A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project

Implementation strategies to increase seasonal influenza vaccination among adults: A rapid scoping review

Many strategies have been applied to increase seasonal influenza vaccination; however, gaps in coverage remain. We synthesized the evidence on effectiveness of implementation strategies to increase seasonal influenza vaccination among U.S. adults. Studies performed from February 2010-August 2023 in the United States, focused on seasonal influenza vaccination, and measuring uptake and coverage were included. Guidance from Cochrane was followed. Interventions were mapped to Expert Recommendations for Implementing Change strategies. A total of 1,585 non-duplicate records were identified, full-text screening was performed for 353 records, and 51 studies met inclusion criteria. Among these studies, implementation strategies included those that engaged consumers, trained and educated stakeholders, and supported providers. Considerable heterogeneity was found in the study setting, populations, design, and methods. Substantial study variation limits the ability to conclude which strategies are most effective at increasing influenza vaccination uptake and coverage in U.S. adults.

Implementation strategies for improving the care of familial hypercholesterolaemia from the International Atherosclerosis Society: next steps in implementation science and practice

Familial hypercholesterolaemia (FH) is the most common monogenic condition associated with premature atherosclerotic cardiovascular disease. Early detection and initiation of cholesterol lowering therapy combined with lifestyle changes improves the prognosis of patients with FH significantly. The International Atherosclerosis Society (IAS) published a new guidance for implementing best practice in the care of FH. Previous guidelines and position statements seldom provided implementation recommendations. To address this, an implementation science approach was used to generate implementation strategies for the clinical recommendations made. This process entailed the generation by consensus of strong implementation recommendations according to the Expert Recommendations for Implementing Change (ERIC) taxonomy. A total of 80 general and specific implementation recommendations were generated, addressing detection (screening, diagnosis, genetic testing and counselling) and management (risk stratification, treatment of adults or children with heterozygous or homozygous FH, therapy during pregnancy and use of apheresis) of patients with FH. We describe here the IAS guidance core implementation strategies to assist with the adoption of clinical recommendations into routine practice for at-risk patients and families worldwide. We summarise the IAS guidance core implementation strategies as operative statements.

Evidence adaptation and tailored implementation of family bereavement support in specialised palliative care: A multi-method study

Background

Families experiencing the loss of their close other following advanced illness have varying degrees of needs that stretch into bereavement. Evidence-based recommendations for bereavement support are often not well implemented in palliative care services due to multiple system barriers and lack of contextual fit. To close this know-do gap, we undertook an implementation science research project.

Objective

To adapt evidence-informed recommendations for supporting bereaved families to the local context, and to develop a tailored implementation strategy for their integration in specialised palliative care services.

Settings and participants

Two specialised palliative care services located at urban teaching hospitals in German-speaking Switzerland. Participants were palliative care staff working in the service, including nurses, physicians, chaplains, psychologists, and two service users.

Methods

Multi-method implementation research project combining community engagement strategies, qualitative contextual analysis, and theory-driven implementation design processes for integrating evidence-informed interventions in new contexts: First, evidence was identified and adapted through co-design staff workshops and service user consultations, following intervention adaptation guidelines. Next, focus group interviews were held to identify barriers and facilitators to implementation, informed by the Consolidated Framework for Implementation Research and analysed using qualitative content analysis. Drawing on implementation mapping methodology, a systematic and participatory process was used to develop an implementation plan that specified activities needed to address identified barriers and support integration into palliative care services.

Results

The study resulted in an adapted bereavement support pathway with three core functions of evidence-informed practices delivered during dying, at death, three-to-six, and if necessary nine-to-twelve months post-loss: screening and assessing family needs and risks, intervention and support activities for families, and team collaboration and coordination within and across providers. Implementation was expected to be influenced by the features of the intervention itself, staff competencies, and organisational conditions, with resources required being a frequent barrier, whereas workplace culture and the project-related network acted as facilitators. A multifaceted implementation strategy with 16 distinct activities was developed to reach 70 % of bereaved families: designing a practical, implementable pathway, creating necessary team capacity and roles, optimizing workflow, offering education and clinician support, ensuring leadership and organisational commitment, and facilitating mutual exchange and learning. An implementation research logic model specified expected mechanisms of impact and outcomes.

Conclusions

The project resulted in an adapted bereavement support intervention fitted to local palliative care contexts and a tailored implementation plan. Adapting evidence to specific contexts and understanding potential barriers and facilitators is necessary to prepare implementation.

Registration

https://osf.io/qgr7y.

Formative Evaluation to Inform Implementation of Sepsis Bundles in Emergency Departments

STUDY OBJECTIVE

Sepsis bundles are effective in reducing mortality for sepsis, the leading cause of admissions to intensive care units. However, little is known about factors that hinder and facilitate the delivery of sepsis bundles in emergency departments. Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, the objective of the present study was to characterize determinants of implementing sepsis bundles in emergency departments in the United States.

METHODS

A formative evaluation guided by the EPIS was conducted with nurses, physicians, and pharmacists using qualitative interviews (N=66 interviews) and quantitative surveys (N=86 surveys). Qualitative interviews were analyzed using a matrix-guided rapid analytic approach. Quantitative surveys were analyzed descriptively.

RESULTS

Scores on quantitative measures indicated that participants perceived evidence-based interventions positively and had moderately positive perceptions of implementation climate and organizational readiness for change. Qualitative results indicate barriers aligned with the EPIS constructs of outer context (eg, perceived rigidity related to Centers for Medicare & Medicaid Services bundle requirements), inner context (eg, alert fatigue), bridging factors (eg, staffing shortages), and innovation factors (eg, concerns about fluid overload). Participants reported facilitators including nurse-driven protocols (inner context) and bundles being straightforward (innovation factors).

CONCLUSIONS

Findings highlight areas that warrant attention during sepsis bundle implementation efforts in emergency departments, including staff turnover, hesitancy in initiating bundles, competing or misaligned priorities related to bundle implementation, and developing hospital cultures that promote sepsis bundle compliance. These findings will be used to tailor implementation strategies that will support bundle compliance in a hybrid type II effectiveness-implementation trial.

Enhancing Behavioral Health Implementation in a Care Coordination Program at a Federally Qualified Health Center: A Case Study Applying Implementation Frameworks

Federally Qualified Health Centers are charged with providing comprehensive health care in traditionally underserved areas, underscoring their importance in caring for and promoting health equity for the large portion of historically marginalized communities in this setting. There is a significant need to ensure Federally Qualified Health Centers are equipped to appropriately address the immense behavioral health needs common among patients served. Care coordination is an evidence-based model that is increasingly utilized in Federally Qualified Health Centers to improve care equity and outcomes. Addressing and supporting behavioral health needs is a key aspect of such care coordination models. Context-specific considerations and programmatic supports, particularly those that address the needs of care coordinators and the complex patients they serve, are needed to ensure such models can appropriately meet and address the behavioral health concerns of the diverse populations served. The goal of this study was to present a mixed-methods case study that systematically applies implementation frameworks to conduct a needs and context assessment to inform the development and testing of evidence-based practice strategies and implementation support as part of a care coordination program within a partnered Federally Qualified Health Center.

Optimization of carbon membrane performance in reverse osmosis systems for reducing salinity, nitrates, phosphates, and ammonia in aquaculture wastewater

This study investigates the performance of various types of carbon membranes in reverse osmosis systems aimed at reducing salinity, nitrates, phosphates, and ammonia in aquaculture wastewater. As sustainable aquaculture practices become increasingly essential, effective treatment solutions are needed to mitigate pollution from nutrient-rich effluents. The research highlights several carbon membranes types, including carbon molecular sieves, activated carbon membranes, carbon nanotube membranes, and graphene oxide membranes, all of which demonstrate exceptional filtration capabilities due to their unique structural properties. Findings reveal that these carbon membranes can achieve removal efficiencies exceeding 90 % for critical pollutants, thereby significantly improving water quality and supporting environmental sustainability. The study also explores the development of hybrid membranes and nanocomposites, which enhance performance by combining the strengths of different materials, allowing for customized solutions tailored to the specific requirements of aquaculture wastewater treatment. Additionally, operational parameters such as pH, temperature, and feed water characteristics are crucial for maximizing membrane efficiency. The integration of real-time monitoring technologies is proposed to enable prompt adjustments to treatment processes, thereby improving system performance and reliability. Overall, this research emphasizes the importance of interdisciplinary collaboration among researchers and industry stakeholders to drive innovation in advanced filtration technologies. The findings underscore the substantial potential of carbon membranes in tackling the pressing water quality challenges faced by the aquaculture sector, ultimately contributing to the sustainability of aquatic ecosystems and ensuring compliance with environmental standards for future generations.

Impact of a multi-component implementation strategy to increase outdoor free play opportunities in early childhood education and care (ECEC) services: the get outside get active (GOGA) randomised controlled trial

BACKGROUND

Increased outdoor free play is associated with health and developmental benefits for preschool-aged children. It is therefore recommended that early childhood education and care (ECEC) services provide increased time for outdoor free play. This study seeks to understand the impact of a multi-component implementation strategy (Get Outside Get Active) on ECEC service provision of opportunities for outdoor free play.

METHODS

This was a parallel-group randomised controlled trial involving 84 ECEC services located in one region of New South Wales, Australia. Forty-one services were randomised to a 6-month multi-component implementation strategy or to a usual care group (n = 43). To increase total scheduled outdoor free play time, services were supported to modify their routines to increase provision of outdoor free play and/or indoor-outdoor free play opportunities (whereby children are allowed to move freely between indoor and outdoor spaces). The primary trial outcome, mean minutes per day of outdoor free play opportunities provided in ECEC services, was measured at baseline, 6-months (primary endpoint), and 18-months. Secondary outcomes were mean minutes of indoor-outdoor free play only and proportion implementing indoor-outdoor free play for the full day. The quality of the movement environment was assessed using direct observations in 30 ECECs at 6 months only.

RESULTS

At 6 months, the intervention group showed a significant increase in mean daily minutes of outdoor free play (61.3 min; 95% CI 2.5 to 120.01; p = 0.041) and indoor-outdoor free play (59.1 min; 95% CI 9.1 to 109.1; p = 0.021) relative to the control group. However, no significant between-group differences were observed at 18 months. The proportion implementing a full-day indoor-outdoor program (OR 1.97; 95% CI 0.81 to 4.78; p = 0.196) and the quality of movement environments did not differ between groups at 6 months.

CONCLUSIONS

The implementation strategy significantly increased outdoor free play opportunities in ECEC services post-intervention, though the between group effects were not sustained at 18 months. Future research should focus on ensuring the long-term impact of implementation strategies and understanding the factors driving changes in control group behaviour.

TRIAL REGISTRATION

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12621000987864).

Design for Dissemination: Leaders Suggest Local Strategies for Implementing a Health Communications Campaign

PurposeUsing evidence-based health communication campaigns (EBHCC) is critical for addressing disparities in tobacco-related health outcomes among LGBTQ+ populations; therefore, this study aimed to examine processes and supports for community-based organizations (CBOs) to integrate evidence-based solutions into practice using a design-for-dissemination framework.ApproachQualitative interviews were conducted.SettingCBOs serving LGBTQ+ populations.Participants22 staff from U.S.-based CBOs participated in video interviews.MethodWe used reflexive thematic analysis to generate themes.Results3 key themes included: (1) leaders perceived storytelling as a desirable and effective way to operationalize hyperlocal adaptation of content, particularly when in-group stories came from the community and included video content (which was perceived to maximize reach); (2) researcher participation in content production/delivery was seen as a compelling implementation strategy; and (3) these requested components were seen as adding value rather than as substitutions for text- and image-based EBHCC content.Adaptations envisioned by participants are associated with increased demand for limited resources (ie, requiring more time or financial resources), on the part of CBOs, the research team, or both. Researcher strategies were identified to support meeting CBOs' needs given these contextual constraints.ConclusionThis research explores supports and processes requested by CBOs serving LGBTQ+ populations as part of the adaptations envisioned in implementing EBHCCs and highlights possible avenues to better meet CBOs' needs in effectively utilizing interventions.

Approvers, Disapprovers, and Strugglers: a Q-methodology study of rectal cancer MRI proforma use

OBJECTIVES

Rectal cancer MRI (rcMRI) allows accurate staging and informs treatment decisions in rectal cancer. There is variability in reporting completeness; however, template proforma reports can significantly increase the inclusion of key tumour descriptors. We aimed to identify socially shared viewpoints of radiologists relating to barriers to implementing proforma reporting. Measuring the subjectivity of opinions relative to other radiologists will allow identification of common patterns preventing implementation.

METHODS

Specialist gastrointestinal radiologists from 16 hospital trusts were invited to a Q-methodology study. Participants ranked 56 statements on barriers to using proforma reports (the Q-set) in a normal distribution (Q-grid). Factor analyses were undertaken to identify independent accounts, and additional survey data were used to support interpretation.

RESULTS

Twenty-seven radiologists participated; 11 (41%) had more than 10 years reporting rcMRIs. Three distinct accounts of radiologist attitudes to proforma-use were identified: Approvers, Disapprovers, and Struggling champions. The highest ranked barriers related to proforma format, individual radiologists' preferences and beliefs about efficacy and factors relating to wider multidisciplinary teams and health system-level implementation.

CONCLUSIONS

Radiologists that disapprove of proformas are unlikely to use them unless external influences are applied, such as a requirement by treating clinicians. Increased internal and organizational support would also increase use. Targeted implementation strategies focusing on these barriers has the potential to increase uptake of similar interventions.

ADVANCES IN KNOWLEDGE

Specialist radiologists require a multi-level adaptive implementation strategy, tailored to proforma characteristics as well as individual and organizational barriers to increase proforma reporting for rcMRI to support accurate treatment decision making.

Tentative renderings: Describing local data infrastructures that support the implementation and evaluation of national evaluation Initiatives

OBJECTIVE

Data journeys are a way to describe and interrogate "the life of data" (Bates et al 2010). Thus far, they have been used to clarify the mobile nature of data by visualizing the pathways made by handling and moving data. We wanted to use the data journeys method (Eleftheriou et al. 2018) to compare different data journeys by noticing repetitions, patterns, and gaps.

METHODS

We conducted qualitative interviews with 43 evaluators, implementers and administrators associated with 21 clinical and training programs, called "Enterprise-Wide Initiatives" (EWIs) that are part of a national health system in the United States. We used inductive and deductive coding to identify narratives of data journeys, and then we used the "swim lane" (Collar et al 2012) format to make data journey maps based on those narratives.

RESULTS

Unlike the actors in Eleftheriou et al. (2018)'s work, who built a data infrastructure to manage clinical data, the actors in our study built data infrastructures to evaluate clinical data. We created and compared two data journey maps that helped us explore differences in data production and management. In tracing the pathways available to the data entity of interest, and the processes through which the actors interacted with it, we noticed how the same piece of information was made to work in different ways.

CONCLUSIONS

Researchers often must build a new data infrastructures to respond to the unique needs of their evaluation work. Differing abilities lead to differences in what programs can build, and consequently what kinds of evaluation work they can support. With the goal of straightforward comparisons across different programs, a more limited focus on quantitative values, and a better description of the data journeys used by the evaluation teams, might facilitate more nuanced assessments of the evidence of complex outcomes.

A Mixed Method Evaluation of Practitioners' Perspectives on Implementation Strategies for Healthy Eating and Active Living Policy, Systems, and Environmental Changes

CONTEXT

The National Cooperative Extension System is a leader in delivering healthy eating and active living (HEAL) policy, systems, and environmental (PSE) changes; however, these interventions are challenging, and technical assistance efforts often misalign with implementation science concepts.

OBJECTIVE

The study objective was to understand the importance of implementation strategies and tailoring needs to support Louisiana Nutrition and Community Health (NCH) practitioners' delivery of rural HEAL PSE changes.

DESIGN

An explanatory sequential mixed method study design was used, including a survey to rank the importance of implementation strategies for HEAL PSE changes and a follow-up interview. A review of available implementation strategies (practice activities/resources) for Louisiana HEAL PSE changes was also conducted.

SETTING

This study occurred within Louisiana and focused on NCH practitioners' ongoing HEAL PSE change efforts throughout the state, with emphasis on rural community settings.

PARTICIPANTS

All NCH practitioners were eligible to participate. "Practitioners" included Extension NCH administrators and agents/educators directly delivering HEAL PSE changes.

MAIN OUTCOMES

The main quantitative outcome was the ranked importance of implementation strategies to support NCH practitioners' delivery of HEAL PSE changes. For explanatory interviews, perceptions of higher and lower ranked implementation strategies and tailoring opportunities were of interest. The alignment of available activities/resources with possible implementation strategies was also assessed.

RESULTS

Highly ranked implementation strategies focused on engaging dedicated community partners and community members and starting small to ensure success, generate buy-in, and demonstrate feasibility. Opportunities for capacity building in these areas were identified. A lower ranked implementation strategy, changing organizational structures, was considered less likely to occur but possibly necessary to improve job satisfaction, retention, and return on investment. Available activities/resources overlapped with a few available implementation strategies.

CONCLUSIONS

This study identified opportunities to use implementation science concepts to improve program support for NCH practitioners delivering complex HEAL PSE changes.

Outcomes of an organisational change program aimed at increasing smoking cessation support within Australian community managed mental health organisations: A cluster randomised controlled trial

AIM

To test the effectiveness of an organisational change intervention aimed at increasing the offer of nicotine replacement therapy (NRT) in community managed mental health organisations.

DESIGN

A pragmatic cluster randomised controlled trial with cluster as the unit of randomisation and six- and nine-month follow-up from baseline.

SETTING

Twelve clusters comprising 26 sites providing community based, psychosocial support to people with severe mental illness in New South Wales, Australia, were randomised to control (n = 13 sites, n = 118 consumers) or intervention (n = 13 sites, n = 139 consumers) arms between 2018 and 2019.

PARTICIPANTS

Eligible consumers (aged 16 years and older; self-reported daily or occasional cigarette use) completed surveys at baseline (n = 257) and at six- (n = 162, 63%) and nine-month follow-up (n = 144, 56%).

INTERVENTION

The intervention included a financial grant, face-to-face and on-line training and proactive monthly support to guide implementation. The active control condition included on-line training and generic, scheduled support via email.

MEASUREMENTS

The primary outcome was whether consumers reported receiving an offer of NRT at nine-month follow-up. Secondary outcomes at the consumer, staff and organisational level were also measured.

FINDINGS

Consumers in the intervention group had statistically significantly higher odds of being offered NRT at nine-month follow-up compared with control (intention to treat missing = no offer: 38% versus 7%, odds ratio 5.72, 95% confidence interval = 2.2, 14.9). There were no statistically significant differences in seven-day point prevalence or continuous abstinence at six- or nine-month follow-ups.

CONCLUSIONS

An organisational change-based program led to an increase in the offer of nicotine replacement therapy (NRT) nine months after program initiation in community managed mental health organisations, compared with active control. There was evidence of greater NRT use in the intervention condition at nine months but no evidence of differences on abstinence measures at six or nine months.

The difference-making role of staff support in implementing nurse care management for opioid use disorder treatment: A configurational analysis

INTRODUCTION

Understanding conditions in which interventions succeed or fail is critical. The PRimary care Opioid Use Disorders treatment (PROUD) trial, a cluster-randomized hybrid study, tested whether implementation of office-based addiction treatment supported by a nurse increased medication of OUD. Six health systems each provided two primary care (PC) clinics that were randomly assigned to implement the intervention or usual care. This secondary, exploratory study used an innovative mixed methods approach to understand contextual factors that consistently distinguished intervention clinics that increased OUD treatment from those that did not.

METHODS

The study collected contextual information through field notes, health system debriefs, and nurse interviews. Rapid qualitative analysis using a template based on the Practical, Robust Implementation and Sustainability Model identified themes reflecting the external environment, recipients, and implementation infrastructure. The study used qualitative themes to create binary factors reflecting barriers and facilitators potentially critical to implementation success and assigned clinics a factor value of 1 if present and 0 if absent. Two clinic-level outcomes were defined: 1) significant increase in patient-years of OUD treatment from baseline to two-year follow-up; and 2) high rate of OUD treatment at two-year follow-up (≥20 per 10,000 patient-years). Coincidence analysis, a cross-case configurational method, identified difference-makers for both OUD outcomes across intervention clinics.

RESULTS

Qualitative analysis yielded 11 themes which were dichotomized and consolidated into 9 factors. Two factor values perfectly distinguished between intervention clinics with and without increased OUD treatment (outcome #1): (a) presence of strong support from PC staff and providers and (b) lack of OUD treatment in the community. Intervention clinics increased OUD treatment when either factor value was present; when both were absent, clinics did not increase treatment. Strong support from PC staff and providers was independently sufficient to achieve high rates of OUD treatment (outcome #2) while the absence of support explained low rates of treatment. Importantly, strong support from leadership was not sufficient for either outcome.

CONCLUSION

Strong support from staff and providers consistently differentiated between clinics with increased OUD treatment across both outcomes in the PROUD trial from those without. OUD programs should consider increasing support across clinic roles.

Enhancing implementation of information and communication technologies for post-discharge care among hospitalized older adult patients: development of a multifaceted implementation intervention package using the behavior change wheel and implementation research logic model

BACKGROUND

The integration of information and communication technologies in clinical practice can supplement traditional care pathways on discharge education and has exhibited evident benefits in improving patient health outcomes. However, healthcare providers have reported difficulties in adopting such technologies. The existing evidence on implementation interventions supporting the implementation of information and communication technologies is insufficient, characterized by infrequent utilization or reporting of implementation theories in implementation intervention designs. This study aims to outline the creation of a theory-informed implementation intervention package to enhance the clinical implementation of information and communication technologies for post-discharge self-care among hospitalized older adults.

METHODS

This study systematically applies the Behavior Change Wheel (BCW) approach, involving behavior diagnosis, identification of intervention options, and intervention content selection, informed by conceptual frameworks, empirical data, and relevant literature. Additionally, the Implementation Research Logic Model is utilized to synthesize, organize, and visually present the collected data.

RESULTS

This structured process identified and selected five intervention functions, 11 behavior change techniques, and four policy categories. A multifaceted implementation intervention package was developed, containing four components: (i) flexible and sustainable training, (ii) mass media and opinion leader campaign, (iii) technology and workflow redesign, and (iv) regular corporate-level audit and feedback.

CONCLUSIONS

The study addresses the incomplete evidence base for implementation interventions supporting clinical information and communication technology implementation, presenting a practical, evaluable, and scalable theory-informed implementation intervention package. By providing an example of the application of the BCW approach and logic model, this study contributes to the knowledge on implementation intervention design, offering valuable insights for researchers and practitioners aiming to improve healthcare providers' behavior change and post-discharge care management with technology-based interventions.

Using implementation science to encourage Serious Illness Conversations on general medicine inpatient services: An interrupted time series

BACKGROUND

Serious Illness Conversations (SICs) are not consistently integrated into existing inpatient workflows.

OBJECTIVE

We assessed the implementation of multiple interventions aimed at encouraging SICs with hospitalized patients.

METHODS

We used the Consolidated Framework for Implementation Research to identify determinants for conducting SICs by interviewing providers and the Expert Recommendations for Implementing Change to develop a list of interventions. Adult patient encounters with a Readmission Risk Score (RRS) > 28% admitted to a general medicine service from January 2019 to October 2021 and without standardized SIC documentation in the prior year were included. A multivariable segmented logistic regression model, suitable for an interrupted time series analysis, was used to assess changes in the odds of standardized SIC documentation.

RESULTS

Barriers included those associated with the COVID-19 pandemic, such as extreme census. Facilitators included the presence of the Speaking About Goals and Expectations program and palliative care consultations. Key interventions included patient identification via the existing Quality and Safety Dashboard (QSD), weekly emails, in-person outreach, and training for faculty and trainees. There was no significant change in the odds of standardized SIC documentation despite interventions (change in temporal trend odds ratio (OR) 1.16, 95% Confidence Interval (CI) 0.98-1.39).

CONCLUSION

The lack of significant change in standardized SIC documentation may be attributed to insufficient or ineffective interventions and COVID-19-related challenges. Although patient identification is a known barrier to SICs, this issue was minimized with the use of the QSD and RRS. Further research is needed to enhance the implementation of SICs in inpatient settings.

Development of recommendations to improve implementation of medical amnesty policies in collegiate athletic settings

OBJECTIVE

To make recommendations for improving medical amnesty policy implementation in collegiate athletics based on exploration of relevant policy implementation, implementation frameworks, and athletic department input.

PARTICIPANTS

54 published peer-reviewed articles, 78 collegiate athletics professionals, 5 content experts with direct responsibilities related to policies that impact college student and athlete well-being, and 113 higher education institutions' Athletics Healthcare Administrators (AHA).

METHODS

Mixed methods using narrative literature review, surveys, and interview data. Data coding was guided by the Consolidated Framework for Implementation Research (CFIR) and quantitative data were analyzed with descriptive statistics.

RESULTS

Using coded data from the literature review and needs assessment, we identified modifiable implementation determinants and mapped these onto implementation strategies. With feedback from key organizational representatives, ten recommendations were developed and mostly viewed as feasible.

CONCLUSIONS

We present recommendations for amnesty policy implementation within athletics departments, but additional research and evidence-based resources are needed to support implementation.

Improving Patient Experience With Provider Communication: Systematic Review of Interventions, Implementation Strategies, and Their Effectiveness

BACKGROUND

Provider communication with patients may be improved through training, shadow coaching, and other in-service interventions. We aim to synthesize these interventions, implementation strategies, and their impact on the patient experience.

METHODS

A systematic review of contemporary evidence (2015-2023). Six scientific databases, specialty journals, and snowballing searches identified training, shadow coaching, and other in-service interventions for improving provider communication with patients, evaluated by standardized patient experience measures. Studies without inferential statistics were excluded. Two independent reviewers assessed the studies' eligibility and methodological quality and mapped the implementation strategies against a widely used taxonomy of 73 strategies.

RESULTS

Of 1237 papers screened, 14 were included: 10 controlled studies (5 randomized) and 4 prepost. Nine studies were on communication skills training and 3 on shadow coaching; all but one of these used a train-the-trainer implementation strategy. Eight studies (controlled n=4) used 5.5-8 hours of communication training and showed significant improvements in selected experience outcomes. Brief (45 min) communication training showed no significant results. Two controlled studies showed that shadow coaching and recoaching achieve short-term improvements but eroded without booster sessions. The use of transparent surgeon masks improved selected communication outcomes, but periodic reminders sent to clinicians on communication etiquette did not.

DISCUSSION

In-service communication training (≥5.5 h) or shadow (re-)coaching by trained peers can improve patients' experience with provider-patient communication. To implement such interventions, organizations need to identify and train trainers/coaches, intentionally support the program, monitor effectiveness, and add boosters as needed. Brief communication etiquette training or simple reminders did not improve the patients' experiences with provider-patient communication.

CAEP 2024 Academic Symposium: adaptive platform trials in emergency medicine in Canada

OBJECTIVE

The Canadian Association of Emergency Physicians 2024 Academic Symposium Panel on adaptive platform trials explored whether adaptive platform trials could be implemented in Canadian emergency departments (EDs). This panel aimed to propose and refine recommendations formulated by the results of a rapid review and responses from a panel of experts about conducting adaptive platform trials in EDs.

METHODS

From November 2023 to May 2024, a rapid review was conducted on the existing logistical and ethical barriers and facilitators to structuring adaptive platform trials in emergency medicine. The emerging themes and ideas were collected and used to conduct individual semi-structured interviews with key stakeholders, including leaders in emergency medicine research, methodologists and biostatisticians specializing in these designs, patient partners, research personnel, and investigators involved in platform trials across Canada and abroad.

RESULTS

From 23 articles and 17 expert interviews, we identified facilitators and barriers to adaptive platform trials in Canadian emergency medicine spread across five domains: evidence strength and quality, relative advantage, adaptability, complexity, and implementation climate and readiness. The most salient needs according to investigators were purposeful and clinically relevant trial design, methodological expertise, and harmonious collaboration with ethics authorities. We provide 14 recommendations across 4 levels: policy, trialist, site, and patient to address barriers to adaptive platform trials in emergency medicine. For each recommendation, we provided corresponding implementation strategies from the Expert Recommendations for Implementing Change (ERIC).

CONCLUSIONS

Adaptive trial designs are well suited for emergency settings provided the interventions are both easy for clinicians to administer and relevant enough to ameliorate the practice of emergency medicine. These designs are particularly tailored to tackle confirmatory trials, emerging diseases, and trauma care, but barriers like a chaotic ED, complex statistical and methodological requirements, and regulatory considerations persist and require thoughtful implementation strategies.

Finding the balance between rigour and relevance: implementing adaptations to the implementation of a pragmatic randomised controlled trial of a two-way texting intervention for voluntary medical male circumcision in South Africa

OBJECTIVES

To document adaptations that were made to the implementation of the two-way texting (2wT) randomised controlled trial (RCT) for voluntary medical male circumcision (VMMC) in South Africa and to provide a nuanced discussion on the differences between adaptations and fidelity in this context.

DESIGN

We conducted a qualitative study using the Framework for Reporting Adaptations and Modifications in Evidence-based Implementation Strategies (FRAME-IS) to examine 2wT adaptations. We reported adaptations to the 2wT intervention using two steps. First, we categorised adaptations in a shared study-specific Google Docs that documented participant engagement with the 2wT system, tracked daily RCT implementation notes, reported software bugs and noted reminder emails about adaptations for the research team. Second, we conducted a qualitative assessment of the influence of adaptations on project outcomes via 10 periodic reflection meetings with VMMC implementers. Reflection documentation included notes from field observations, meeting minutes and informal partner check-ins to complete adaptation documentation. Using the FRAME-IS as a codebook, adaptations were categorised.

SETTING

The RCT was conducted in rural and urban VMMC clinics in the North West and Gauteng districts of South Africa.

PARTICIPANTS

Implementation scientists and VMMC implementers who implemented the 2wT pragmatic randomised controlled trial (pRCT) were participants for the adaptation study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the adaptations that were made during the implementation of the 2wT pRCT. The secondary outcome measures were fidelity and rigour of implementing adaptations to the 2wT pRCT.

RESULTS

Between June 2021 and February 2022, 13 adaptations were identified in three phases during the implementation of the 2wT pRCT. The first phase of adaptations aimed to augment study recruitment, including conducting weekend VMMC recruitment camps, using mobile outreach services in the rural site, adding two urban sites to increase recruitment, using weekly WhatsApp calls for updates with all implementing teams, using virtual meetings to implement the 2wT strategy remotely during COVID-19 restrictions and allocating one clinician to work outside of normal working hours. The second phase of adaptations further enhanced enrolments, including adding two local language translations in the usability survey for 2wT men and contributing a portion towards the salary of the implementing staff by the research partner. The third phase included the exclusion of two rural clinics as recruitment sites due to inconsistent mobile phone networks, adding another layer of data quality checks to ensure data quality, training non-clinical counsellors to help with enrolling clients, retraining of staff in the rural site with high staff turnover and using both primary and alternative phone numbers for enrolment to reduce loss to follow-up.

CONCLUSIONS

This study made adaptations to the 2wT pRCT without compromising the fidelity of the study. The 2wT pRCT balances rigour (fidelity) and relevance (adaptation). Adaptations should not be confined by rigour but should also not go unchallenged or unverified. We conclude that fidelity can be maintained with adaptations that are implemented to close the gap between research in the laboratory and practice.

TRIAL REGISTRATION NUMBER

The trial from which this study was conducted, 'Expanding and Scaling Two-way Texting to Reduce Unnecessary Follow-Up and Improve Adverse Event Identification Among Voluntary Medical Male Circumcision (VMMC) Participants in the Republic of South Africa', was registered at ClinicalTrials.gov (ID: NCT04327271) on 31 March 2020.

Assessing Clinician Engagement with a Passive Clinical Decision Support System for Liver Fibrosis Risk Stratification in a Weight Management Clinic

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) is common in obesity. Guidelines recommend liver fibrosis risk stratification with tools such as Fibrosis-4 (FIB-4) index, liver stiffness measurement with vibration-controlled transient elastography (VCTE) and/or hepatology referral for elevated FIB-4. Despite recommendations, implementation remains limited. Using mixed methods, we evaluated a three-strategy implementation bundle to improve fibrosis risk stratification-a FIB-4-based electronic health record embedded clinical decision support system (CDSS), educational outreach, and internal facilitation in a weight management clinic.

METHODS

The primary outcome was penetration: the proportion of patients with elevated FIB-4 completing VCTE or hepatology referral. We compared rates, pre and post activation of implementation bundle using Fischer's exact test. Semi-structured provider interviews, guided by the i-PARIHS framework, assessed acceptability and feasibility three months post-implementation.

RESULTS

In the pre-activation phase, 880/3933 (22.4%) weight management visits had the necessary labs to calculate automated FIB-4 scores with 128 elevated scores. In the post-activation phase, 2513/4,634 weight management visits (54.2%) had automated FIB-4 scores; with 234 elevated score. Pre-activation, there were no VCTE and 2 hepatology referrals. Post-activation, there were 3 VCTE referrals and 2 hepatology referrals (Fischer's exact test p-value=1.00). Providers cited shared responsibility with primary care, low awareness and trust in risk-stratification tools, workflow challenges, and competing demands as barriers. Educational outreach and facilitation improved CDSS engagement, while technical issues reduced it.

CONCLUSION

This implementation strategy bundle did not achieve meaningful MASLD fibrosis risk stratification. EHR based CDSS shows promise but requires alignment with provider priorities, seamless workflow integration, and robust technical infrastructure.

Development and validation of a pragmatic measure of context at the organizational level: The Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS)

BACKGROUND

Successful implementation and sustainment of interventions is heavily influenced by context. Yet the complexity and dynamic nature of context make it challenging to connect and translate findings across implementation efforts. Existing methods to assess context are typically qualitative, limiting potential replicability and utility. Existing quantitative measures and the siloed nature of implementation efforts limit possibilities for data poolinXg and harmonization. The Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS) was developed to be a pragmatic, quantitative, organizational-level assessment of contextual factors. The intention is to characterize context with a measure that may enhance replication and reproducibility of findings beyond single implementation case studies. Here, we present the development and validation of the IFASIS.

METHODS

A literature review was conducted to identify major concepts of established theories and frameworks to be retained. IFASIS data were examined in relation to implementation outcomes gathered from two studies. Psychometric validation efforts included content and face validity, reliability, internal consistency, and predictive and concurrent validity. Predictive validity was evaluated using generalized estimating equations (GEE) for longitudinal data on three implementation outcomes: reach, effectiveness, and implementation quality. Pragmatic properties were also evaluated.

RESULTS

The IFASIS is a 27-item, team-based, instrument that quantitatively operationalizes context. Two rating scales capture current state and importance of each item to an organization. It demonstrated strong reliability, internal consistency, and predictive and concurrent validity. There were significant associations between higher IFASIS scores and improved implementation outcomes. A one-unit increase in total IFASIS score corresponded to a 160% increase in the number of patients receiving a medication (reach). IFASIS domains of factors outside the organization, factors within the organization, and factors about the intervention, and subscales of organizational readiness, community support, and recipient needs and values, were predictive of successful implementation outcomes. IFASIS scores were also significantly associated with measures of implementation quality.

CONCLUSIONS

The IFASIS is a psychometrically and pragmatically valid instrument to assess contextual factors in implementation endeavors. Its ability to predict key implementation outcomes and facilitate data pooling across projects suggests it can play an important role in advancing the field.

Recommendations for promoting affirming healthcare for gender and sexual minorities with intersecting marginalized identities

BACKGROUND

Many existing implementation frameworks neglect inequity. Theories of intersectionality can help implementation researchers understand the multiplicative burden of certain inequities experienced by people with intersecting marginalized identities. The current project provides an example of engaging primary care providers, staff, and patients in prioritizing recommendations to improve services for lesbian, gay, bisexual, transgender, queer, and other gender and sexual minoritized (LGBTQ+) people from diverse racial, ethnic, cultural, and economic backgrounds.

METHODS

We used the Nominal Group Technique (NGT) to guide two one-time sessions with providers (n = 6) and staff (n = 8) affiliated with four primary care clinics in the United States. These participants brainstormed responses to a single focal question designed to elicit ideas for improving services for LGBTQ+ people with intersecting marginalized identities. Participants then discussed and ranked the ideas generated and considered specific strategies for ranked ideas. Finally, we conducted two focus groups with LGBTQ+ primary care patients (n = 7, n = 4) to obtain their insights into the recommendations for improving services.

RESULTS

The highest-ranked idea by providers was to mandate ongoing high-quality professional development for primary care personnel. The highest-ranked ideas by staff were to offer safe spaces characterized by an ambient atmosphere with trained personnel and LGBTQ+ visuals and to increase availability and funding for transgender providers and services delivered by transgender people and others skilled in caring for this community. Patients affirmed the recommendations from the NGT, while emphasizing inclusive representation in primary care spaces and for providers and staff to critically reflect of their own backgrounds.

CONCLUSIONS

Providers, staff, and patients highlighted the importance of continuing education and training to offer affirming, safe, and equitable care for LGBTQ+ people with intersecting marginalized identities. These implementation suggestions may be helpful for primary care clinics in developing inclusive and equitable medical environments. Further, the NGT, followed by a review of findings by impacted patients, may be useful when considering equitable implementation focused on meeting the needs of people with intersecting marginalized identities.

Effects of a structured SBIRT training program for hospital nursing leaders on utilization of SBIRT within their medical-surgical units: cohort study

BACKGROUND

Psychoactive substances contribute to numerous deaths annually, and more than 60% of the US population aged 12 + years reports past-month substance use. Screening, brief intervention, and referral to treatment (SBIRT) may support identification of substance-related risks and facilitate targeted interventions, but best practices and implementation designs remain elusive. Our study examined whether a standardized SBIRT toolkit and training-of-trainers for nurse site coordinators was prospectively associated with documented performance of core SBIRT-related functions in medical-surgical hospital units.

METHODS

This was a prospective cohort study conducted from January 2018 to May 2019 in 14 adult medical-surgical units (one/hospital). Hospitals were randomly allocated to two groups (n = 7 hospitals/each), which received identical interventions: an SBIRT training-of-trainers (8 h), supportive follow-up, and a toolkit containing information, resources, and guidance. However, group 1 sites were trained four months earlier than group 2 sites. At three points (baseline, 10-months, and 16-months), 61 patient records per hospital unit (n = 854) were randomly selected for extraction. Inclusion criteria for random selection were age (18+) and being admitted and discharged from the selected unit. Main outcome measures were analyzed using generalized linear mixed models, including screening within 24 h of admission, using a validated screening tool, screening positive, and receiving a brief intervention or referral to treatment.

RESULTS

For groups 1 and 2, patients had 1.81 and 2.66 greater odds, respectively, of being screened for alcohol at 10-months, 1.92 and 4.68 greater odds of being screened for drugs, and 1.96 and 2.06 greater odds of being screened for tobacco. For hospital group 2, patients also had greater odds of being screened for alcohol (3.92), drugs (6.31), and tobacco (2.41) at 16-months. For both hospital groups and benchmarks, patients were hundreds of times more likely to be screened with a validated tool, reflecting a shift from near absence of such behaviors (around 1% prevalence) to prevalence rates from 24 to 56%.

CONCLUSIONS

The SBIRT intervention was associated with the initiation and sustained use of validated screening tools for alcohol and drugs, and with short-term increases in overall alcohol, tobacco, and drug screening prevalence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03560076.

Improving postoperative care for neurosurgical patients by a standardised protocol for urinary catheter placement: a multicentre before-and-after implementation study

INTRODUCTION

Urinary catheterisation, including indwelling and clean intermittent catheterisation, is common in perioperative and postoperative care. Despite guidelines, practice variation is significant. Inappropriate catheterisation risks include urinary tract infections and reduced mobility, leading to prolonged hospital stays and increased antibiotic use. This study aims to improve postoperative care through appropriate catheterisation in neurosurgical groups frequently subjected to catheterisation.

METHODS

We conducted a multicentre, before-and-after study in four Dutch hospitals from June 2021 to January 2023, including adult neurosurgical patients who underwent pituitary gland tumour or spinal fusion surgery. Exclusion criteria included conditions requiring chronic catheter use. A multifaceted strategy was implemented, focusing on a uniform protocol, an educational programme and department-specific champions. The primary outcome was inappropriate catheterisation, analysed with ordinal logistic regression. Secondary outcomes included total catheterisations, urinary tract infections and length of hospital stay. Ethical approval was obtained. Strengthening the Reporting of Observational Studies in Epidemiology and SQUIRE checklists were used.

RESULTS

Among 3439 patients screened, 2711 were included, with 544 in the after group. The percentage of patients without inappropriate indwelling catheterisation increased from 46% to 57%, and the proportion without inappropriate clean intermittent catheterisation rose from 34% to 67%. Additionally, overall catheter use decreased: the percentage of patients not receiving an indwelling catheter increased from 54% to 64%, while those not requiring clean intermittent catheterisation rose from 89% to 92%. Infection rates and hospital stay were similar (1.4% and 1.3%; 4.9 and 5.1 days, respectively).

CONCLUSIONS

Implementing a uniform protocol may significantly reduce inappropriate and overall catheterisation in neurosurgical patients, aligning with patient-centred, less invasive healthcare. Ongoing education and adherence to standardised protocols are crucial. Future research should assess the long-term sustainability of these strategies.

Preliminary Outcomes from PrEP Well: A Community-led, Multicomponent HIV Prevention Strategy Implemented in a Transgender Community Health Center

Transgender and nonbinary (TGNB) individuals are disproportionately impacted by HIV, particularly those who identify as racial/ethnic minorities and those who are socioeconomically disadvantaged. Pre-exposure prophylaxis (PrEP) is a highly effective medication to prevent HIV infection, but many TGNB individuals encounter barriers to PrEP uptake and adherence that limit fully realized preventive benefits. We developed PrEP Well, a multicomponent community-led program, to scale and sustain comprehensive PrEP services from a TGNB-led community organization that provides gender-affirming healthcare and social services. We used implementation science frameworks to evaluate initial program outcomes and contextual influences on program implementation. Preliminary data from August 2022 through January 2024 showed promising implementation and effectiveness outcomes. During that time, 113 primarily low-resourced TGNB clients were educated about PrEP and received an HIV test, of whom 60 (53%) attended a visit with a provider and received a PrEP prescription. At 30-day follow-up, urinalysis confirmed uptake of PrEP among 50 (83%) of the clients prescribed PrEP. At 90-day follow-up, 43 (72%) demonstrated continued use of PrEP and 40 (67%) showed protective levels of PrEP adherence. Qualitative interviews and surveys indicated that clients, staff, and leadership viewed the PrEP Well program as highly acceptable, feasible, and sustainable (including willingness to address persistent implementation barriers). Referral patterns and rates of PrEP uptake suggested increasing integration of PrEP Well into the TGNB community center over time. The PrEP Well program demonstrates the potential for TGNB communities to address HIV inequities by integrating community-led HIV prevention services with gender-affirming healthcare in TGNB-specific health centers.

Improving outcomes for people who are homeless and have severe mental illness in Ethiopia, Ghana and Kenya: overview of the HOPE programme

AIM

HOPE (National Institute for Health and Care Research Global Health Research Group on Homelessness and Mental Health in Africa) aims to develop and evaluate interventions that address the unmet needs of people who are homeless and have severe mental illness (SMI) living in three African countries in ways that are rights-based, contextually grounded, scalable and sustainable.

METHODS

We will work in the capital city (Addis Ababa) in Ethiopia, a regional city (Tamale) in Ghana, and the capital city (Nairobi) and a rural county (Makueni) in Kenya to understand different approaches to intervention needed across varied settings.We will be guided by the MRC/NIHR framework on complex interventions and implementation frameworks and emphasise co-production. Formative work will include synthesis of global evidence (systematic review, including grey literature, and a Delphi consensus exercise) on interventions and approaches to homelessness and SMI. We will map contexts; conduct focused ethnography to understand lived experiences of homelessness and SMI; carry out a cross-sectional survey of people who are homeless (n = 750 Ghana/Ethiopia; n = 350 Kenya) to estimate prevalence of SMI and identify prioritised needs; and conduct in-depth interviews and focus group discussions with key stakeholders to understand experiences, challenges and opportunities for intervention. This global and local evidence will feed into Theory of Change (ToC) workshops with stakeholders to establish agreement about valued primary outcomes, map pathways to impact and inform selection and implementation of interventions. Intervention packages to address prioritised needs will be co-produced, piloted and optimised for feasibility and acceptability using participatory action research. We will use rights-based approaches and focus on community-based care to ensure sustainability. Realist approaches will be employed to analyse how contextual variation affects mechanisms and outcomes to inform methods for a subsequent evaluation of larger scale implementation. Extensive capacity-strengthening activities will focus on equipping early career researchers and peer researchers. People with lived experience of SMI and policymakers are an integral part of the research team. Community engagement is supported by working closely with multisectoral Community Advisory Groups.

CONCLUSIONS

HOPE will develop evidence to support action to respond to the needs and preferences of people experiencing homelessness and SMI in diverse settings in Africa. We are creating a new partnership of researchers, policymakers, community members and people with lived experience of SMI and homelessness to enable African-led solutions. Key outputs will include contextually relevant practice and policy guidance that supports achievement of inclusive development.

Implementation Science Methods, Challenges, and Associated Solutions: Transportable Lessons Learned and Best Practices From the Second National Meeting for Research and Community Collaboration Toward Ending the HIV Epidemic in the United States

AIM

To share insights on Implementation Science (IS) methods, challenges, solutions, and best practices derived from the second National Meeting for Research and Community Collaboration toward "Ending the HIV Epidemic (EHE) in the United States."

METHODS

This 2022 hybrid, one-day conference featured presentations from 13 projects funded as NIH supplements to CFARs and ARCs between 2019 and 2022. Selected for their robust findings, projects were grouped into four topics: (1) community-based outreach strategies, (2) taking the clinic to the community, (3) strategies to improve clinical care, and (4) exploring intersectional vulnerabilities and social/structural determinants of health. Standardized presentation formats were used to ensure comparability in gathering insights on IS methodologies, challenges, solutions, and lessons learned. Structured breakout discussions advanced actionable recommendations. Rapid qualitative analysis summarized insights, emphasizing lessons transportability across diverse implementation contexts.

RESULTS

Common IS methods included rapid qualitative analysis, usability testing, surveys, engagement logs, mapping, and administrative data analysis. Recurring challenges were identified, including pandemic-related disruptions, staff turnover, recruitment barriers, communication gaps, and variations in organizational capacity. Effective solutions involved leveraging community partnerships, providing digital tools, conducting flexible training, and securing funding for sustainability. Best practices emphasized early partner engagement, iterative design, equitable power-sharing with communities, and culturally tailored approaches.

CONCLUSIONS

Collaborative engagement with community partners, clinicians, and participants was pivotal to adapting and scaling interventions. Synthesizing transferable methodologies and lessons strengthens the framework for advancing HIV-related IS and achieving sustainable impact in diverse contexts.

Innovation in Providing Equitable Pre-exposure Prophylaxis Services in the United States: Expanding Access in Nontraditional Settings

BACKGROUND

Pre-exposure prophylaxis (PrEP) usage has slowly increased in the United States, but significant disparities persist across race, ethnicity, sex, gender, age, and geography. Determinants of PrEP inequities include stigma and medical mistrust, lack of patient-centered services, lack of access to clinical care, and organizational resistance to change-within a health care system that neglects these barriers.

METHODS

We describe 5 implementation strategies to providing PrEP in nontraditional settings to underserved populations, using an equity-based approach to address key structural determinants. The alternative settings used in these Ending the HIV Epidemic projects (community-based organizations, telePrEP, mobile clinics, pharmacies, emergency departments) were chosen for the setting characteristics and their serving structurally underserved populations.

RESULTS

Community-based organizations have earned trust within communities and can serve as hubs for comprehensive sexual health services, including PrEP. Telehealth, which expanded significantly because of COVID-19, can help overcome transportation and scheduling barriers to PrEP access. Mobile clinics can also broaden PrEP delivery by bringing tailored services directly to communities, often providing shorter wait times and extended hours. Pharmacists can prescribe PrEP in certain states through legislation or collaborative practice agreements, offering a convenient, community-based option. Emergency departments provide an alternative site for PrEP delivery, with the potential to reach individuals not currently engaged in regular care.

CONCLUSION

These alternative PrEP approaches can expand options for accessing PrEP and alleviate key barriers to care in traditional settings, although they may not eliminate all inequities. Offering more choices increases the likelihood that a broader population will be reached, thereby enhancing overall access to PrEP.

Integrating cardiovascular implementation science research within healthcare systems

Only 1 in 5 evidence-based interventions make it to routine clinical practice and the evidence generated from clinical research may take 17 years to be implemented. This represents a lost opportunity to improve clinical care in healthcare systems. Implementation science refers to the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into real-world clinical settings to positively impact population health. Therefore, implementation roadmaps can be crucial for learning healthcare systems (LHS) to bridge the research-to-practice gap, particularly for cardiovascular disease which remains the leading cause of death in the United States. Implementation models exist, all of which require a thorough understanding of the key phases of implementation for effective healthcare system incorporation and optimization (pre-implementation, implementation, monitoring the implementation, evaluation, sustaining, and scaling-up or de-implementation). This review serves as a call-to-action for involvement of large-scale LHS for cardiovascular implementation science, and provides a roadmap by summarizing various implementation science models, highlighting key implementation phases and discussing successful initiatives to improve the process. We also assess challenges associated with implementation science and provide possible solutions to improve translation of evidence in real-world clinical settings.

The Strategies Timeline and Activities Reporting Tables: Improving HIV Care by Improving the Reporting of Implementation Strategies

BACKGROUND

The United States has made significant progress toward achieving the goals of its Ending the HIV Epidemic initiative. However, systematic reviews on HIV implementation research have identified problems regarding strategy specification that limit the research's transparency and replicability, and in turn limit improvements regarding HIV care in real-world practice.

METHODS

The strategies timeline, activities, and resources (STAResources) Table, developed as part of the substance abuse treatment to HIV Care II Project, was completed for it and 3 other HIV implementation research projects funded by the National Institute of Health. Each evaluated it in terms of the extent to which it addressed prior recommendations on strategy specification; issues related to rigor and reproducibility; and the extent to which it seemed pragmatic, simple, adaptable, relevant, helpful, useful, acceptable, appropriate, suitable, applicable, and fitting. Each was rated on a 4-point scale (0 = not at all; 1 = a little; 2 = moderately, and 3 = very much).

RESULTS

Overall, the STAResources Table was rated favorably. It received a mean of 3.0 (SD = 0) in terms of being pragmatic, relevant, helpful, acceptable, appropriate, and applicable. The Strategies Timeline, Activities, and Rationale (STARationale) Table emerged during the process and was also rated favorably.

CONCLUSIONS

To help the Ending the HIV Epidemic initiative achieve its goals, there is a critical need for transparent and replicable implementation research on identifying the most effective strategies for equitably implementing evidence-based practices within real-world settings. Addressing this need, the Strategies Timeline and Activities Reporting (STAReporting)Tables are pragmatic tools for helping improve the transparency and replicability of implementation strategy research.

Policymaker Perspectives on Implementation Determinants of Rapid ART and Same-Day PrEP in Seven Priority Jurisdictions for Ending the HIV Epidemic: A Multisite Qualitative Study

BACKGROUND

Although rapid antiretroviral therapy (ART) and same-day pre-exposure prophylaxis models (henceforth "rapid START") are feasible, acceptable, and cost-effective in various contexts, significant barriers have hindered their broader implementation and scalability in the United States. Ryan White-funded clinics are cornerstones for HIV services, yet strategies are urgently needed to facilitate equitable rapid START adoption across contexts. This study aimed to identify common factors influencing rapid START to inform strategies applicable throughout jurisdictional settings.

METHODS

The Network for Implementation Science in HIV examined the current implementation of rapid START among diverse Ryan White Part A-D-funded organizations across seven Ending the HIV Epidemic jurisdictions across the United States. Semistructured interviews (n = 13) were administered from March 2023 to August 2024, with HIV leadership across jurisdictions to identify rapid START implementation determinants and strategies to catalyze rapid START delivery. Data were deductively analyzed using the Consolidated Framework for Implementation Research.

RESULTS

Prominent barriers to rapid ART implementation across settings included provider/patient hesitancy and awareness gaps, siloed care systems, and funding complexities. Prominent implementation facilitators included learning collaboratives, technology integration, and clear contracting language. Key constraints to same-day pre-exposure prophylaxis implementation included funding inequities and suboptimal client/patient awareness, whereas enablers included integrated care models, availability of starter packs, and medication-assistance programs.

CONCLUSIONS

Several consistent key barriers and facilitators spanned multiple Ending the HIV Epidemic jurisdictions despite contextual differences (eg, Medicaid expansion). Collaborative efforts between system leaders and service providers were universally characterized as essential for equitable adoption and penetration of rapid START models.

Clinical effectiveness of drop-in mental health services in paediatric healthcare settings: a non-randomised multi-site study for children, young people and their families

BACKGROUND

Despite the high prevalence of mental health disorders in children and young people with long-term health conditions, access to timely and effective treatment is often difficult. This study aimed to evaluate the clinical effectiveness of drop-in mental health services for young people with long-term health conditions and their families at six paediatric healthcare settings in England.

METHODS

This was a prospective non-randomised single-arm multi-centre interventional study. Young people up to 25 years old with a long-term health condition, and their families were eligible. The primary outcome was the change in the total difficulties score on the Strengths and Difficulties Questionnaire between baseline and 6 months. Interventions provided were standard evidence-based low intensity cognitive-behaviour therapy, onward referral or signposting. Secondary outcomes included quality of life, depression, anxiety, satisfaction with services and cost.

RESULTS

Accessing the drop-in services led to significant reductions in emotional and behavioural symptoms (p < 0.01; Cohen's d = 0.39) and improved quality of life (p < 0.01; Cohen's d = 0.44). Parental depression and anxiety significantly improved (p < 0.01; Cohen's d = 0.30 and d = 0.34). The average waiting time for an initial assessment was 13.42 days. High levels of satisfaction were reported. The cost per patient was approximately half the estimated cost of a typical course of psychological therapy.

CONCLUSIONS

Drop-in mental health services are effective and acceptable and can be delivered at low cost per patient for young people with long term conditions. This model of care is a feasible approach for increasing access to evidence-based mental health treatment in paediatric healthcare settings.

TRIAL REGISTRATION

ISRCTN15063954, Registered on 9 December 2022.

The implementation of guidelines in palliative care - a scoping review

BACKGROUND

Guidelines are essential tools for ensuring high-quality healthcare. However, discrepancies exist between their availability and practical implementation. In the context of palliative care, the extent to which guidelines are implemented and the barriers and facilitators that influence this process remain unknown.

AIM

The present study aimed at systematically reviewing the international literature on the implementation of palliative care guidelines to evaluate factors that support or hinder implementation of palliative care guidelines globally.

METHOD

A scoping review was conducted following the methodological approach of Arksey and O'Malley (2005). After the formulation of research questions and development of a search string, relevant studies investigating the implementation of guidelines were identified and retrieved from the databases CINAHL, LIVIO, PubMed and Web of Science Core Collection on 4 January 2024. Two researchers independently selected articles for inclusion, employing a blinded process with predefined inclusion and exclusion criteria. The results were subsequently categorised deductively by the same researchers using Petermann's (2014) taxonomy of implementation outcomes. The results were summarised and presented in tabular form.

RESULTS

The search yielded 2,086 records, of which 1,252 were included in the title and abstract screening. Subsequently, 113 full-text articles were reviewed for eligibility, resulting in 29 articles deemed suitable for the final analysis. Six implementation outcomes were identified in the included literature: (1) acceptability (n = 15 articles), (2) adoption (n = 6 articles), (3) appropriateness (n = 9 articles), (4) feasibility (n = 9 articles), (5) fidelity/adherence (n = 14 articles) and (6) penetration (n = 14 articles). The majority of studies employed quantitative approaches (n = 22) and considered the perspective of healthcare professionals and their opinions regarding guideline implementation in palliative care. Only 4 articles considered patient related outcomes or the perspectives of the family caregivers. Ten articles reported on facilitators and barriers. Facilitators included healthcare professionals' motivation and managerial support, while barriers primarily referred to time constraints and limited knowledge.

CONCLUSIONS

Guideline implementation in palliative care is highly variable. Future research should aim at comprehensively analysing facilitators of and barriers to this process, considering diverse implementation outcomes. For these evaluations, mixed-method approaches are recommended.

"It's something we're connected to": Acceptability and adoption of overdose detection technologies implemented in San Francisco permanent supportive housing

INTRODUCTION

The transition from homelessness to permanent supportive housing (PSH) is associated with solitary drug use, which heightens the risk for fatal overdose. Overdose detection technologies show promise in reducing fatal overdose in supportive housing environments. We conducted a longitudinal, mixed-methods study in a 50-unit single-room occupancy PSH building in San Francisco, California-tracing the implementation of wall-mounted, push-activated technologies (Brave Buttons) that alert designated responders to potential onsite emergencies, including overdose.

METHODS

Between May 2021 and February 2022, we conducted 35 days of naturalistic observation as well as serial, semi-structured interviews with 8 building staff (e.g., housing services coordinators, front desk clerks, custodians) and 5 tenant specialists, who promoted and sensitized residents to Brave Buttons prior to their installation. We administered surveys to all residents, assessing acceptability and uses of Brave Buttons. We calculated descriptive statistics regarding Brave Button installations and activations using administrative device data. Through inductive, iterative thematic analysis, we synthesized participant narratives to identify early expectations, implementation determinants, and adaptive strategies to bolster acceptability and adoption of Brave Buttons.

RESULTS

Despite high demand for overdose prevention solutions, staff and tenant specialists initially expressed doubts towards the adoption potential of Brave Buttons in the PSH building, citing resident mistrust of novel technologies with surveillance properties, liability related to (failed) overdose responses, and building staff capacity and willingness to respond to Button activations. Responding to these anticipated implementation constraints, a group of staff and tenant specialists hosted "engagement sessions" to build resident affinity/trust with Brave Buttons and leveraged tenant specialists' rapport with residents for technology sensitization. By December 2021, Buttons were voluntarily installed in 72 % of resident rooms and were used for multiple purposes, including overdoses and safety/wellness checks. The Buttons also helped formalize informal systems of care among residents and strengthened connections between residents and building staff.

CONCLUSION

Adaptive strategic planning, responsive to emerging sources of implementation opposition, was critical to addressing perceived barriers to Brave Button acceptability and adoption in the PSH building.

Mechanisms of change of a multifaceted implementation strategy on fidelity to a guideline for the prevention of mental health problems at the workplace: A mechanism analysis within a cluster-randomized trial

Background: Occupational guidelines exist to support workplaces with the prevention of mental health problems (MHP) among their staff. However, knowledge of effective implementation strategies to support their implementation is limited. This study experimentally tested whether a multifaceted implementation strategy - comprising an educational meeting, five workshops, implementation teams, small cyclical tests of change, and facilitation - improves fidelity to a guideline for preventing MHP in a school setting through the pathway of change of the Capability Opportunity Motivation-Behavior (COM-B)-model. To gain a more granular understanding of the mechanisms of change, the Theoretical Domains Framework (TDF) was used to specify mediators related to capability, opportunity, and motivation. This study tested whether the multifaceted strategy versus a discrete strategy (1) improves fidelity, (2) enhances capability, opportunity, and motivation over time, and (3) if the strategy's effect on fidelity is mediated by capability, opportunity, and motivation. Methods: 55 schools were randomly assigned to a multifaceted strategy or a discrete strategy. Fidelity was measured by questionnaires at baseline and 12 months, while capability, opportunity, and motivation were assessed three times within this period (directly after the educational meeting and at three and nine months). The Determinants of Implementation Behavior Questionnaire was used to assess TDF hypothesized mediators corresponding to the COM-B components. Separate pathways were analyzed for each mediator. Linear Mixed Modeling was employed to test the strategy's effect on fidelity, and mediation analyses were conducted using the PROCESS Macro. Results: The multifaceted strategy led to improved fidelity at 12 months (B= 2.81, p<.001). Multifaceted schools reported higher scores for all mediators after nine months compared to schools receiving the discrete strategy. The effect of the multifaceted strategy on fidelity was partially mediated by all TDF mediators (p=<.05) except for beliefs about consequences. Capability-related mediators, including skills (Proportion-mediated= 41%, p=<.01) and behavioral regulation (Proportion-mediated= 35%, p=<.001), accounted for the largest proportion of the effect, followed by the motivation-related mediator goals (Proportion-mediated = 34%, p=<.01). Conclusions: The multifaceted strategy improved guideline fidelity by enhancing capability, opportunity, and motivation confirming the proposed function of COM-B. This study addresses calls for experimental evidence on how multifaceted implementation strategies achieve implementation outcomes. Trial registration: ClinicalTrials.org dr.nr 2020-01214.

How do we leverage implementation science to support and accelerate uptake of clinical practice guidelines in transfusion medicine

BACKGROUND

Developing and disseminating clinical practice guidelines is a common strategy used to inform practice and address evidence-to-practice gaps that are prominent in transfusion medicine. Despite a highly systematic method for synthesizing evidence into guideline recommendations, comparatively little attention is paid to the real-world implementation of the recommendations in routine practice. A more scientific approach drawing on learnings from the field of implementation science is therefore warranted.

STUDY DESIGN AND METHODS

In this article, we propose a methodological roadmap to embed implementation science principles, frameworks, and methods to facilitate the development and uptake of transfusion medicine guidelines. We draw upon research undertaken in partnership with the International Collaboration of Transfusion Medicine Guidelines (ICTMG) to illustrate the roadmap in action.

RESULTS

The methodological roadmap constitutes five steps which have been matched to existing processes for developing and implementing clinical practice guidelines: (1) environmental scan; (2) detailing who needs to do what differently, per guideline recommendation; (3) barriers and enablers assessment; (4) tailoring implementation strategies to identified barriers and enablers; and (5) implementation and evaluation of implementation strategies. For each step, we define the key concepts and methods involved, and share examples from work done with ICTMG to support transfusion medicine guideline implementation.

DISCUSSION

We intend this methodological roadmap for clinicians, researchers, and organizations involved in supporting clinical practice guideline use. Informed by principles, frameworks, and methods from implementation science, the roadmap can provide a more structured, transparent, and replicable approach to improve the implementation of guideline recommendations in transfusion medicine.

Lessons learned on social health integration: evaluating a novel social health integration and social risk-informed care online continuing professional development course for primary care providers

BACKGROUND

Adjusting clinical care to account for social risks and needs is vital to patient-centered care, but little attention has been paid to implementing it in routine practice. Kaiser Permanente co-designed and developed a continuing professional development (CPD) course to orient providers to adjustment activities, or social risk-informed care. We evaluated the dissemination and implementation of this course.

METHODS

We evaluated the dissemination and implementation of the online CPD using the RE-AIM implementation framework and the Kirkpatrick model of evaluation for training and learning programs. Administrative records and completion reports were generated to track dissemination and completion. A pre- and post-survey design was utilized to assess provider changes in knowledge, attitudes, beliefs, and self-efficacy in delivering social risk-informed care, and semi-structured interviews were conducted to describe effectiveness of the online CPD, adoption of social risk-informed care, and sustainability of the online CPD and other Kaiser Permanente social health integration initiatives.

RESULTS

From April 2022-February 2023, 82 individuals completed the online CPD; 52 participants completed the pre-survey and 38 completed the post-survey. A total of 17 interviews were conducted over two phases of qualitative data collection (passive dissemination versus active dissemination). Interviewees felt the online CPD provided foundational knowledge in social health and social risk-informed care but requested more region- and role-specific resources. They also identified several systems-level barriers to social health integration.

CONCLUSIONS

Co-designing medical education courses with various stakeholders is vital to ensuring relevant and effective educational material. However, high-quality, intentionally designed educational material needs to be complemented with multifaceted and targeted implementation strategies to achieve intended provider behavior change and improved patient outcomes.

Deimplementation of ineffective and harmful medical practices: a data-driven commentary

Deimplementation is the discontinuation or abandonment of medical practices that are ineffective or of unclear effectiveness, ranging from simply unhelpful to harmful. With epidemiology expanding to include more translational sciences, epidemiologists can contribute to deimplementation by defining evidence, establishing causality, and advising on study design. An estimated 10%-30% of health care practices have minimal to no benefit to patients and should be targeted for deimplementation. The steps in deimplementation are (1) identify low-value clinical practices, (2) facilitate the deimplementation process, (3) evaluate deimplementation outcomes, and (4) sustain deimplementation, each of which is a complex project. Deimplementation science involves researchers, health care and clinical stakeholders, and patient and community partners affected by the medical practice. Increasing collaboration between epidemiologists and implementation scientists is important to optimizing health care delivery.

The sustainability of health interventions implemented in Africa: an updated systematic review on evidence and future research perspectives

BACKGROUND

Sustaining evidence-based interventions in resource-limited settings is critical to optimizing gains in health outcomes. In 2015, we published a review of the sustainability of health interventions in African countries, highlighting gaps in the measurement and conceptualization of sustainability in the region. This review updates and expands upon the original review to account for developments in the past decade and recommendations for promoting sustainability.

METHODS

First, we searched five databases (PubMed, SCOPUS, Web of Science, Global Health, and Cumulated Index to Nursing and Allied Health Literature (CINAHL)) for studies published between 2015 and 2022. We repeated the search in 2023 and 2024. The review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies were included if they reported on the sustainability of health interventions implemented in African countries. Study findings were summarized using descriptive statistics and narrative synthesis, and sustainability strategies were categorized based on the Expert Recommendations for Implementing Change (ERIC) strategies.

RESULTS

Thirty-four publications with 22 distinct interventions were included in the review. Twelve African countries were represented in this review, with Nigeria (n = 6) having the most representation of available studies examining sustainability. Compared to the 2016 review, a similar proportion of studies clearly defined sustainability (52% in the current review versus 51% in the 2015 review). Eight unique strategies to foster sustainability emerged, namely: a) multi-sectorial partnership and developing stakeholder relationships, b) tailoring strategies to enhance program fit and integration, c) active stakeholder engagement and collaboration, d) capacity building through training, e) accessing new funding, f) adaptation, g) co-creation of intervention and implementation strategies and h) providing infrastructural support. The most prevalent facilitators of sustainability were related to micro-level factors (e.g., intervention fit and community engagement). In contrast, salient barriers were related to structural-level factors (e.g., limited financial resources).

CONCLUSIONS

This review highlights some progress in the published reports on the sustainability of evidence-based intervention in Africa. The review emphasizes the importance of innovation in strategies to foster funding determinants for sustainable interventions. In addition, it underscores the need for developing contextually relevant sustainability frameworks that emphasize these salient determinants of sustainability in the region.

An evaluation of barriers and facilitators to implementing multiplex rapid antigen testing for SARS-CoV-2 and influenza A and B in congregate living settings

Introduction

Point of care multiplex rapid antigen testing (RAT) is a tool that can be used to mitigate and respond to facility-based infectious disease outbreaks. However, little is known about how to optimally implement this testing in congregate living settings (CLSs), including long term care homes (LTCHs), retirement homes (RHs), and shelters serving people experiencing homelessness. Our objective was to explore the barriers and facilitators to implementing a new device for multiplex RAT for COVID-19 and influenza across CLSs in the Greater Toronto Area, Canada.

Materials and methods

Using key informant interviews, we assessed barriers and facilitators to implementing multiplex RAT across CLSs. Qualitative coding using the framework approach was used to identify themes. We used the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR) to identify individual and contextual-level barriers and facilitators to implementation. Identified barriers were then mapped to implementation strategies using theoretically-rooted frameworks and tools.

Results

We completed 45 interviews with staff at CLSs (8 LTCHs, 4 RHs, 12 shelters) between January 2022 and March 2023. Four barriers to RAT implementation in CLSs emerged including: limited material resources for implementation; insufficient staff capacity to perform RAT testing; complexity of RAT implementation; and reluctance among staff to adopt a new testing process. Five facilitators to implementation were described including: training and implementation support for staff at the CLSs; site-level implementation champions; access to materials to support testing; perceived advantages of simultaneous testing for COVID-19 and influenza; and the usability and functionality of the RAT testing device. Twenty implementation strategies were identified through implementation strategy mapping.

Discussion

Multiplex RAT options can empower CLS staff to promptly identify and respond to viral respiratory outbreaks. The use of evidence-based implementation strategies can enhance the effectiveness of using multiplex RAT to control outbreaks in CLSs.

Integration and evaluation of implementation strategies to improve guideline-concordant bladder cancer surveillance: a prospective observational study

BACKGROUND

Despite guideline recommendations, our prior work revealed more than half of low-risk bladder cancer patients within the Department of Veterans Affairs (VA) undergo too many surveillance procedures and about a third of high-risk patients do not undergo enough procedures. Thus, we developed and integrated implementation strategies to improve risk-aligned bladder cancer surveillance for the VA.

METHODS

Prior work used Implementation Mapping to develop nine implementation strategies: change record systems, educational meetings, champions, tailoring, preparing patients to be active participants, external facilitation, remind clinicians, audit & feedback, and a blueprint. We integrated these strategies as improvement approaches across four VA urology clinics. Primary implementation outcomes were qualitatively measured via coding of semi-structured interviews with clinicians and co-occurrence of codes. Implementation outcomes included: appropriateness, acceptability, and feasibility. Exploratory quantitative outcomes included clinicians' recommendations for guideline-concordant bladder cancer surveillance intervals and sustainability.

RESULTS

Eleven urologists were interviewed. Co-occurrence analysis of codes across strategies indicated that urologists most commonly reported on the acceptability and appropriateness of changing the record system, preparing patients to be active participants ("surveillance grid"), reminders (i.e., cheat sheet), and educational sessions. We confirmed feasibility of all implementation strategies. Urologists indicated that changing the record system had a high impact, reduced documentation time, and guided resident physicians. Preparing patients to be active participants using the "surveillance grid" was seen as an effective but time-consuming tool. Educational sessions were seen as critical to support implementation. In quantitative analyses, clinicians recommended guideline-concordant surveillance about 65% of the time at baseline for low-risk patients, and this improved to 70% during evaluation. Across all risk levels, the largest improvement was observed at site 2 while site 3 did not improve. All sites sustained use of the changed record system, while sustainability of other strategies was variable.

CONCLUSIONS

Based on summative interpretation of results, the most appropriate, acceptable, and feasible strategies include changing record systems via a template and educational meetings focused on guideline-concordant surveillance. Future work should assess the impact of the improvement approaches on clinical care processes, particularly on reducing overuse of surveillance procedures among low-risk patients.

TRIAL REGISTRATION

The implementation strategies were not considered a healthcare intervention on human participants by the governing funding agency and IRB. Rather, they were seen as quality improvement interventions. Thus, this study did not meet criteria for a clinical trial and was not registered as such.

Achieving health-promotion practice in primary care using a multifaceted implementation strategy: a non-randomized parallel group study

BACKGROUND

Evidence-based healthcare recommendations exist for tobacco use, harmful alcohol consumption, low physical activity, and poor diet. However, the uptake of these recommendations in Swedish primary healthcare is poor, and the potential benefits for patients are not fully realized. Our aim was to evaluate the effect (i.e. the uptake) of a 12-month multifaceted implementation strategy to achieve a more health-promoting practice. We hypothesized that primary healthcare centers receiving this strategy would increase and sustain their health-promotion practices to a significantly greater extent than control centers, from baseline to the 6-month follow-up.

METHODS

In a non-randomized parallel group study, 5 intervention centers and 5 matched control centers were compared regarding health-promotion activities delivered in relation to visits to each center. The intervention centers received a multifaceted implementation strategy over at least 12 months based on established strategies, the Astrakan model of leading change, and findings from pre-implementation studies. The main strategies were: using external and internal facilitators to combine bottom-up and top-down perspectives, and emphasizing leadership responsibility for change. Medical record data on health-promotion activities, including prescribed physical activity and use of lifestyle screening forms, were collected monthly for 2 years: 6 months before and after implementation, and during the implementation phase. The implementation strategy effect was estimated using generalized linear mixed models.

RESULTS

During the 12-month implementation phase, the intervention and control sites had 135 002 and 160 987 healthcare visits, respectively; conducted 8839 and 6171 health-promotion activities, respectively; and administered 2423 and 282 lifestyle screening forms, respectively. A statistically significant higher relative uptake rate of health-promotion activities was found in intervention sites compared to control sites after the implementation period compared to before. The effect increased during the active phase, with the intervention sites having on average 1.07 and 2.0 times the uptake rate of the control sites at 1 and 12 months, respectively; this effect was largely maintained during the 6-month post-intervention phase. A significant absolute effect, in terms of difference in predicted uptake per 1000 visits, was evident 7 months into the implementation phase.

CONCLUSION

This multi-faceted implementation strategy was successful in achieving a more health-promoting practice. (ClinicalTrials.gov ref: NCT04 799,860, 03/04/2021, https://clinicaltrials.gov/study/NCT04799860 ).

TRIAL REGISTRATION

This study is part of the Act in Time project, registered at ClinicalTrials.gov on 4 March 2021 (ref: NCT04 799,860).

Methods for community-engaged data collection and analysis in implementation research

BACKGROUND

Community engagement is widely recognized as critical to successful and equitable implementation of evidence-based practices, programs, and policies. However, there are no clear guidelines for community involvement in data collection and analysis in implementation research.

METHODS

We describe three specific methods for engaging community members in data collection and analysis: concept mapping, rapid ethnographic assessment, and Photovoice. Common elements are identified from a case study of each method: 1) selection and adaptation of evidence-based strategies for improving adolescent HPV vaccine initiation rates in disadvantaged communities, 2) strategies for implementing medication for opioid use disorders among low-income Medicaid enrollees during natural disasters, and 3) interventions to improve the physical health of adults with severe mental illness living in supportive housing.

RESULTS

In all three cases, community members assisted in participant recruitment, provided data, and validated preliminary findings created by researchers. In the Photovoice case study, community members participated in both data collection and analysis, while in the concept mapping, community members also participated in the initial phase of organizing and prioritizing evidence-based strategies during the data analysis.

CONCLUSIONS

Community involvement in implementation research data collection and analysis contributes to greater engagement and empowerment of community members and validation of study findings. Use of methods that exhibit both scientific rigor and community relevance of implementation research also contributes to greater community investment in successful implementation outcomes. Nevertheless, the case studies point to the importance and efficiency of the division of labor embedded in community-engaged implementation research. Building capacity for community members to assume greater roles in obtaining and organizing data for preliminary analysis prior to interpretation is recommended.

Re-Think the Strip: de-implementing a low value practice in primary care

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a low value health care practice that does not benefit most patients with non-insulin treated type 2 diabetes (T2DM). This paper evaluates Re-Think the Strip (RTS), a multi-component study aimed at de-implementing SMBG among non-insulin treated T2DM patients in primary care.

METHODS

This study used a pre-post design to evaluate the effectiveness and implementation of Re-Think the Strip in 20 primary care clinics with a comparison group of 34 clinics within one health system. De-implementation strategies were implemented over 12 months and practices were followed for 18 months.

RESULTS

There was an overall decrease in the odds of receiving a prescription for diabetes testing supplies (i.e., test strips and/or lancets) between the baseline and 12-month intervention follow-up for intervention and comparison clinics (OR 0.96, 95% CI 0.94, 0.98). However, there was no statistically significant difference in prescribing between the intervention and comparison clinics. In sensitivity analyses, a small intervention effect was observed for those patients newly diagnosed with T2DM or newly assigned to a study clinic (OR = 0.97, 95% CI 0.95, 1.00).

CONCLUSIONS

De-implementation strategies are feasible in primary care practices. Although prescriptions for SMBG decreased in intervention practices, they also decreased in the comparison practices. Newly diagnosed patients or new patients may be more receptive to de-implementation. Other factors, including the COVID-19 pandemic and baseline prescribing rates may have limited the effectiveness of the RTS de-implementation strategy.

Description and Evaluation of Practice-Based Training in OUD Care for Hospital-Based Generalist Physicians

BACKGROUND

Hospitalizations are important opportunities to deliver evidence-based opioid use disorder (OUD) care, yet most hospital-based generalist physicians receive minimal OUD training. We describe a novel OUD training for generalists and mixed-methods evaluation in a large urban hospital.

METHODS

Training Description: Hospital-based generalist physicians received a single, 1-hour, small-group, in-person OUD training (OUD diagnosis, initiating medications for OUD [MOUD], and discharge planning) and post-training support. Evaluation: We examined self-reported changes in knowledge, confidence, skill, and frequency of providing OUD care; barriers and facilitators to applying training skills; and suggestions for training modification. Data collection included the following: (1) end-of-training questionnaires; (2) 12-month follow-up questionnaires (retrospective pre-post-design); and (3) qualitative interviews and a focus group. Stuart Maxwell tests were used to examine pre-/post-differences in knowledge, confidence, and skill. Rapid qualitative analysis identified barriers and facilitators to applying training skills.

RESULTS

Nineteen generalist physicians participated, with 11 (58%) providing 12-month follow-up data. At 12 months, compared to pre-training, more participants agreed or highly agreed that after the training, they had adequate knowledge (100% vs 44%), confidence (100% vs 44%), and skill (89% vs 44%) in OUD care, but differences were not statistically significant. Self-reported frequency of providing OUD care was unchanged. During qualitative interviews (2 participants) and the focus group (3 participants), participants appreciated the training format but described confidence declining over time. Ongoing barriers to MOUD initiation included challenges with counseling patients about MOUD, discharge planning, accessing OUD care protocols and decision aides, lack of interprofessional collaboration, and time pressures.

CONCLUSION

Generalist physicians reported increases in knowledge, confidence, and skill with OUD training, but a single session was insufficient to maintain confidence and change practice. Additional training sessions emphasizing patient counseling and discharge planning should be developed and evaluated in a larger sample. Simultaneous efforts to address systemic barriers are also needed.

Facilitators and barriers to implementation of early intensive manual therapies for young children with cerebral palsy across Canada

BACKGROUND

Cerebral Palsy (CP) is the most common childhood-onset motor disability. Play-based early intensive manual therapies (EIMT) is an evidence-based practice to improve long-term hand function particularly for children with asymmetric hand use due to CP. For children under two years old, this therapy is often delivered by caregivers who are coached by occupational therapists (OTs). However, why only a few Canadian sites implement this therapy is unclear. There is a need to identify strategies to support implementation of EIMT. The primary objective of this study was to identify the facilitators and barriers to EIMT implementation from the perspectives of (1) caregivers of children with CP (2), OTs and (3) healthcare administrators for paediatric therapy programs.

METHODS

The Consolidated Framework for Implementation Research (CFIR) was used to guide development of an online 5-point Likert scale survey to identify facilitators (scores of 4 and 5) and barriers (scores of 1 and 2) to implementation of EIMT. Three survey versions were co-designed with knowledge user partners for distribution to caregivers, OTs, and healthcare administrators across Canada. The five most frequently endorsed facilitators and barriers were identified for each respondent group.

RESULTS

Fifteen caregivers, 54 OTs, and 11 healthcare administrators from ten Canadian provinces and one territory participated in the survey. The majority of the identified facilitators and barriers were within the 'Inner Setting' CFIR domain, with 'Structural Characteristics' emerging as the most reported CFIR construct. Based on the categorization of the most frequently endorsed facilitators and barriers within the CFIR domains, the key facilitators to EIMT implementation included the characteristics of the intervention and establishing positive workplace relationships and culture. The key barriers included having workplace restrictions on EIMT delivery models and external influences (e.g., funding) on EIMT uptake.

CONCLUSIONS

We identified key facilitators and barriers to implementing EIMT from a multi-level Canadian context. These findings will inform the next steps of designing evidence-informed and theory-driven implementation strategies to support increased delivery of EIMT for children under two years old with asymmetric hand use due to CP across Canada.

The road to successful implementation of innovation in radiotherapy: A research-based implementation protocol

BACKGROUND AND PURPOSE

Radiotherapy (RT) is rapidly advancing, yet only 50 % of innovations are implemented promptly. Despite the availability of Implementation Science (ImpSci) theories, models, and frameworks (TMFs), a theory-practice gap persists in effectively applying these insights in RT clinical practice. This study aims to develop a consensus-based implementation protocol for RT innovations using validated ImpSci knowledge.

MATERIAL AND METHODS

A literature review of TMFs (May-August 2023) and 20 semi-structured interviews with Dutch RT professionals (August-December 2023) identified key RT components for implementation. These insights informed a draft RT implementation protocol, which was refined through a three-round international Delphi study (March-September 2024) involving 11 RT and 5 ImpSci experts. Consensus was determined using a 5-point Likert scale, analysing medians, interquartile ranges (IQRs), and percentage scoring.

RESULTS

The Knowledge-to-Action (KTA) Framework and input from expert interviews were used to draft the protocol. Delphi response rates were 100 %, 93.8 %, and 88.9 % across rounds. In round 1, 88.9 % of elements achieved consensus (median = 4.0, IQR = 0.0-1.3); only the application of a prediction model for timely implementation (step 3c) needed revision after rounds 1 and 2. In round 3, also for step 3c consensus was reached (median = 4.0, IQR = 0.3). The protocol includes defining innovation types, stakeholder analysis, tailored implementation strategies, and a phased evaluation plan to ensure sustainability.

CONCLUSION

This is the first consensus-based RT innovation implementation protocol, addressing the theory-practice gap with a structured clinical approach. Future research should validate the protocol and assess the impact of preparation on implementation success.

Clinical implementation of AI-based screening for risk for opioid use disorder in hospitalized adults

Adults with opioid use disorder (OUD) are at increased risk for opioid-related complications and repeated hospital admissions. Routine screening for patients at risk for an OUD to prevent complications is not standard practice in many hospitals, leading to missed opportunities for intervention. The adoption of electronic health records (EHRs) and advancements in artificial intelligence (AI) offer a scalable approach to systematically identify at-risk patients for evidence-based care. This pre-post quasi-experimental study evaluated whether an AI-driven OUD screener embedded in the EHR was non-inferior to usual care in identifying patients for addiction medicine consultations, aiming to provide a similarly effective but more scalable alternative to human-led ad hoc consultations. The AI screener used a convolutional neural network to analyze EHR notes in real time, identifying patients at risk and recommending consultations. The primary outcome was the proportion of patients who completed a consultation with an addiction medicine specialist, which included interventions such as outpatient treatment referral, management of complicated withdrawal, medication management for OUD and harm reduction services. The study period consisted of a 16-month pre-intervention phase followed by an 8-month post-intervention phase, during which the AI screener was implemented to support hospital providers in identifying patients for consultation. Consultations did not change between periods (1.35% versus 1.51%, P < 0.001 for non-inferiority). In secondary outcome analysis, the AI screener was associated with a reduction in 30-day readmissions (odds ratio: 0.53, 95% confidence interval: 0.30-0.91, P = 0.02) with an incremental cost of US$6,801 per readmission avoided, demonstrating its potential as a scalable, cost-effective solution for OUD care. ClinicalTrials.gov registration: NCT05745480 .

Connecting Care Closer to Home: Evaluation of a Regional Motor Neurone Disease Multidisciplinary Clinic

The optimal approach to managing motor neurone disease (MND) is through integrated, person-centred care (PCC), complemented by access to specialised MND multidisciplinary clinics (MDCs). However, in Australia, MND care is fragmented and uncoordinated.

OBJECTIVES

To evaluate participant experiences of the implementation of a new regional MND MDC in New South Wales, Australia, and explore factors influencing its implementation.

METHODS

A qualitative evaluation was conducted. We used semi-structured interviews with people living with MND (plwMND) (n = 4), family carers (n = 2), healthcare providers (n = 6), and social care providers (n = 2). First, deductive analysis using the Theoretical Domains Framework and COM-B model was applied to identify factors influencing the adoption and sustainability of the MDC. Then, an inductive thematic analysis identified the impact of the MND MDC from participant perspectives.

RESULTS

The MND MDC was found to be appropriate and acceptable for providing equitable access to PCC MND care that was 'closer to home'. The three main themes from the inductive analysis indicated that: 1. Implementing it was a 'good idea' [the MND-MDC]; 2. It 'flushes out' local service gaps and/or challenges; and 3. It results in positive outcomes. Key facilitators to implementation identified from the deductive analysis were staff expertise, strong trusting relationships with all clinic participants, and the belief that the MND MDC optimised care. Barriers to implementation included a lack of staff remuneration, organisational boundaries, limited representation of specialities, and anticipated difficulties in coordinating care with existing services.

CONCLUSIONS

The commitment to providing equitable access to an MND MDC in a regional area is crucial to optimise care for plwMND and their families. However, overcoming complex organisational boundaries, creating local solutions, and building strong partnerships are key challenges to securing ongoing financial support and local health district 'buy-in' to support sustainability.