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Paniagua-Avila A, Shelton RC, Figueroa JC, Guzman AL, Gutierrez L, Hernandez-Galdamez DR, Ramirez JM, Rodriguez J, Irazola V, Ramirez-Zea M, Fort MP. Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: an application of the RE-AIM/PRISM extension for sustainability and health equity. Implement Sci Commun 2024; 5:23. [PMID: 38491376 PMCID: PMC10941412 DOI: 10.1186/s43058-024-00560-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic necessitated rapid changes in healthcare delivery in Guatemala's public primary care settings. A new hypertension program, implemented as part of a type 2 hybrid trial since 2019, exemplifies an implementation effort amidst a changing context in an under-resourced setting. We assessed the implementation of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care), raising implications for health equity and sustainability. We present innovative application of systems thinking visuals. METHODS Conducting a convergent mixed methods analysis, we assessed implementation in response to contextual changes across five Ministry of Health (MoH) districts at the pandemic's onset. Utilizing quantitative programmatic data and qualitative interviews with stakeholders (n=18; health providers, administrators, study staff), we evaluated dimensions of "Reach, Effectiveness, Adoption, Implementation and Maintenance," RE-AIM (Reach, Implementation delivery + adaptations), and "Practical Robust Implementation and Sustainability Model," PRISM (Organizational perspective on the EBI, Fit, Implementation and sustainability infrastructure) frameworks. We assessed representativeness by comparing participants to census data. To assess implementation delivery, we built behavior-over-time (BOT) graphs with quantitative programmatic data (July 2019-July 2021). To assess adaptations and contextual changes, we performed matrix-based thematic qualitative analysis. We converged quantitative implementation delivery data + qualitative adaptations data in joint displays. Finally, we analyzed qualitative and quantitative results across RE-AIM/PRISM and health districts to identify equity and sustainability considerations. RESULTS Contextual factors that facilitated program delivery included the perception that the EBI was beneficial, program champions, and staff communication. Key barriers to implementation delivery included competition with other primary care activities and limited implementation infrastructure (e.g., equipment, medications). Contextual changes related to COVID-19 hindered implementation delivery, threatened sustainability, and may have exacerbated inequities. However, adaptations that were planned enhanced implementation delivery and may have supported improved equity and sustainability. CONCLUSIONS Recognition of an EBI's benefits and program champions are important for supporting initial uptake. The ability to plan adaptations amid rapid contextual changes has potential advantages for sustainability and equitable delivery. Systems thinking tools and mixed methods approaches may shed light on the relations between context, adaptations, and equitable and sustainable implementation. TRIAL REGISTRATION NCT03504124.
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Affiliation(s)
- Alejandra Paniagua-Avila
- Epidemiology Department, Mailman School of Public Health, Columbia University, New York, NY, USA.
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala.
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Juan Carlos Figueroa
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
- Department of Epidemiology, Dornsife School of Public Health, Urban Health Collaborative, Drexel University, Philadelphia, PA, USA
| | - Ana Lissette Guzman
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Laura Gutierrez
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Diego Rolando Hernandez-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Juan Manuel Ramirez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Javier Rodriguez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
- Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
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Wellmann IA, Ayala LF, Rodríguez JJ, Guetterman TC, Irazola V, Palacios E, Huffman MD, Rohloff P, Heisler M, Ramírez-Zea M, Flood D. Implementing integrated hypertension and diabetes management using the World Health Organization's HEARTS model: protocol for a pilot study in the Guatemalan national primary care system. Implement Sci Commun 2024; 5:7. [PMID: 38195600 PMCID: PMC10775666 DOI: 10.1186/s43058-023-00539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala. METHODS A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning. DISCUSSION This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries. TRIAL REGISTRATION ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.
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Affiliation(s)
- Irmgardt Alicia Wellmann
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Luis Fernando Ayala
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - José Javier Rodríguez
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | | | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Eduardo Palacios
- National Program for the Prevention of Chronic Non-Communicable Diseases and Cancer, Ministry of Health, Guatemala City, Guatemala
| | - Mark D Huffman
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Peter Rohloff
- Center for Indigenous Health Research, Wuqu' Kawoq, Tecpán, Guatemala
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele Heisler
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Manuel Ramírez-Zea
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - David Flood
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala.
- Center for Indigenous Health Research, Wuqu' Kawoq, Tecpán, Guatemala.
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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Weber MB, Baumann AA, Rakhra A, Akwanalo C, Gladys Amaning Adjei K, Andesia J, Apusiga K, Ha DA, Hosseinipour MC, Muula AS, Nguyen HL, Price LN, Ramirez-Zea M, Fitzpatrick AL, Fort MP. Global implementation research capacity building to address cardiovascular disease: An assessment of efforts in eight countries. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002237. [PMID: 37708090 PMCID: PMC10501667 DOI: 10.1371/journal.pgph.0002237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/01/2023] [Indexed: 09/16/2023]
Abstract
Cardiovascular diseases are the leading causes of morbidity and mortality worldwide, but implementation of evidence-based interventions for risk factors such as hypertension is lacking, particularly in low and middle income countries (LMICs). Building implementation research capacity in LMICs is required to overcome this gap. Members of the Global Research on Implementation and Translation Science (GRIT) Consortium have been collaborating in recent years to establish a research and training infrastructure in dissemination and implementation to improve hypertension care. GRIT includes projects in Ghana, Guatemala, India, Kenya, Malawi, Nepal, Rwanda, and Vietnam. We collected data from each site on capacity building activities using the Potter and Brough (2004) model, mapping formal and informal activities to develop (a) structures, systems and roles, (b) staff and infrastructure, (c) skills, and (d) tools. We captured information about sites' needs assessments and metrics plus program adaptations due to the COVID-19 pandemic. All sites reported capacity building activities in each layer of the Capacity Pyramid, with the largest number of activities in the Skills and Tools categories, the more technical and easier to implement categories. All sites included formal and informal training to build Skills. All sites included a baseline needs assessment to guide capacity building activities or assess context and inform intervention design. Sites implementing evidence-based hypertension interventions used common implementation science frameworks to evaluate implementation outcomes. Although the COVID-19 pandemic affected timelines and in-person events, all projects were able to pivot and carry out planned activities. Although variability in the activities and methods used existed, GRIT programs used needs assessments to guide locally appropriate design and implementation of capacity building activities. COVID-19 related changes were necessary, but strong collaborations and relationships with health ministries were maintained. The GRIT Consortium is a model for planning capacity building in LMICs.
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Affiliation(s)
- Mary Beth Weber
- Hubert Department of Global Health, Emory University, Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Ana A. Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Ashlin Rakhra
- Department of Population Health, NYU Grossman School of Medicine, New York City, New York, United States of America
| | | | - Kezia Gladys Amaning Adjei
- Department of Physiology, School of Medicine and Dentistry, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Josephine Andesia
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Kingsley Apusiga
- Department of Physiology, School of Medicine and Dentistry, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Duc A. Ha
- Health Strategy and Policy Institute, Vietnam Ministry of Health, Hanoi, Vietnam
| | - Mina C. Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Adamson S. Muula
- College of Medicine, University of Malawi and the Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Hoa L. Nguyen
- University of Massachusetts Chan Medical School, Boston, Massachusetts, United States of America
| | - LeShawndra N. Price
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Annette L. Fitzpatrick
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Meredith P. Fort
- Colorado School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora, Colorado, United States of America
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Fort MP, Manson SM, Glasgow RE. Applying an equity lens to assess context and implementation in public health and health services research and practice using the PRISM framework. FRONTIERS IN HEALTH SERVICES 2023; 3:1139788. [PMID: 37125222 PMCID: PMC10137153 DOI: 10.3389/frhs.2023.1139788] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/13/2023] [Indexed: 05/02/2023]
Abstract
Dissemination and implementation science seeks to enhance the uptake, successful implementation, and sustainment of evidence-based programs and policies. While a focus on health equity is implicit in many efforts to increase access to and coverage of evidence-based programs and policies, most implementation frameworks and models do not explicitly address it. Disparities may in fact be increased by emphasizing high intensity interventions or ease of delivery over meeting need within the population, addressing deep-rooted structural inequities, and adapting to local context and priorities. PRISM (Practical, Robust Implementation and Sustainability Model), the contextual expansion of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework has several elements that address health equity, but these have not been explicated, integrated, or illustrated in one place. We present guidance for applying PRISM with an equity lens across its four context domains (external environment; multi-level perspectives on the intervention; characteristics of implementers and intended audience; and the implementation and sustainability infrastructure-as well as the five RE-AIM outcome dimensions. We then present an example with health equity considerations and discuss issues of representation and participation, representativeness and the importance of ongoing, iterative assessment of dynamic context and structural drivers of inequity. We also elaborate on the importance of a continuous process that requires addressing community priorities and responding to capacity and infrastructure needs and changes. We conclude with research and practice recommendations for applying PRISM with an increased emphasis on equity.
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Affiliation(s)
- Meredith P. Fort
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, United States
- Department of Health Systems, Management and Policy, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, United States
| | - Spero M. Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, United States
| | - Russell E. Glasgow
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus, and Eastern Colorado Veterans Administration, Aurora, CO, United States
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Figueroa JC, Paniagua-Avila A, Sub Cuc I, Cardona S, Ramirez-Zea M, Irazola V, Fort MP. Explanatory models of hypertension in Guatemala: recognizing the perspectives of patients, family members, health care providers and administrators, and national-level health system stakeholders. BMC Public Health 2022; 22:2320. [PMID: 36510216 PMCID: PMC9743515 DOI: 10.1186/s12889-022-14668-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Uncontrolled hypertension is a major public health burden and the most common preventable risk factor for cardiovascular diseases in Guatemala and other low- and middle-income countries. Prior to an initial trial that evaluated a hypertension intervention in rural Guatemala, we collected qualitative information on the needs and knowledge gaps of hypertension care within Guatemala's public healthcare system. This analysis applied Kleinman's Explanatory Models of Illness to capture how patients, family members, community-, district-, and provincial-level health care providers and administrators, and national-level health system stakeholders understand hypertension. METHODS: We conducted in-depth interviews with three types of participants: 1) national-level health system stakeholders (n = 17), 2) local health providers and administrators from district, and health post levels (25), and 3) patients and family members (19) in the departments of Sololá and Zacapa in Guatemala. All interviews were conducted in Spanish except for 6 Maya-Kaqchikel interviews. We also conducted focus group discussions with auxiliary nurses (3) and patients (3), one in Maya-Tz'utujil and the rest in Spanish. Through framework and matrix analysis, we compared understandings of hypertension by participant type using the Explanatory Model of Illness domains -etiology, symptoms, pathophysiology, course of illness, and treatment. RESULTS Health providers and administrators, and patients described hypertension as an illness that spurs from emotional states like sadness, anger, and worry; is inherited and related to advanced age; and produces symptoms that include a weakened body, nerves, pain, and headaches. Patients expressed concerns about hypertension treatment's long-term consequences, despite trying to comply with treatment. Patients stated that they combine biomedical treatment (when available) with natural remedies (teas and plants). Health providers and administrators and family members stated that once patients feel better, they often disengage from treatment. National-level health system stakeholders referred to lifestyle factors as important causes, considered patients to typically be non-compliant, and identified budget limitations as a key barrier to hypertension care. The three groups of participants identified structural barriers to limited hypertension care (e.g., limited access to healthy food and unaffordability of medications). CONCLUSION As understandings of hypertension vary between types of participants, it is important to describe their similarities and differences considering the role each has in the health system. Considering different perceptions of hypertension will enable better informed program planning and implementation efforts.
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Affiliation(s)
- Juan Carlos Figueroa
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala.
- Dornsife School of Public Health, Department of Epidemiology and Biostatistics, Drexel University, Urban Health Collaborative, Philadelphia, PA, USA.
| | - Alejandra Paniagua-Avila
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York City, New York, USA
| | - Ingrid Sub Cuc
- Department of Native American Studies, University of California, Davis, Davis, CA, , USA
| | - Sayra Cardona
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
- Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
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Glasgow RE, Battaglia C, McCreight M, Ayele R, Maw AM, Fort MP, Holtrop JS, Gomes RN, Rabin BA. Use of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to guide iterative adaptations: Applications, lessons learned, and future directions. FRONTIERS IN HEALTH SERVICES 2022; 2:959565. [PMID: 36925843 PMCID: PMC10012751 DOI: 10.3389/frhs.2022.959565] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/23/2022] [Indexed: 02/07/2023]
Abstract
Introduction Implementation science frameworks have been used widely for planning and evaluation, but seldom to guide adaptations during program implementation. There is great potential for these frameworks to be used to inform conceptual and data-driven decisions about adaptations. Methods We summarize recent applications using Iterative RE-AIM to capture and guide adaptations. Iterative RE-AIM can be repeated at multiple time points customized to each project and involves the following activities: identification of key implementation partners; rating importance of and progress on each RE-AIM dimension (reach, effectiveness, adoption, implementation, and maintenance); use of summary data on ratings to identify one or two RE-AIM dimensions for adaptations and implementation strategies; and evaluation of progress and impact of adaptations. We summarize recent and ongoing Iterative RE-AIM applications across multiple care coordination and pain management projects within the Veterans Health Administration, a hypertension control trial in Guatemala, a hospital-based lung ultrasound implementation pilot, and a colorectal cancer screening program in underserved communities. Results Iterative RE-AIM appears feasible, helpful, and broadly applicable across diverse health care issues, interventions, contexts, and populations. In general, the RE-AIM dimension showing the largest gap between importance and progress has been Reach. The dimensions most frequently selected for improvement have been Reach and Implementation. We discuss commonalities, differences and lessons learned across these various applications of Iterative RE-AIM. Challenges include having objective real time data on which to make decisions, having key implementation staff available for all assessments, and rapidly scoring and providing actionable feedback. We discuss print and online resources and materials to support Iterative RE-AIM. Conclusions The use of Iterative RE-AIM to guide and support understanding of adaptations has proven feasible across diverse projects and in multiple case studies, but there are still questions about its strengths, limitations, essential components, efficiency, comparative effectiveness, and delivery details. Future directions include investigating the optimal frequency and timing for iterative applications; adding contextual assessments; developing more continuous and rapid data on which to make adaptation decisions; identifying opportunities to enhance health equity; and determining the level of facilitation that is most cost-effective.
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Affiliation(s)
- Russell E. Glasgow
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Catherine Battaglia
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veteran Affairs, VA Eastern Colorado Health Care System, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veteran Affairs, VA Eastern Colorado Health Care System, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Roman Ayele
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veteran Affairs, VA Eastern Colorado Health Care System, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Anna M. Maw
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Meredith P. Fort
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Health Systems, Management and Policy Department, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jodi Summers Holtrop
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Rebekah N. Gomes
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Borsika Adrienn Rabin
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Dissemination and Implementation Science Center, Altman Clinical and Translational Research Center, Herbert Wertheim School of Public Health and Human Longevity in Science, University of California, San Diego, CA, United States
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