and documentation of multi-strategy implementation initiatives is needed.

Plain Language Summary

Most implementation studies focus on the impact of a relatively small number of discrete implementation strategies on the uptake of a practice. However, studies that systematically survey providers find that dozens or more discrete implementation strategies can be identified in the context of the implementation initiative. This study engaged experts in implementation science and clinical practice in a structured recommendation process to identify which of the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies were considered absolutely essential, likely essential, likely inessential, and absolutely inessential for each of the three distinct mental health care practices: depression outcome monitoring in primary care, prolonged exposure therapy for posttraumatic stress disorder, and metabolic safety monitoring for patients taking antipsychotic medications. The results highlight that experts consider a large number of strategies as absolutely or likely essential for supporting the implementation of mental health care practices. For example, 26 strategies were identified as absolutely essential for all three mental health care practices. Another 27 strategies were identified as either absolutely or likely essential across all three practices. This study points to the need for future studies to document the decision-making process an initiative undergoes to identify which strategies to include and exclude in an implementation effort. In particular, a structured approach to this documentation may be necessary to identify strategies that may be endogenous to a care setting and that may not be otherwise be identified as being "deliberately" used to support a practice or intervention.

Effectiveness-implementation hybrid type 2 study evaluating an intervention to support 'information work' in dementia care: an implementation study protocol

INTRODUCTION

Patients with long-term conditions consistently report a lack of information around services and support available to them. This unmet need for information is significant among people with dementia and family carers. A quality improvement intervention is being carried out to tackle this issue as part of a co-creation initiative in the North East of England (UK). The intervention consists of the dissemination (via the local Community Mental Health Services for Older People) of a leaflet about services available to people with dementia and their family carers in the study site. This protocol is reported in accordance with the Standards for Reporting Implementation Studies.

METHODS AND ANALYSIS

This effectiveness-implementation hybrid type 2 study aims at understanding (1) the unfolding and outcomes of the implementation strategy, (2) the outcomes of the intervention (for people with dementia and family carers, staff implementing the intervention and local service providers) and (3) the contribution of co-creation to the design and implementation of the intervention and its outcomes. The prospective theory of change of the intervention articulated by local stakeholders is used as a reference framework against which to assess the implementation and outcomes of the intervention. Evaluation data will be collected through in-depth interviews with people with dementia and family carers receiving the intervention, staff implementing the intervention and managers from local service providers. Referral data from local service providers will be collected to triangulate the interview data. A focus group with key stakeholders will support the sense-making of findings. The realist configuration of mechanism-context-outcome, operationalised using an information behaviour model, will inform data analysis and interpretation.

ETHICS AND DISSEMINATION

Ethical and research governance approvals have been obtained from the West Midlands-South Birmingham Research Ethics Committee. The results of the study will be submitted for publication in peer-reviewed journals and disseminated through conferences.

A Scoping Review of Implementation Science in Adult Critical Care Settings

OBJECTIVES

The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation.

DATA SOURCES

A librarian-assisted search was performed using three electronic databases.

STUDY SELECTION

Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included.

DATA EXTRACTION

Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system.

DATA SYNTHESIS

Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes.

CONCLUSIONS

The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.

An overview of reviews on strategies to reduce health inequalities

BACKGROUND

Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions.

OBJECTIVE

Identify and synthesize strategies or interventions that facilitate the reduction of health inequalities.

METHODS

A systematic search strategy was carried out up until August 2019 in MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews, LILACS, Scopus, Scielo and Epistemonikos. In addition, a snowball strategy was used. Literature reviews (LRs) of experimental and quasi-experimental studies were included. The identified interventions and outcomes were categorized based on the recommendation by the Cochrane group in "Effective Practice and Organization of Care". The quality of the included LRs was evaluated using the AMSTAR 2 tool.

RESULTS

Four thousand ninety-five articles were identified, of which 97 were included in the synthesis of evidence. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes.

CONCLUSION

The strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors of the health system. It is essential to continue generating interventions focused on strengthening health systems in order to achieve adequate universal health coverage, with a process of comprehensive and quality care.

Effects of oncological care pathways in primary and secondary care on patient, professional and health systems outcomes: a systematic review and meta-analysis

BACKGROUND

Pathways are frequently used to improve care for cancer patients. However, there is little evidence about the effects of pathways used in oncological care. Therefore, we performed a systematic review and meta-analysis aiming to identify and synthesize existing literature on the effects of pathways in oncological care.

METHODS

All patients diagnosed with cancer in primary and secondary/tertiary care whose treatment can be characterized as the strategy "care pathways" are included in this review. A systematic search in seven databases was conducted to gather evidence. Studies were screened by two independent reviewers. Study outcomes regarding patients, professionals, and system level were extracted from each study.

RESULTS

Out of 13,847 search results, we selected 158 articles eligible for full text assessment. One hundred fifty studies were excluded and the remaining eight studies represented 4786 patients. Most studies were conducted in secondary/tertiary care. Length of stay (LOS) was the most common used indicator, and was reported in five studies. Meta-analysis based on subgroups showed an overall shorter LOS regarding gastric cancer (weighted mean difference (WMD)): - 2.75, CI: - 4.67 to - 0.83) and gynecological cancer (WMD: - 1.58, CI: - 2.10 to - 1.05). Costs were reported in six studies and most studies reported lower costs for pathway groups.

CONCLUSIONS

Despite the differences between the included studies, we were able to present an evidence base for cancer care pathways performed in secondary/tertiary care regarding the positive effects of LOS in favor of cancer care pathways.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017057592.

Partners in School: An Implementation Strategy to Promote Alignment of Evidence-Based Practices Across Home and School for Children with Autism Spectrum Disorder

When parents and teachers align their practices across home and school, it may optimize services for children with autism spectrum disorder (ASD). Partners in School is a multi-faceted implementation strategy designed to improve ASD services in schools. The goal is to increase parents' and teachers' use of evidence-based practices (EBPs) and to align those EBPs across settings. We piloted Partners in School with 49 parent-teacher dyads to assess administration and the factors associated with reported fidelity to the model. Specifically, we measured the number of intervention steps both parents and teachers completed (reported alignment) and the characteristics associated with intervention alignment. Partners in School involves parent-teacher participation in a pre-consultation interview, an in-person consultation meeting, active implementation of the same EBPs in their respective settings, and a post-consultation interview. Parents and teachers also completed surveys pre- and post-consultation. On average, parents and teachers completed approximately five EBP steps on their own in their respective settings (i.e., at home or at school). Of these five steps, parents and teachers both completed three of the same EBPs steps, on average. Different factors were related to reported alignment for parents versus teachers; however, a similarity noted for both parents and teachers was that communication variables were associated with reported alignment. Our findings indicate the important role of communication in aligning stakeholders for ASD service delivery models.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

BACKGROUND

Health care professionals (HCPs) use clinical practice guidelines (CPGs) to make evidence-informed decisions regarding patient care. Although a large number of cancer-related CPGs exist, it is unknown which CPG dissemination and implementation strategies are effective for improving HCP behaviour and patient outcomes in a cancer care context. This review aimed to determine the effectiveness of CPG dissemination and/or implementation strategies among HCPs in a cancer care context.

METHODS

A comprehensive search of five electronic databases was conducted. Studies were limited to the dissemination and/or implementation of a CPG targeting both medical and/or allied HCPs in cancer care. Two reviewers independently coded strategies using the Mazza taxonomy, extracted study findings, and assessed study quality.

RESULTS

The search strategy identified 33 studies targeting medical and/or allied HCPs. Across the 33 studies, 23 of a possible 49 strategies in the Mazza taxonomy were used, with a mean number of 3.25 (SD = 1.45) strategies per intervention. The number of strategies used per intervention was not associated with positive outcomes. Educational strategies (n = 24), feedback on guideline compliance (n = 11), and providing reminders (n = 10) were the most utilized strategies. When used independently, providing reminders and feedback on CPG compliance corresponded with positive significant changes in outcomes. Further, when used as part of multi-strategy interventions, group education and organizational strategies (e.g. creation of an implementation team) corresponded with positive significant changes in outcomes.

CONCLUSIONS

Future CPG dissemination and implementation interventions for cancer care HCPs may benefit from utilizing the identified strategies. Research in this area should aim for better alignment between study objectives, intervention design, and evaluation measures, and should seek to incorporate theory in intervention design, so that behavioural antecedents are considered and measured; doing so would enhance the field's understanding of the causal mechanisms by which interventions lead, or do not lead, to changes in outcomes at all levels.

Landscape of HIV Implementation Research Funded by the National Institutes of Health: A Mapping Review of Project Abstracts

In 2019, the requisite biomedical and behavioral interventions to eliminate new HIV infections exist. "Ending the HIV Epidemic" now becomes primarily a challenge of will and implementation. This review maps the extent to which implementation research (IR) has been integrated into HIV research by reviewing the recent funding portfolio of the NIH. We searched NIH RePORTER for HIV and IR-related research projects funded from January 2013 to March 2018. The 4629 unique studies identified were screened using machine learning and manual methods. 216 abstracts met the eligibility criteria of HIV and IR. Key study characteristics were then abstracted. NIH currently funds HIV studies that are either formally IR (n = 109) or preparatory for IR (n = 107). Few (13%) projects mentioned a guiding implementation model, theory, or framework, and only 56% of all studies explicitly mentioned measuring an implementation outcome. Considering the study aims along an IR continuum, 18 (8%) studies examined barriers and facilitators, 43 (20%) developed implementation strategies, 46 (21%) piloted strategies, 73 (34%) tested a single strategy, and 35 (16%) compared strategies. A higher proportion of formal IR projects involved established interventions (e.g., integrated services) compared to newer interventions (e.g., pre-exposure prophylaxis). Prioritizing HIV-related IR in NIH and other federal funding opportunity announcements and expanded training in implementation science could have a substantial impact on ending the HIV pandemic. This review serves as a baseline by which to compare funding patterns and the sophistication of IR in HIV research over time.

A pragmatic method for costing implementation strategies using time-driven activity-based costing

BACKGROUND

Implementation strategies increase the adoption of evidence-based practices, but they require resources. Although information about implementation costs is critical for decision-makers with budget constraints, cost information is not typically reported in the literature. This is at least partly due to a need for clearly defined, standardized costing methods that can be integrated into implementation effectiveness evaluation efforts.

METHODS

We present a pragmatic approach to systematically estimating detailed, specific resource use and costs of implementation strategies that combine time-driven activity-based costing (TDABC), a business accounting method based on process mapping and known for its practicality, with a leading implementation science framework developed by Proctor and colleagues, which guides specification and reporting of implementation strategies. We illustrate the application of this method using a case study with synthetic data.

RESULTS

This step-by-step method produces a clear map of the implementation process by specifying the names, actions, actors, and temporality of each implementation strategy; determining the frequency and duration of each action associated with individual strategies; and assigning a dollar value to the resources that each action consumes. The method provides transparent and granular cost estimation, allowing a cost comparison of different implementation strategies. The resulting data allow researchers and stakeholders to understand how specific components of an implementation strategy influence its overall cost.

CONCLUSION

TDABC can serve as a pragmatic method for estimating resource use and costs associated with distinct implementation strategies and their individual components. Our use of the Proctor framework for the process mapping stage of the TDABC provides a way to incorporate cost estimation into implementation evaluation and may reduce the burden associated with economic evaluations in implementation science.

How guideline can shape clinical practice globally: the diagnosis and rationale for action against cow's milk allergy experience

PURPOSE OF REVIEW

Allergic diseases are increasing worldwide and are considered an important public health problem causing severe and even life-threatening reactions. The creation of guidelines aims to help clinicians improving the quality of diagnosis and management of such diseases. Clinical practice guidelines alone are not sufficient and there is a need for implementation strategies for their introduction into daily practice. We report here the main international allergy guidelines with a more focused look on the Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines and their effect on clinical practice.

RECENT FINDINGS

DRACMA guidelines have clearly modified the approach to cow's milk allergy (CMA) from its diagnosis to treatment tailoring the choices for each patient. Although they strongly recommend oral food challenge for diagnosing CMA, they also indicate that it may not be necessary in many cases with the introduction of the pretest probability of CMA. Studies on the implementation of DRACMA guidelines show how they influenced the formula market, making appropriate treatments more affordable.

SUMMARY

DRACMA reconciled international differences in the diagnosis and management of CMA. They introduced the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology in the field of food allergy and highlighted the importance for meta-analyses to be able to adapt recommendations to the local context.

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services

BACKGROUND

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement evidence-based policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

OBJECTIVES

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to: 1. Examine the cost or cost-effectiveness of such strategies; 2. Examine any adverse effects of such strategies on childcare services, service staff or children; 3. Examine the effect of such strategies on child diet, physical activity or weight status. 4. Describe the acceptability, adoption, penetration, sustainability and appropriateness of such implementation strategies.

SEARCH METHODS

We searched the following electronic databases on February 22 2019: Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, Embase, PsycINFO, ERIC, CINAHL and SCOPUS for relevant studies. We searched reference lists of included studies, handsearched two international implementation science journals, the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

SELECTION CRITERIA

We included any study (randomised or nonrandomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy. Centre-based childcare services included preschools, nurseries, long daycare services and kindergartens catering for children prior to compulsory schooling (typically up to the age of five to six years).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened study titles and abstracts, extracted study data and assessed risk of bias; we resolved discrepancies via consensus. We performed meta-analysis using a random-effects model where studies with suitable data and homogeneity were identified; otherwise, findings were described narratively.

MAIN RESULTS

Twenty-one studies, including 16 randomised and five nonrandomised, were included in the review. The studies sought to improve the implementation of policies, practices or programmes targeting healthy eating (six studies), physical activity (three studies) or both healthy eating and physical activity (12 studies). Studies were conducted in the United States (n = 12), Australia (n = 8) and Ireland (n = 1). Collectively, the 21 studies included a total of 1945 childcare services examining a range of implementation strategies including educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing, reminders and tailored interventions. Most studies (n = 19) examined implementation strategies versus usual practice or minimal support control, and two compared alternative implementation strategies. For implementation outcomes, six studies (one RCT) were judged to be at high risk of bias overall. The review findings suggest that implementation strategies probably improve the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention in childcare services. Of the 19 studies that compared a strategy to usual practice or minimal support control, 11 studies (nine RCTs) used score-based measures of implementation (e.g. childcare service nutrition environment score). Nine of these studies were included in pooled analysis, which found an improvement in implementation outcomes (SMD 0.49; 95% CI 0.19 to 0.79; participants = 495; moderate-certainty evidence). Ten studies (seven RCTs) used dichotomous measures of implementation (e.g. proportion of childcare services implementing a policy or specific practice), with seven of these included in pooled analysis (OR 1.83; 95% CI 0.81 to 4.11; participants = 391; low-certainty evidence). Findings suggest that such interventions probably lead to little or no difference in child physical activity (four RCTs; moderate-certainty evidence) or weight status (three RCTs; moderate-certainty evidence), and may lead to little or no difference in child diet (two RCTs; low-certainty evidence). None of the studies reported the cost or cost-effectiveness of the intervention. Three studies assessed the adverse effects of the intervention on childcare service staff, children and parents, with all studies suggesting they have little to no difference in adverse effects (e.g. child injury) between groups (three RCTs; low-certainty evidence). Inconsistent quality of the evidence was identified across review outcomes and study designs, ranging from very low to moderate. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used.

AUTHORS' CONCLUSIONS

Current research suggests that implementation strategies probably improve the implementation of policies, practices or programmes by childcare services, and may have little or no effect on measures of adverse effects. However such strategies appear to have little to no impact on measures of child diet, physical activity or weight status.

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.

To call or not to call: behavioral determinants influencing the decision of intensivists to consult poison centers for calcium channel blocker poisoning

Purpose: This study aimed to define the behavioral determinants influencing the decision of intensivists to consult a poison center (PC) when managing patients with calcium channel blocker (CCB) poisoning.Material and methods: Semi-structured interviews were conducted involving a convenience sample of 18 intensivists. Two independent reviewers analyzed the interview responses using the Theoretical Domains Framework. Based on the impact and frequency of the reported behaviors, we selected the most relevant domains likely to influence intensivists' decision to consult a PC for CCB poisoning.Results: Beliefs influencing physicians positively to consult a PC for CCB poisoning were identified in the following domains: knowledge (e.g., lower level of evidence), social or professional role and identity (e.g., high credibility attributed to the PC), reinforcement (e.g., multiple drug poisoning, infrequent or potentially lethal poisoning, medicolegal considerations), and behavioral regulation (e.g., facilitated access of PC to patient's hospital chart, direct communication with a toxicologist). Beliefs deterring physicians from consulting a PC for CCB poisoning were identified in the following domains: knowledge (e.g., better awareness of recommendations decreases tendency to call), goals (e.g., priority for patient stabilization), and memory, attention, and decision process (e.g., cognitive overload due to an unstable patient).Conclusion: This qualitative study identified potential behavioral targets that future implementation strategies should address to improve collaboration between PCs and intensivists. In light of our results, the Québec PC now asks clinicians if the poisoned patient is unstable prior to collecting any other information. When necessary, a teleconference with the toxicologist is proposed earlier than before.

Optimisation: defining and exploring a concept to enhance the impact of public health initiatives

BACKGROUND

Repeated, data-driven optimisation processes have been applied in many fields to rapidly transform the performance of products, processes and interventions. While such processes may similarly be employed to enhance the impact of public health initiatives, optimisation has not been defined in the context of public health and there has been little exploration of its key concepts.

METHODS

We used a modified, three-round Delphi study with an international group of researchers, public health policy-makers and practitioners to (1) generate a consensus-based definition of optimisation in the context of public health and (2i) describe key considerations for optimisation in that context. A pre-workshop literature review and elicitation of participant views regarding optimisation in public health (round 1) were followed by a daylong workshop and facilitated face-to-face group discussions to refine the definition and generate key considerations (round 2); finally, post-workshop discussions were undertaken to refine and finalise the findings (round 3). A thematic analysis was performed at each round. Study findings reflect an iterative consultation process with study participants.

RESULTS

Thirty of 33 invited individuals (91%) participated in the study. Participants reached consensus on the following definition of optimisation in public health: "A deliberate, iterative and data-driven process to improve a health intervention and/or its implementation to meet stakeholder-defined public health impacts within resource constraints". A range of optimisation considerations were explored. Optimisation was considered most suitable when existing public health initiatives are not sufficiently effective, meaningful improvements from an optimisation process are anticipated, quality data to assess impacts are routinely available, and there are stable and ongoing resources to support it. Participants believed optimisation could be applied to improve the impacts of an intervention, an implementation strategy or both, on outcomes valued by stakeholders or end users. While optimisation processes were thought to be facilitated by an understanding of the mechanisms of an intervention or implementation strategy, no agreement was reached regarding the best approach to inform decisions about modifications to improve impact.

CONCLUSIONS

The study findings provide a strong basis for future research to explore the potential impact of optimisation in the field of public health.