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Smits GH, Bots ML, Hollander M, Wit AD, van Doorn S. Practice visitations in primary care to improve performance of cardiovascular risk management: an observational study. BJGP Open 2024:BJGPO.2023.0213. [PMID: 38479757 DOI: 10.3399/bjgpo.2023.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/06/2024] [Accepted: 02/20/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Despite programmatic protocolised care and structured support, considerable variation is observed in completeness of registration and achieving targets of cardiovascular risk management (CVRM) between individual GPs in the Netherlands. AIM To determine whether completeness of registration and achieved targets of cardiovascular risk factors improves with practice visitation. DESIGN & SETTING Observational study utilising the care group's database (2016-2019), comparing changes in registration and achieved targets in non-visited practices and visited practices. METHOD We compared completeness scores of registration and scores of targets achieved before visitation and 1 year after visitation. Data were analysed on patient level and GP level. Separate analyses were performed among GPs who were ranked in the lower 25% of score distributions. RESULTS We observed no clinically relevant improvements in completeness of registration and targets achieved in 2017, 2018, and 2019 that could be attributed to visitations in the previous year, both on individual patient level and on aggregated level per general practice. In practices ranked in the lower 25% of the distribution, improvements over time were clinically relevant and larger than the overall changes. Yet, these findings were irrespective of the number of practice visitations. CONCLUSION Practice visitations in our setting did not seem to lead to improvements in practice performance, nor in completeness of registration of risk factors or in reaching predefined target goals for cardiovascular risk factors.
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Affiliation(s)
- Geert Hjm Smits
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ardine de Wit
- Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Michelsen HÖ, Lidin M, Bäck M, Duncan TS, Ekman B, Hagström E, Hägglund M, Lindahl B, Schlyter M, Leósdóttir M. The effect of audit and feedback and implementation support on guideline adherence and patient outcomes in cardiac rehabilitation: a study protocol for an open-label cluster-randomized effectiveness-implementation hybrid trial. Implement Sci 2024; 19:35. [PMID: 38790045 DOI: 10.1186/s13012-024-01366-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs. METHODS The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation. DISCUSSION Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI. TRIAL REGISTRATION ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23.
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Affiliation(s)
- Halldóra Ögmundsdóttir Michelsen
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
- Department of Emergency medicine and Geriatrics, Helsingborg Hospital, Helsingborg, Sweden.
| | - Matthias Lidin
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Health, Medicine and Caring Sciences, Unit of Physiotherapy, Linköping University, Linköping, Sweden
| | - Therese Scott Duncan
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Björn Ekman
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Maria Hägglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Mona Schlyter
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Margrét Leósdóttir
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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Sanchez A, Pijoan JI, Sainz de Rozas R, Lekue I, San Vicente R, Quindimil JA, Rotaeche R, Etxeberria A, Mozo C, Martinez-Cengotitabengoa M, Monge M, Gómez-Ramírez C, Samper R, Ogueta Lana M, Celorrio S, Merino-Inda N, Llarena M, Gonzalez Saenz de Tejada M, García-Alvarez A, Grandes G. De-imFAR phase II project: a study protocol for a cluster randomised implementation trial to evaluate the effectiveness of de-implementation strategies to reduce low-value statin prescribing in the primary prevention of cardiovascular disease. BMJ Open 2024; 14:e078692. [PMID: 38631840 PMCID: PMC11029292 DOI: 10.1136/bmjopen-2023-078692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION This study aims to reduce potentially inappropriate prescribing (PIP) of statins and foster healthy lifestyle promotion in cardiovascular disease (CVD) primary prevention in low-risk patients. To this end, we will compare the effectiveness and feasibility of several de-implementation strategies developed following the structured design process of the Behaviour Change Wheel targeting key determinants of the clinical decision-making process in CVD prevention. METHODS AND ANALYSIS A cluster randomised implementation trial, with an additional control group, will be launched, involving family physicians (FPs) from 13 Integrated Healthcare Organisations (IHOs) of Osakidetza-Basque Health Service with non-zero incidence rates of PIP of statins in 2021. All FPs will be exposed to a non-reflective decision assistance strategy based on reminders and decision support tools. Additionally, FPs from two of the IHOs will be randomly assigned to one of two increasingly intensive de-implementation strategies: adding a decision information strategy based on knowledge dissemination and a reflective decision structure strategy through audit/feedback. The target population comprises women aged 45-74 years and men aged 40-74 years with moderately elevated cholesterol levels but no diagnosed CVD and low cardiovascular risk (REGICOR<7.5%), who attend at least one appointment with any of the participating FPs (May 2022-May 2023), and will be followed until May 2024. We use the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate outcomes. The main outcome will be the change in the incidence rate of PIP of statins and healthy lifestyle counselling in the study population 12 and 24 months after FPs' exposure to the strategies. Moreover, FPs' perception of their feasibility and acceptability, and patient experience regarding the quality of care received will be evaluated. ETHICS AND DISSEMINATION The study was approved by the Basque Country Clinical Research Ethics Committee and was registered in ClinicalTrials.gov (NCT04022850). Results will be disseminated in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04022850.
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Affiliation(s)
- Alvaro Sanchez
- Primary Care Research Unit of Bizkaia, Deputy Directorate of Healthcare Assistance, Osakidetza-Basque Health Service, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Jose Ignacio Pijoan
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Clinical Epidemiology Unit, Osakidetza-Basque Health Service, Barakaldo, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Rita Sainz de Rozas
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Itxasne Lekue
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Ricardo San Vicente
- Zumarraga Health Center, Goierri-Alto Urola Integrated Health Organization, Osakidetza-Basque Health Service, Zumarraga, Spain
| | - Jose Antonio Quindimil
- Sestao Health Center, Barakaldo-Sestao Integrated Health Organization, Osakidetza-Basque Health Service, Sestao, Spain
| | - Rafael Rotaeche
- Primary Care Research Unit of Gipuzkoa, Organization of Integrated Health Services of Gipuzkoa, Osakidetza-Basque Health Service, Biogipuzkoa Health Research Institute, Donostia-San Sebastian, Spain
| | - Arritxu Etxeberria
- Primary Care Pharmacy, Donostialdea Integrated Health Organization, Osakidetza-Basque Health Service, Hernani, Spain
| | - Carmela Mozo
- Primary Care Pharmacy, Donostialdea Integrated Health Organization, Osakidetza-Basque Health Service, Hernani, Spain
| | - Monica Martinez-Cengotitabengoa
- School of Pharmacy, University of the Basque Country, Vitoria-Gasteiz, Spain
- Primary Care Pharmacy Unit, Barakaldo-Sestao Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Monica Monge
- Muskiz Health Center, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Muskiz, Spain
| | - Cristina Gómez-Ramírez
- Cardiology Department, Cruces University Hospital, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Ricardo Samper
- Corporate Pharmacy Service, Directorate of Healthcare Assistance, Central Services, Osakidetza-Basque Health Service, Vitoria-Gasteiz, Spain
| | - Mikel Ogueta Lana
- Subdirectorate of Quality and Health Information Systems, Central Services, Osakidetza-Basque Health Service, Vitoria-Gasteiz, Spain
| | - Sara Celorrio
- Barakaldo-Sestao Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | | | - Marta Llarena
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Marta Gonzalez Saenz de Tejada
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Arturo García-Alvarez
- Primary Care Research Unit of Bizkaia, Deputy Directorate of Healthcare Assistance, Osakidetza-Basque Health Service, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Gonzalo Grandes
- Primary Care Research Unit of Bizkaia, Deputy Directorate of Healthcare Assistance, Osakidetza-Basque Health Service, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
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Harvey G, Rycroft-Malone J, Seers K, Wilson P, Cassidy C, Embrett M, Hu J, Pearson M, Semenic S, Zhao J, Graham ID. Connecting the science and practice of implementation - applying the lens of context to inform study design in implementation research. FRONTIERS IN HEALTH SERVICES 2023; 3:1162762. [PMID: 37484830 PMCID: PMC10361069 DOI: 10.3389/frhs.2023.1162762] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
The saying "horses for courses" refers to the idea that different people and things possess different skills or qualities that are appropriate in different situations. In this paper, we apply the analogy of "horses for courses" to stimulate a debate about how and why we need to get better at selecting appropriate implementation research methods that take account of the context in which implementation occurs. To ensure that implementation research achieves its intended purpose of enhancing the uptake of research-informed evidence in policy and practice, we start from a position that implementation research should be explicitly connected to implementation practice. Building on our collective experience as implementation researchers, implementation practitioners (users of implementation research), implementation facilitators and implementation educators and subsequent deliberations with an international, inter-disciplinary group involved in practising and studying implementation, we present a discussion paper with practical suggestions that aim to inform more practice-relevant implementation research.
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Affiliation(s)
- Gillian Harvey
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Jo Rycroft-Malone
- Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Kate Seers
- Warwick Medical School, Faculty of Science, University of Warwick, Coventry, United Kingdom
| | - Paul Wilson
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, United Kingdom
| | - Christine Cassidy
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Mark Embrett
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Jiale Hu
- College of Health Professions, Virginia Commonwealth University, Richmond, VA, United States
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, United Kingdom
| | - Sonia Semenic
- Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Junqiang Zhao
- Centre for Research on Health and Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Ian D. Graham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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5
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Aifah AA, Hade EM, Colvin C, Henry D, Mishra S, Rakhra A, Onakomaiya D, Ekanem A, Shedul G, Bansal GP, Lew D, Kanneh N, Osagie S, Udoh E, Okon E, Iwelunmor J, Attah A, Ogedegbe G, Ojji D. Study design and protocol of a stepped wedge cluster randomized trial using a practical implementation strategy as a model for hypertension-HIV integration - the MAP-IT trial. Implement Sci 2023; 18:14. [PMID: 37165382 PMCID: PMC10173657 DOI: 10.1186/s13012-023-01272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/21/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND As people living with HIV (PLWH) experience earlier and more pronounced onset of noncommunicable diseases (NCDs), advancing integrated care networks and models in low-resource-high-need settings is critical. Leveraging current health system initiatives and addressing gaps in treatment for PLWH, we report our approach using a late-stage (T4) implementation research study to test the adoption and sustainability of a proven-effective implementation strategy which has been minimally applied in low-resource settings for the integration of hypertension control into HIV treatment. We detail our protocol for the Managing Hypertension Among People Living with HIV: an Integrated Model (MAP-IT) trial, which uses a stepped wedge cluster randomized trial (SW-CRT) design to evaluate the effectiveness of practice facilitation on the adoption of a hypertension treatment program for PLWH receiving care at primary healthcare centers (PHCs) in Akwa Ibom State, Nigeria. DESIGN In partnership with the Nigerian Federal Ministry of Health (FMOH) and community organizations, the MAP-IT trial takes place in 30 PHCs. The i-PARiHS framework guided pre-implementation needs assessment. The RE-AIM framework will guide post-implementation activities to evaluate the effect of practice facilitation on the adoption, implementation fidelity, and sustainability of a hypertension program, as well as blood pressure (BP) control. Using a SW-CRT design, PHCs sequentially crossover from the hypertension program only (usual care) to hypertension plus practice facilitation (experimental condition). PHCs will recruit and enroll an average of 28-32 patients to reach a maximum of 960 PLWH participants with uncontrolled hypertension who will be followed longitudinally for BP outcomes. DISCUSSION Given the need for integrated NCD-HIV care platforms in low-resource settings, MAP-IT will underscore the challenges and opportunities for integrating hypertension treatment into HIV care, particularly concerning adoption and sustainability. The evaluation of our integration approach will also highlight the potential impact of a health systems strengthening approach on BP control among PLWH. TRIAL REGISTRATION Clinicaltrials.gov ( NCT05031819 ). Registered on 2nd September 2021.
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Affiliation(s)
- Angela A Aifah
- Institute for Excellence in Health Equity, New York University (NYU) Grossman School of Medicine, New York, NY, USA.
- Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY, USA.
| | - Erinn M Hade
- Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Calvin Colvin
- Institute for Excellence in Health Equity, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Daniel Henry
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, University of Abuja, Gwagwalada, Abuja, Nigeria
| | - Shivani Mishra
- Institute for Excellence in Health Equity, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Ashlin Rakhra
- Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Deborah Onakomaiya
- Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Anyiekere Ekanem
- Department of Community Medicine, Faculty of Clinical Sciences, University of Uyo, Uyo, Akwa Ibom State, Nigeria
| | - Gabriel Shedul
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, University of Abuja, Gwagwalada, Abuja, Nigeria
- Department of Family Medicine, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | | | - Daphne Lew
- Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Nafesa Kanneh
- Institute for Excellence in Health Equity, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Samuel Osagie
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, University of Abuja, Gwagwalada, Abuja, Nigeria
| | - Ememobong Udoh
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, University of Abuja, Gwagwalada, Abuja, Nigeria
| | - Esther Okon
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, University of Abuja, Gwagwalada, Abuja, Nigeria
| | - Juliet Iwelunmor
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, USA
| | - Angela Attah
- Akwa Ibom Primary Healthcare Development Board, State Primary Health Care Development Board, Uyo, Akwa Ibom State, Nigeria
| | - Gbenga Ogedegbe
- Institute for Excellence in Health Equity, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Dike Ojji
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Gwagwalada, Abuja, Nigeria
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Peters S, Sukumar K, Blanchard S, Ramasamy A, Malinowski J, Ginex P, Senerth E, Corremans M, Munn Z, Kredo T, Remon LP, Ngeh E, Kalman L, Alhabib S, Amer YS, Gagliardi A. Trends in guideline implementation: an updated scoping review. Implement Sci 2022; 17:50. [PMID: 35870974 PMCID: PMC9308215 DOI: 10.1186/s13012-022-01223-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review. Methods We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics. Results We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions. Conclusions Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact. Trial registration The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01223-6.
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7
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Nguyen AM, Cleland CM, Dickinson LM, Barry MP, Cykert S, Duffy FD, Kuzel AJ, Lindner SR, Parchman ML, Shelley DR, Walunas TL. Considerations Before Selecting a Stepped-Wedge Cluster Randomized Trial Design for a Practice Improvement Study. Ann Fam Med 2022; 20:255-261. [PMID: 35606135 PMCID: PMC9199039 DOI: 10.1370/afm.2810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/01/2021] [Accepted: 09/30/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design's advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings. METHODS The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design. RESULTS All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends. CONCLUSIONS The challenges experienced by EvidenceNOW grantees suggest that certain favorable real-world conditions constitute a context that increases the odds of a successful SW-CRT. An existing infrastructure can support the recruitment of many practices. Strong retention plans are needed to continue to engage sites waiting to start the intervention. Finally, study outcomes should be ones already captured in routine practice; otherwise, funders and investigators should assess the feasibility and cost of data collection.VISUAL ABSTRACT.
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Affiliation(s)
- Ann M Nguyen
- Rutgers University, Center for State Health Policy, New Brunswick, New Jersey
| | | | | | - Michael P Barry
- SUNY Downstate Health Sciences University College of Medicine, Brooklyn, New York
| | - Samuel Cykert
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - F Daniel Duffy
- University of Oklahoma Health Sciences Center, Tulsa, Oklahoma
| | - Anton J Kuzel
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Donna R Shelley
- New York University School of Global Public Health, New York, New York
| | - Theresa L Walunas
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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8
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Ballengee LA, Rushton S, Lewinski AA, Hwang S, Zullig LL, Ricks KAB, Ramos K, Brahmajothi MV, Moore TS, Blalock DV, Cantrell S, Kosinski AS, Gordon A, Ear B, Williams JW, Gierisch JM, Goldstein KM. Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review. J Gen Intern Med 2022; 37:885-899. [PMID: 34981354 PMCID: PMC8904663 DOI: 10.1007/s11606-021-07217-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A culture of improvement is an important feature of high-quality health care systems. However, health care teams often need support to translate quality improvement (QI) activities into practice. One method of support is consultation from a QI coach. The literature suggests that coaching interventions have a positive impact on clinical outcomes. However, the impact of coaching on specific process outcomes, like adoption of clinical care activities, is unknown. Identifying the process outcomes for which QI coaching is most effective could provide specific guidance on when to employ this strategy. METHODS We searched multiple databases from inception through July 2021. Studies that addressed the effects of QI coaching on process of care outcomes were included. Two reviewers independently extracted study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE. RESULTS We identified 1983 articles, of which 23 cluster-randomized trials met eligibility criteria. All but two took place in a primary care setting. Overall, interventions typically targeted multiple simultaneous processes of care activities. We found that coaching probably has a beneficial effect on composite process of care outcomes (n = 9) and ordering of labs and vital signs (n = 6), and possibly has a beneficial effect on changes in organizational process of care (n = 5), appropriate documentation (n = 5), and delivery of appropriate counseling (n = 3). We did not perform meta-analyses because of conceptual heterogeneity around intervention design and outcomes; rather, we synthesized the data narratively. Due to imprecision, inconsistency, and high risk of bias of the included studies, we judged the certainty of these results as low or very low. CONCLUSION QI coaching interventions may affect certain processes of care activities such as ordering of labs and vital signs. Future research that advances the identification of when QI coaching is most beneficial for health care teams seeking to implement improvement processes in pursuit of high-quality care will support efficient use of QI resources. PROTOCOL REGISTRATION This study was registered and followed a published protocol (PROSPERO: CRD42020165069).
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Affiliation(s)
- Lindsay A Ballengee
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA.
- Department of Orthopaedic Surgery, Duke University School of Medicine, Division of Physical Therapy, Duke University, Durham, NC, USA.
| | | | - Allison A Lewinski
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Leah L Zullig
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Katharine A Ball Ricks
- Cecil G. Sheps Center for Health Service Research, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Ramos
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Medicine Geriatrics, Duke University, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Mulugu V Brahmajothi
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, USA
| | - Thomasena S Moore
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Dan V Blalock
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Adelaide Gordon
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Belinda Ear
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - John W Williams
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Karen M Goldstein
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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9
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Brunström M, Ng N, Dahlström J, Lindholm LH, Norberg M, Nyström L, Weinehall L, Carlberg B. Association of education and feedback on hypertension management with risk for stroke and cardiovascular disease. Blood Press 2022; 31:31-39. [PMID: 35179089 DOI: 10.1080/08037051.2022.2041393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PURPOSE Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution.
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Affiliation(s)
- Mattias Brunström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Nawi Ng
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,School of Public Health and Community Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - John Dahlström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Lars H Lindholm
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Margareta Norberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Lennarth Nyström
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Lars Weinehall
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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10
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Havsteen-Franklin D, Swanepoel M, Jones J, Conradie U. Families and Collective Futures: Developing a Program Logic Model for Arts-Based Psychosocial Practice With South African Rural Communities. Front Psychol 2021; 12:745809. [PMID: 34955965 PMCID: PMC8692948 DOI: 10.3389/fpsyg.2021.745809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/27/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: This aim of this study is to describe the development of a program logic model to guide arts-based psychosocial practice delivered in rural South African farming communities affected by transgenerational traumas. Background: The rationale for developing a program logic model for arts-based psychosocial practice in South Africa was based on the lack of evidence for effective community arts-based psychosocial interventions for collective trauma, unknown consensus about best practices and the need for developing cogent collective psychosocial practices. Further to this, the aims and benefits of the practice required clarity given the psychosocial complexity of the environment within which the practices for this population are being offered. The logic model offers a valuable resource for practitioners, participants and funders to understand the problem being addressed, how practice is defined, as well as the impact of practice and on intermediate and longer term goals. Methods: The authors used a systematic iterative approach to describe the operationalization of arts-based psychosocial practice. This resulted in the design of the logic model being informed by data from focus groups, an overview of the literature regarding transgerenational trauma in this population, operational policies and organizational documents. The development of the logic model involved actively investigating with practitioners their work with remote farming communities. We thematised practitioners practice constructs to identify salient practice elements and their relationship to perceived benefits and lastly feedback from practitioners and participants following implementation to make adjustments to the logic model. Results: The results were clearly identified in the form of visual mapping using the design of a program logic model. The logic model was divided into 5 parts and was verified by practitioners following implementation. The parts of the program logic model are (Part 1) main presenting problem, (Part 2) operational processes, (Part 3) practice elements, (Part 4) benefits, and impact and (Part 5) review.
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Affiliation(s)
- Dominik Havsteen-Franklin
- Central and North West London NHS Foundation Trust, London, United Kingdom.,Arts and Humanities, Brunel University London, Uxbridge, United Kingdom
| | - Marlize Swanepoel
- Sp(i)eel Creative Arts Therapies Collective, Cape Town, South Africa
| | - Jesika Jones
- Sp(i)eel Creative Arts Therapies Collective, Cape Town, South Africa
| | - Uné Conradie
- Sp(i)eel Creative Arts Therapies Collective, Cape Town, South Africa
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11
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Gupta B, Li D, Dong P, Acri MC. From intention to action: A systematic literature review of provider behaviour change-focused interventions in physical health and behavioural health settings. J Eval Clin Pract 2021; 27:1429-1445. [PMID: 33565177 DOI: 10.1111/jep.13547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/31/2020] [Accepted: 01/17/2021] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES It is clear there are significant delays in the uptake of best practices as part of routine care in the healthcare system, yet there is conflicting evidence on how to specifically align provider behaviour with best practices. METHOD We conducted a review of interventions utilized to change any aspect of provider behaviour. To extend prior research, studies were included in the present review if they had an active intervention targeting behaviour change of providers in health or behavioural-health settings and were published between 2001 and 2020. RESULTS Of 1547 studies, 44 met inclusion criteria. Of 44 studies identified, 28 studies utilized contextually relevant interventions (eg, tailored to a specific provider population). Twenty six interventions with a contextually relevant approach resulted in provider behaviour change. CONCLUSIONS Findings are promising for encouraging provider behaviour change when interventions are tailored to be contextually relevant, as both single-component and multifaceted interventions were successful when they were contextually relevant. It is critical to conduct additional research to ensure that providers sustain behaviour changes over a long-term beyond an intervention's implementation and evaluation period.
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Affiliation(s)
- Brinda Gupta
- Social Policy Institute, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Dongze Li
- Social Policy Institute, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Peiyu Dong
- Social Policy Institute, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mary C Acri
- Social Policy Institute, Washington University in St. Louis, St. Louis, Missouri, USA
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12
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Aifah AA, Odubela O, Rakhra A, Onakomaiya D, Hu J, Nwaozuru U, Oladele DA, Odusola AO, Idigbe I, Musa AZ, Akere A, Tayo B, Ogedegbe G, Iwelunmor J, Ezechi O. Integration of a task strengthening strategy for hypertension management into HIV care in Nigeria: a cluster randomized controlled trial study protocol. Implement Sci 2021; 16:96. [PMID: 34789277 PMCID: PMC8597211 DOI: 10.1186/s13012-021-01167-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In regions with weak healthcare systems, critical shortages of the healthcare workforce, and increasing prevalence of dual disease burdens, there is an urgent need for the implementation of proven effective interventions and strategies to address these challenges. Our mixed-methods hybrid type II effectiveness-implementation study is designed to fill this evidence-to-practice gap. This study protocol describes a cluster randomized controlled trial which evaluates the effectiveness of an implementation strategy, practice facilitation (PF), on the integration, adoption, and sustainability of a task-strengthening strategy for hypertension control (TASSH) intervention within primary healthcare centers (PHCs) in Lagos State, Nigeria. DESIGN Guided by the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM), this study tests the impact of a proven effective implementation strategy to integrate hypertension management into the HIV care cascade, across 30 PHCs. The study will be conducted in three phases: (1) a pre-implementation phase that will use CFIR to develop a tailored PF intervention for integrating TASSH into HIV clinics; (2) an implementation phase that will use RE-AIM to compare the clinical effectiveness of PF vs. a self-directed condition (receipt of information on TASSH without PF) on BP reduction; and (3) a post-implementation phase that will use RE-AIM to evaluate the effect of PF vs. self-directed condition on adoption and sustainability of TASSH. The PF intervention components comprise (a) an advisory board to provide leadership support for implementing TASSH in PHCs; (b) training of the HIV nurses on TASSH protocol; and (c) training of practice facilitators, who will serve as coaches, provide support, and performance feedback to the HIV nurses. DISCUSSION This study is one of few, if any trials, to evaluate the impact of an implementation strategy for integrating hypertension management into HIV care, on clinical and implementation outcomes. Findings from this study will advance implementation science research on the effectiveness of tailoring an implementation strategy for the integration of an evidence-based, system-level hypertension control intervention into HIV care and treatment. TRIAL REGISTRATION ClinicalTrials.gov ( NCT04704336 ). Registered on 11 January 2021.
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Affiliation(s)
| | | | | | | | - Jiyuan Hu
- NYU Grossman School of Medicine, New York City, USA
| | | | | | | | - Ifeoma Idigbe
- Nigerian Institute of Medical Research, Lagos, Nigeria
| | | | | | - Bamidele Tayo
- Loyola University Parkinson School of Health Sciences and Public Health, Maywood, USA
| | - Gbenga Ogedegbe
- Institute for Excellence in Health Equity (IEHE), NYU Langone Health, New York City, USA.
| | | | - Oliver Ezechi
- Nigerian Institute of Medical Research, Lagos, Nigeria
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13
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Korevaar E, Kasza J, Taljaard M, Hemming K, Haines T, Turner EL, Thompson JA, Hughes JP, Forbes AB. Intra-cluster correlations from the CLustered OUtcome Dataset bank to inform the design of longitudinal cluster trials. Clin Trials 2021; 18:529-540. [PMID: 34088230 DOI: 10.1177/17407745211020852] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sample size calculations for longitudinal cluster randomised trials, such as crossover and stepped-wedge trials, require estimates of the assumed correlation structure. This includes both within-period intra-cluster correlations, which importantly differ from conventional intra-cluster correlations by their dependence on period, and also cluster autocorrelation coefficients to model correlation decay. There are limited resources to inform these estimates. In this article, we provide a repository of correlation estimates from a bank of real-world clustered datasets. These are provided under several assumed correlation structures, namely exchangeable, block-exchangeable and discrete-time decay correlation structures. METHODS Longitudinal studies with clustered outcomes were collected to form the CLustered OUtcome Dataset bank. Forty-four available continuous outcomes from 29 datasets were obtained and analysed using each correlation structure. Patterns of within-period intra-cluster correlation coefficient and cluster autocorrelation coefficients were explored by study characteristics. RESULTS The median within-period intra-cluster correlation coefficient for the discrete-time decay model was 0.05 (interquartile range: 0.02-0.09) with a median cluster autocorrelation of 0.73 (interquartile range: 0.19-0.91). The within-period intra-cluster correlation coefficients were similar for the exchangeable, block-exchangeable and discrete-time decay correlation structures. Within-period intra-cluster correlation coefficients and cluster autocorrelations were found to vary with the number of participants per cluster-period, the period-length, type of cluster (primary care, secondary care, community or school) and country income status (high-income country or low- and middle-income country). The within-period intra-cluster correlation coefficients tended to decrease with increasing period-length and slightly decrease with increasing cluster-period sizes, while the cluster autocorrelations tended to move closer to 1 with increasing cluster-period size. Using the CLustered OUtcome Dataset bank, an RShiny app has been developed for determining plausible values of correlation coefficients for use in sample size calculations. DISCUSSION This study provides a repository of intra-cluster correlations and cluster autocorrelations for longitudinal cluster trials. This can help inform sample size calculations for future longitudinal cluster randomised trials.
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Affiliation(s)
- Elizabeth Korevaar
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University, Melbourne, VIC, Australia
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.,Duke Global Health Institute, Durham, NC, USA
| | - Jennifer A Thompson
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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14
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Gold HT, Siman N, Cuthel AM, Nguyen AM, Pham-Singer H, Berry CA, Shelley DR. A practice facilitation-guided intervention in primary care settings to reduce cardiovascular disease risk: a cost analysis. Implement Sci Commun 2021; 2:15. [PMID: 33549152 PMCID: PMC7868016 DOI: 10.1186/s43058-021-00116-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background A stepped-wedge, cluster randomized controlled trial assessed the effectiveness of practice facilitation (PF) for adoption of guidelines for prevention and treatment of cardiovascular disease risk factors. This study estimated the associated cost of PF for guideline adoption in small, private primary care practices. Methods The cost analysis included categories for start-up costs, intervention costs, and practice staff costs for the implemented PF-guided intervention. We estimated the total 1-year costs to operate the program and calculated the mean and range of the cost-per-practice by quarter of the intervention. We estimated the lower and upper bounds for all salary expenses, rounding to the nearest $100. Results Total 1-year intervention costs for all 261 practices ranged from $7,900,000 to $10,200,000, with program and practice salaries comprising $6,600,000–$8,400,000 of the total. Start-up costs were a small proportion (3%) of the total 1-year costs. Excluding start-up costs, quarter 1 cost-per-practice was the most expensive at $20,400–$26,700, and quarter 4 was the least expensive at about $10,000. Practice staff time (compared with program staff time) was the majority of the staffing costs at 75–84%. Conclusions The PF strategy costs approximately $10,000 per practice per quarter for program and practice costs, once implemented and running at highest efficiency. Whether this program is “worth it” to the decision-maker depends on the relative costs and effectiveness of their other options for improving cardiovascular risk reduction. Trial registration This study is retrospectively registered on January 5, 2016, at www.clinicaltrials.gov as NCT02646488.
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Affiliation(s)
- Heather T Gold
- Department of Population Health, NYU Langone Health, New York, NY, USA.
| | - Nina Siman
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, NY, USA
| | - Ann M Nguyen
- Rutgers Center for State Health Policy, Rutgers University, New Brunswick, NJ, USA
| | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Carolyn A Berry
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Donna R Shelley
- Department of Policy and Public Health Management, School of Global Public Health, New York University, New York, NY, USA
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15
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Wolfenden L, Foy R, Presseau J, Grimshaw JM, Ivers NM, Powell BJ, Taljaard M, Wiggers J, Sutherland R, Nathan N, Williams CM, Kingsland M, Milat A, Hodder RK, Yoong SL. Designing and undertaking randomised implementation trials: guide for researchers. BMJ 2021; 372:m3721. [PMID: 33461967 PMCID: PMC7812444 DOI: 10.1136/bmj.m3721] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Implementation science is the study of methods to promote the systematic uptake of evidence based interventions into practice and policy to improve health. Despite the need for high quality evidence from implementation research, randomised trials of implementation strategies often have serious limitations. These limitations include high risks of bias, limited use of theory, a lack of standard terminology to describe implementation strategies, narrowly focused implementation outcomes, and poor reporting. This paper aims to improve the evidence base in implementation science by providing guidance on the development, conduct, and reporting of randomised trials of implementation strategies. Established randomised trial methods from seminal texts and recent developments in implementation science were consolidated by an international group of researchers, health policy makers, and practitioners. This article provides guidance on the key components of randomised trials of implementation strategies, including articulation of trial aims, trial recruitment and retention strategies, randomised design selection, use of implementation science theory and frameworks, measures, sample size calculations, ethical review, and trial reporting. It also focuses on topics requiring special consideration or adaptation for implementation trials. We propose this guide as a resource for researchers, healthcare and public health policy makers or practitioners, research funders, and journal editors with the goal of advancing rigorous conduct and reporting of randomised trials of implementation strategies.
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Affiliation(s)
- Luke Wolfenden
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family Medicine and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St Louis, St Louis, MI, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Wiggers
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Rachel Sutherland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Nicole Nathan
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Kingsland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Andrew Milat
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca K Hodder
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Sze Lin Yoong
- Swinburne University of Technology, School of Health Sciences, Faculty Health, Arts and Design, Hawthorn, VIC, Australia
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16
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Nguyen AM, Cuthel AM, Rogers ES, Van Devanter N, Pham-Singer H, Shih S, Berry CA, Shelley DR. Attributes of High-Performing Small Practices in a Guideline Implementation: A Multiple-Case Study. J Prim Care Community Health 2020; 11:2150132720984411. [PMID: 33356790 PMCID: PMC7768565 DOI: 10.1177/2150132720984411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. Methods A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. Results Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. Conclusions These attributes may be important determinants of high performance, indicating not only a small practice’s capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.
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Affiliation(s)
| | | | | | | | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Sarah Shih
- New York City Department of Health and Mental Hygiene, New York, NY, USA
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Cykert S, Keyserling TC, Pignone M, DeWalt D, Weiner BJ, Trogdon JG, Wroth T, Halladay J, Mackey M, Fine J, In Kim J, Cene C. A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices. Health Serv Res 2020; 55:944-953. [PMID: 33047340 DOI: 10.1111/1475-6773.13571] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices. STUDY SETTING A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018. STUDY DESIGN We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk-stratified adults, aged 40-79 years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention. DATA COLLECTION/ EXTRACTION METHODS Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry. PRINCIPLE FINDINGS ASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low-income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions. CONCLUSION A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices. Registration: ClinicalTrials.Gov 15-0479.
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Affiliation(s)
- Samuel Cykert
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Thomas C Keyserling
- Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Health Promotion and Disease Prevention, The Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael Pignone
- Department of Internal Medicine, The Dell Medical School, University of Texas, Austin, Texas, USA
| | - Darren DeWalt
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bryan J Weiner
- Department of Global Public Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, The Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Thomas Wroth
- Community Care of North Carolina, Raleigh, North Carolina, USA
| | - Jacqueline Halladay
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Family Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Monique Mackey
- The North Carolina Area Health Education Centers Program, Chapel Hill, North Carolina, USA
| | - Jason Fine
- Department of Biostatistics, The Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jung In Kim
- Department of Statistics, Eberly College of Science, The Pennsylvania State University, University Park, Pennsylvania, USA.,Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Crystal Cene
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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18
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Berry CA, Nguyen AM, Cuthel AM, Cleland CM, Siman N, Pham-Singer H, Shelley DR. Measuring Implementation Strategy Fidelity in HealthyHearts NYC: A Complex Intervention Using Practice Facilitation in Primary Care. Am J Med Qual 2020; 36:270-276. [PMID: 32964719 DOI: 10.1177/1062860620959450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Few studies have assessed the fidelity of practice facilitation (PF) as an implementation strategy, and none have used an a priori definition or conceptual framework of fidelity to guide fidelity assessment. The authors adapted the Conceptual Framework for Implementation Fidelity to guide fidelity assessment in HealthyHearts NYC, an intervention that used PF to improve adoption of cardiovascular disease evidence-based guidelines in primary care practices. Data from a web-based tracking system of 257 practices measured fidelity using 4 categories: frequency, duration, content, and coverage. Almost all (94.2%) practices received at least the required 13 PF visits. Facilitators spent on average 26.3 hours at each site. Most practices (95.7%) completed all Task List items, and 71.2% were educated on all Chronic Care Model strategies. The majority (65.8%) received full coverage. This study provides a model that practice managers and implementers can use to evaluate fidelity of PF, and potentially other implementation strategies.
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Affiliation(s)
- Carolyn A Berry
- NYU Langone Health, New York, NY New York City Department of Health and Mental Hygiene, New York, NY New York University, New York, NY
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Machline-Carrion MJ, Soares RM, Damiani LP, Campos VB, Sampaio B, Fonseca FH, Izar MC, Amodeo C, Pontes-Neto OM, Santos JY, Gomes SPDC, Saraiva JFK, Ramacciotti E, Barros E Silva PGDM, Lopes RD, Brandão da Silva N, Guimarães HP, Piegas L, Stein AT, Berwanger O. Effect of a Multifaceted Quality Improvement Intervention on the Prescription of Evidence-Based Treatment in Patients at High Cardiovascular Risk in Brazil: The BRIDGE Cardiovascular Prevention Cluster Randomized Clinical Trial. JAMA Cardiol 2020; 4:408-417. [PMID: 30942842 DOI: 10.1001/jamacardio.2019.0649] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Studies have found that patients at high cardiovascular risk often fail to receive evidence-based therapies in community practice. Objective To evaluate whether a multifaceted quality improvement intervention can improve the prescription of evidence-based therapies. Design, Setting, and Participants In this 2-arm cluster randomized clinical trial, patients with established atherothrombotic disease from 40 public and private outpatient clinics (clusters) in Brazil were studied. Patients were recruited from August 2016 to August 2017, with follow-up to August 2018. Data were analyzed in September 2018. Interventions Case management, audit and feedback reports, and distribution of educational materials (to health care professionals and patients) vs routine practice. Main Outcomes and Measures The primary end point was prescription of evidence-based therapies (ie, statins, antiplatelet therapy, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) using the all-or-none approach at 12 months after the intervention period in patients without contraindications. Results Of the 1619 included patients, 1029 (63.6%) were male, 1327 (82.0%) had coronary artery disease (843 [52.1%] with prior acute myocardial infarction), 355 (21.9%) had prior ischemic stroke or transient ischemic attack, and 197 (12.2%) had peripheral vascular disease, and the mean (SD) age was 65.6 (10.5) years. Among randomized clusters, 30 (75%) were cardiology sites, 6 (15%) were primary care units, and 26 (65%) were teaching institutions. Among eligible patients, those in intervention clusters were more likely to receive a prescription of evidence-based therapies than those in control clusters (73.5% [515 of 701] vs 58.7% [493 of 840]; odds ratio, 2.30; 95% CI, 1.14-4.65). There were no differences between the intervention and control groups with regards to risk factor control (ie, hyperlipidemia, hypertension, or diabetes). Rates of education for smoking cessation were higher among current smokers in the intervention group than in the control group (51.9% [364 of 701] vs 18.2% [153 of 840]; odds ratio, 11.24; 95% CI, 2.20-57.43). The rate of cardiovascular mortality, acute myocardial infarction, and stroke was 2.6% for patients from intervention clusters and 3.4% for those in the control group (hazard ratio, 0.76; 95% CI, 0.43-1.34). Conclusions and Relevance Among Brazilian patients at high cardiovascular risk, a quality improvement intervention resulted in improved prescription of evidence-based therapies. Trial Registration ClinicalTrials.gov identifier: NCT02851732.
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Affiliation(s)
| | | | | | | | - Bruna Sampaio
- HCor Research Institute, Hospital do Coração, São Paulo, São Paulo, Brazil
| | | | | | - Celso Amodeo
- Instituto Dante Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, São Paulo, Brazil.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Nilton Brandão da Silva
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Airton T Stein
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Otávio Berwanger
- HCor Research Institute, Hospital do Coração, São Paulo, São Paulo, Brazil
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20
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Shade L, Reeves K, Rees J, Hendrickson L, Halladay J, Dolor RJ, Bray P, Tapp H. Research nurses as practice facilitators to disseminate an asthma shared decision making intervention. BMC Nurs 2020; 19:40. [PMID: 32477003 PMCID: PMC7236364 DOI: 10.1186/s12912-020-00414-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 03/20/2020] [Indexed: 12/01/2022] Open
Abstract
Background Practice facilitation is a method of introducing and sustaining organizational change. It involves the use of skilled healthcare professionals called practice facilitators (PFs) to help address the challenges associated with implementing evidence-based guidelines and complex interventions into practice. PFs provide a framework for translating research into practice by building relationships, improving communication, fostering change, and sharing resources. Nurses are well positioned to serve as PFs for the implementation of complex interventions, however, there is little evidence currently available to describe nurses in this role. Additionally, the best strategies to implement complex interventions into practices are still not fully understood. Combining practice facilitation with the train-the-trainer model has the potential to spread knowledge and skills. Shared decision making (SDM), which involves patients and providers jointly engaging in decisions around treatment options, has been shown to improve outcomes for patients with asthma. The goal of this manuscript is to describe and evaluate the practice facilitation process from the ADAPT-NC Study which successfully utilized research nurses to implement a complex asthma SDM toolkit intervention into primary care practices. Methods As part of a larger study, 10 primary care practices were recruited for a facilitator-led dissemination intervention involving a 12-week rollout of an asthma SDM toolkit (trial registration: 1.28.2014, #NCT02047929). An experienced lead PF trained research nurses as PFs from each of the 4 participating practice-based research networks (PBRNs) in a train-the-trainer model utilizing a one-day training event and subsequent remote meetings. Evaluation of PF engagement was measured through process improvement surveys. Results Overall, the asthma SDM intervention was successfully implemented within the 4 PBRNs. All 10 facilitator-led practices remained engaged with their PFs, with 8 out of the 10 practices able to incorporate and sustain SDM visits or clinics. Responses from the surveys for process improvement yielded improved PF communication and team dynamics over time. Conclusions This study demonstrated effective use of research nurses as practice facilitators during the dissemination of an asthma SDM intervention into primary care practices, adding to the knowledge of best practices by describing a model of large-scale implementation of a complex intervention through practice facilitation with nurses. Trial registration “Comparing Traditional and Participatory Dissemination of a Shared Decision Making Intervention” was retrospectively registered at https://clinicaltrials.gov/ on January 28th, 2014 (NCT02047929).
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Affiliation(s)
- Lindsay Shade
- 1Atrium Health, Department of Family Medicine Research, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Kelly Reeves
- 1Atrium Health, Department of Family Medicine Research, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Jennifer Rees
- 2University of North Carolina at Chapel Hill, 160 N. Medical Drive, CB 7064, Chapel Hill, NC 27599 USA
| | - Lori Hendrickson
- 3Duke University Medical Center, 2608 Erwin Road, Suite 210, Durham, NC 27705 USA
| | - Jacqueline Halladay
- 4Department of Family Medicine, University of North Carolina at Chapel Hill, 590 Manning Drive, CB 7595, Chapel Hill, NC 27599-7595 USA
| | - Rowena J Dolor
- 5Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 200 Morris Street, 3rd Floor, Durham, NC 27701 USA
| | - Paul Bray
- Vidant Medical Group, 2000 Venture Tower Drive, Greenville, NC 27834 USA
| | - Hazel Tapp
- 1Atrium Health, Department of Family Medicine Research, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
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Shelley DR, Gepts T, Siman N, Nguyen AM, Cleland C, Cuthel AM, Rogers ES, Ogedegbe O, Pham-Singer H, Wu W, Berry CA. Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation. Am J Prev Med 2020; 58:683-690. [PMID: 32067871 DOI: 10.1016/j.amepre.2019.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention. STUDY DESIGN The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019. SETTING/PARTICIPANTS A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves. INTERVENTION The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines. MAIN OUTCOME MEASURES The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). RESULTS The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002). CONCLUSIONS Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02646488.
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Affiliation(s)
- Donna R Shelley
- Department of Policy and Public Health Management, College of Global Public Health, New York University, New York, New York.
| | - Thomas Gepts
- University of California Berkeley, Department of Sociology, Berkeley, California
| | - Nina Siman
- Department of Population Health, NYU Langone Health, New York, New York
| | - Ann M Nguyen
- Department of Population Health, NYU Langone Health, New York, New York
| | - Charles Cleland
- Department of Population Health, NYU Langone Health, New York, New York
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, New York
| | - Erin S Rogers
- Department of Population Health, NYU Langone Health, New York, New York
| | | | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Winfred Wu
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Carolyn A Berry
- Department of Population Health, NYU Langone Health, New York, New York
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22
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Hill JE, Stephani AM, Sapple P, Clegg AJ. The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review. Implement Sci 2020; 15:23. [PMID: 32306984 PMCID: PMC7168964 DOI: 10.1186/s13012-020-0975-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/19/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach. METHODS We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English. RESULTS Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities. CONCLUSIONS Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach. TRIAL REGISTRATION Protocol registered on PROSPERO (CRD42018088309).
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Affiliation(s)
- James E. Hill
- Faculty of Health and Wellbeing, University of Central Lancashire (UCLan), Preston, Lancashire PR1 2HE UK
| | - Anne-Marie Stephani
- Faculty of Health and Wellbeing, University of Central Lancashire (UCLan), Preston, Lancashire PR1 2HE UK
| | | | - Andrew J. Clegg
- Faculty of Health and Wellbeing, University of Central Lancashire (UCLan), Preston, Lancashire PR1 2HE UK
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23
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Nguyen AM, Cuthel A, Padgett DK, Niles P, Rogers E, Pham-Singer H, Ferran D, Kaplan SA, Berry C, Shelley D. How Practice Facilitation Strategies Differ by Practice Context. J Gen Intern Med 2020; 35:824-831. [PMID: 31637651 PMCID: PMC7080927 DOI: 10.1007/s11606-019-05350-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/10/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts. OBJECTIVE To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context. DESIGN Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines. PARTICIPANTS 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs). MAIN MEASURES Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach. KEY RESULTS Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts. CONCLUSIONS Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.
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Affiliation(s)
- Ann M Nguyen
- NYU Langone Health, Department of Population Health, New York, NY, USA.
| | - Allison Cuthel
- NYU Langone Health, Ronald O. Perelman Department of Emergency Medicine, New York, NY, USA
| | - Deborah K Padgett
- Silver School of Social Work, New York University, New York, NY, USA
| | - Paulomi Niles
- Rory Myers College of Nursing, New York University, New York, NY, USA
| | - Erin Rogers
- NYU Langone Health, Department of Population Health, New York, NY, USA
| | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Diane Ferran
- Community Health Care Association of New York State, New York, NY, USA
| | - Sue A Kaplan
- NYU Langone Health, Department of Population Health, New York, NY, USA
| | - Carolyn Berry
- NYU Langone Health, Department of Population Health, New York, NY, USA
| | - Donna Shelley
- NYU Langone Health, Department of Population Health, New York, NY, USA
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Agarwal P, Kithulegoda N, Bouck Z, Bosiak B, Birnbaum I, Reddeman L, Steiner L, Altman L, Mawson R, Propp R, Thornton J, Ivers N. Feasibility of an Electronic Health Tool to Promote Physical Activity in Primary Care: Pilot Cluster Randomized Controlled Trial. J Med Internet Res 2020; 22:e15424. [PMID: 32130122 PMCID: PMC7055803 DOI: 10.2196/15424] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/07/2019] [Accepted: 12/15/2019] [Indexed: 12/21/2022] Open
Abstract
Background Physical inactivity is associated with increased health risks. Primary care providers (PCPs) are well positioned to support increased physical activity (PA) levels through screening and provision of PA prescriptions. However, PCP counseling on PA is not common. Objective This study aimed to assess the feasibility of implementing an electronic health (eHealth) tool to support PA counseling by PCPs and estimate intervention effectiveness on patients’ PA levels. Methods A pragmatic pilot study was conducted using a stepped wedge cluster randomized trial design. The study was conducted at a single primary care clinic, with 4 pre-existing PCP teams. Adult patients who had a periodic health review (PHR) scheduled during the study period were invited to participate. The eHealth tool involved an electronic survey sent to participants before their PHR via an email or a tablet; data were used to automatically produce tailored resources and a PA prescription in the electronic medical record of participants in the intervention arm. Participants assigned to the control arm received usual care from their PCP. Feasibility was assessed by the proportion of completed surveys and patient-reported acceptability and fidelity measures. The primary effectiveness outcome was patient-reported PA at 4 months post-PHR, measured as metabolic equivalent of task (MET) minutes per week. Secondary outcomes assessed determinants of PA, including self-efficacy and intention to change based on the Health Action Process Approach behavior change theory. Results A total of 1028 patients receiving care from 34 PCPs were invited to participate and 530 (51.55%) consented (intervention [n=296] and control [n=234]). Of the participants who completed a process evaluation, almost half (88/178, 49.4%) stated they received a PA prescription, with only 42 receiving the full intervention including tailored resources from their PCP. A cluster-level linear regression analysis yielded a non–statistically significant positive difference in MET-minutes reported per week at follow-up between intervention and control conditions (mean difference 1027; 95% CI −155 to 2209; P=.09). No statistically significant differences were observed for secondary outcomes. Conclusions Our results suggest that it is feasible to build an eHealth tool that screens and provides tailored resources for PA in a primary care setting but suboptimal intervention fidelity suggests greater work must be done to address PCP barriers to resource distribution. Participant responses to the primary effectiveness outcome (MET-minutes) were highly variable, reflecting a need for more robust measures of PA in future trials to address limitations in patient-reported data. Trial Registration ClinicalTrials.gov NCT03181295; https://clinicaltrials.gov/ct2/show/NCT03181295
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Affiliation(s)
- Payal Agarwal
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Natasha Kithulegoda
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Zachary Bouck
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Beth Bosiak
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Ilana Birnbaum
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Lindsay Reddeman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Liora Altman
- Ontario Ministry of Health and Long-Term Care, Toronto, ON, Canada
| | - Robin Mawson
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Roni Propp
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Jane Thornton
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
| | - Noah Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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25
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Sanchez A, Pijoan JI, Pablo S, Mediavilla M, de Rozas RS, Lekue I, Gonzalez-Larragan S, Lantaron G, Argote J, García-Álvarez A, Latorre PM, Helfrich CD, Grandes G. Addressing low-value pharmacological prescribing in primary prevention of CVD through a structured evidence-based and theory-informed process for the design and testing of de-implementation strategies: the DE-imFAR study. Implement Sci 2020; 15:8. [PMID: 31969175 PMCID: PMC6977270 DOI: 10.1186/s13012-020-0966-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND De-implementation or abandonment of ineffective or low-value healthcare is becoming a priority research field globally due to the growing empirical evidence of the high prevalence of such care and its impact in terms of patient safety and social inefficiency. Little is known, however, about the factors, barriers, and facilitators involved or about interventions that are effective in promoting and accelerating the de-implementation of low-value healthcare. The De-imFAR study seeks to carry out a structured, evidence-based, and theory-informed process involving the main stakeholders (clinicians, managers, patients, and researchers) for the design, deployment, and assessment of de-implementation strategies for reducing low-value pharmacological prescribing. METHODS A phase I formative study using a systematic and comprehensive framework based on theory and evidence for the design of implementation strategies-specifically, the Behavior Change Wheel (BCW)-will be conducted to design and model de-implementation strategies to favor reductions in low-value pharmacological prescribing of statins in primary prevention of cardiovascular disease (CVD) by main stakeholders (clinicians, managers, patients, and researchers) in a collegiate way. Subsequently, a phase II comparative hybrid trial will be conducted to assess the feasibility and potential effectiveness of at least one active de-implementation strategy to reduce low-value pharmacological prescribing of statins in primary prevention of CVD compared to the usual procedures for dissemination of clinical practice guidelines ("what-not-to-do" recommendations). A mixed-methods evaluation will be used: quantitative for the results of the implementation at the professional level (e.g., adoption, reach and implementation or execution of the recommended clinical practice); and qualitative to determine the feasibility and perceived impact of the de-implementation strategies from the clinicians' perspective, and patients' experiences related to the clinical care received. DISCUSSION The DE-imFAR study aims to generate valid scientific knowledge about the design and development of de-implementation strategies using theory- and evidence-based methodologies suggested by implementation science. It will explore the effectiveness of these strategies and their acceptability among clinicians, policymakers, and patients. Its ultimate goal is to maximize the quality and efficiency of our health system by abandoning low-value pharmacological prescribing. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04022850. Registered 17 July 2019.
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Affiliation(s)
- Alvaro Sanchez
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Jose Ignacio Pijoan
- Clinical Epidemiology Unit, Hospital Universitario de Cruces. BioCruces Bizkaia Health Research Institute, Basque Healthcare Service-Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Susana Pablo
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Marta Mediavilla
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Rita Sainz de Rozas
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization – Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Itxasne Lekue
- Primary Care Pharmacy Unit, Barakaldo-Sestao Integrated Health Organization–Osakidetza, Antonio Miranda Etorbidea, E-48902 Barakaldo, Spain
| | - Susana Gonzalez-Larragan
- Department of Health Science Library, Cruces University Hospital-Osakidetza, Biocruces Bizkaia Health Research Institute, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Gaspar Lantaron
- Healthcare Integration Directorate, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization–Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Jon Argote
- Healthcare Integration Directorate, Barakaldo-Sestao Integrated Health Organization–Osakidetza, Antonio Miranda Etorbidea, E-48902 Barakaldo, Spain
| | - Arturo García-Álvarez
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Pedro Maria Latorre
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Christian D. Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Health Care System, Seattle, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, USA
| | - Gonzalo Grandes
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
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Loeb DF, Monson SP, Lockhart S, Depue C, Ludman E, Nease DE, Binswanger IA, Kline DM, de Gruy FV, Good DG, Bayliss EA. Mixed method evaluation of Relational Team Development (RELATED) to improve team-based care for complex patients with mental illness in primary care. BMC Psychiatry 2019; 19:299. [PMID: 31615460 PMCID: PMC6792180 DOI: 10.1186/s12888-019-2294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED). METHODS RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate. RESULTS We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching. CONCLUSIONS RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.
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Affiliation(s)
- Danielle F. Loeb
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | | | - Steven Lockhart
- 0000 0001 0703 675Xgrid.430503.1Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO USA
| | - Cori Depue
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Evette Ludman
- 0000 0004 0615 7519grid.488833.cKaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | - Donald E. Nease
- 0000 0001 0703 675Xgrid.430503.1Department of Family Medicine, University of Colorado, Aurora, USA
| | - Ingrid A. Binswanger
- 0000 0000 9957 7758grid.280062.eKaiser Permanente Colorado Institute for Health Research, Aurora, CO USA
| | - Danielle M. Kline
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Frank V. de Gruy
- 0000 0001 0703 675Xgrid.430503.1Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Dixie G. Good
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Elizabeth A. Bayliss
- 0000 0000 9957 7758grid.280062.eKaiser Permanente Colorado Institute for Health Research, Aurora, CO USA
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Joshi R, Agrawal T, Fathima F, Usha T, Thomas T, Misquith D, Kalantri S, Chidambaram N, Raj T, Singamani A, Hegde S, Xavier D, Devereaux PJ, Pais P, Gupta R, Yusuf S. Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial. Am Heart J 2019; 216:9-19. [PMID: 31377568 DOI: 10.1016/j.ahj.2019.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 06/11/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is a need to identify and test low-cost approaches for cardiovascular disease (CVD) risk reduction that can enable health systems to achieve such a strategy. OBJECTIVE Community health workers (CHWs) are an integral part of health-care delivery system in lower income countries. Our aim was to assess impact of CHW based interventions in reducing CVD risk factors in rural households in India. METHODS We performed an open-label cluster-randomized trial in 28 villages in 3 states of India with the household as a unit of randomization. Households with individuals at intermediate to high CVD risk were randomized to intervention and control groups. In the intervention group, trained CHWs delivered risk-reduction advice and monitored risk factors during 6 household visits over 12 months. Households in the non-intervention group received usual care. Primary outcomes were a reduction in systolic BP (SBP) and adherence to prescribed BP lowering drugs. RESULTS We randomized 2312 households (3261 participants at intermediate or high risk) to intervention (1172 households) and control (1140 households). At baseline prevalence of tobacco use (48.5%) and hypertension (34.7%) were high. At 12 months, there was significant decline in SBP (mmHg) from baseline in both groups- controls 130.3 ± 21 to 128.3 ± 15; intervention 130.3 ± 21 to 127.6 ± 15 (P < .01 for before and after comparison) but there was no difference between the 2 groups at 12 months (P = .18). Adherence to antihypertensive drugs was greater in intervention vs control households (74.9% vs 61.4%, P = .001). CONCLUSION A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact SBP. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.
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Affiliation(s)
- Rajnish Joshi
- Department of Medicine, All India Institute of Medical Sciences, Bhopal, India.
| | - Twinkle Agrawal
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - Farah Fathima
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - Thammattoor Usha
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - Tinku Thomas
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - Dominic Misquith
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - Shriprakash Kalantri
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, India
| | | | - Tony Raj
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - Alben Singamani
- Department of Clinical Research, Narayana Health Bangalore, India
| | | | - Denis Xavier
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Prem Pais
- Departments of Pharmacology, Community Medicine, and Division of Clinical Research and Training, St John's Medical College and Research Instiutute, Bangalore, India
| | - Rajeev Gupta
- Department of Preventive Cardiology and Internal Medicine, Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Loeb DF, Kline DM, Kroenke K, Boyd C, Bayliss EA, Ludman E, Dickinson LM, Binswanger IA, Monson SP. Designing the relational team development intervention to improve management of mental health in primary care using iterative stakeholder engagement. BMC FAMILY PRACTICE 2019; 20:124. [PMID: 31492096 PMCID: PMC6728939 DOI: 10.1186/s12875-019-1010-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/19/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Team-based models of care are efficacious in improving outcomes for patients with mental and physical illnesses. However, primary care clinics have been slow to adopt these models. We used iterative stakeholder engagement to develop an intervention to improve the implementation of team-based care for this complex population. METHODS We developed the initial framework for Relational Team Development (RELATED) from a qualitative study of Primary Care Providers' (PCPs') experiences treating mental illness and a literature review of practice facilitation and psychology clinical supervision. Subsequently, we surveyed 900 Colorado PCPs to identify factors associated with PCP self-efficacy in management of mental illness and team-based care. We then conducted two focus groups for feedback on RELATED. Lastly, we convened an expert panel to refine the intervention. RESULTS We developed RELATED, a two-part intervention delivered by a practice facilitator with a background in clinical psychology. The facilitator observes PCPs during patient visits and provides individualized coaching. Next, the facilitator guides the primary care team through a practice change activity with a focus on relational team dynamics. CONCLUSION The iterative development of RELATED using stakeholder engagement offers a model for the development of interventions tailored to the needs of these stakeholders. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Danielle F. Loeb
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave, Aurora, CO 80045 USA
| | - Danielle M. Kline
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave, Aurora, CO 80045 USA
| | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN USA
| | - Cynthia Boyd
- John Hopkins University School of Medicine, Baltimore, MD USA
| | | | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | - L. Miriam Dickinson
- Department of Biostatistics & Informatics, Colorado School of Public Health; Department of Family Medicine, University of Colorado, Aurora, CO USA
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Dahrouge S, Armstrong CD, Hogg W, Singh J, Liddy C. High-performing physicians are more likely to participate in a research study: findings from a quality improvement study. BMC Med Res Methodol 2019; 19:171. [PMID: 31387540 PMCID: PMC6685269 DOI: 10.1186/s12874-019-0809-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/18/2019] [Indexed: 12/31/2022] Open
Abstract
Background Participants in voluntary research present a different demographic profile than those who choose not to participate, affecting the generalizability of many studies. Efforts to evaluate these differences have faced challenges, as little information is available from non-participants. Leveraging data from a recent randomized controlled trial that used health administrative databases in a jurisdiction with universal medical coverage, we sought to compare the quality of care provided by participating and non-participating physicians prior to the program’s implementation in order to assess whether participating physicians provided a higher baseline quality of care. Methods We conducted clustered regression analyses of baseline data from provincial health administrative databases. Participants included all family physicians who were eligible to participate in the Improved Delivery of Cardiovascular Care (IDOCC) project, a quality improvement project rolled out in a geographically defined region in Ontario (Canada) between 2008 and 2011. We assessed 14 performance indicators representing measures of access, continuity, and recommended care for cancer screening and chronic disease management. Results In unadjusted and patient-adjusted models, patients of IDOCC-participating physicians had higher continuity scores at the provider (Odds Ratio (OR) [95% confidence interval]: 1.06 [1.03–1.09]) and practice (1.06 [1.04–1.08]) level, lower risk of emergency room visits (Rate Ratio (RR): 0.93 [0.88–0.97]) and hospitalizations (RR:0.87 [0.77–0.99]), and were more likely to have received recommended diabetes tests (OR: 1.25 [1.06–1.49]) and cancer screening for cervical cancer (OR: 1.32 [1.08–1.61] and breast cancer (OR: 1.32 [1.19–1.46]) than patients of non-participating physicians. Some indicators remained statistically significant in the model after adjusting for provider factors. Conclusions Our study demonstrated a participation bias for several quality indicators. Physician characteristics can explain some of these differences. Other underlying physician or practice attributes also influence interest in participating in quality improvement initiatives and existing quality levels. The standard for addressing participation bias by controlling for basic physician and practice level variables is inadequate for ensuring that results are generalizable to primary care providers and practices. Electronic supplementary material The online version of this article (10.1186/s12874-019-0809-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simone Dahrouge
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, 113-43, rue Bruyère St, K1N 5C7, Annex E, Ottawa, ON, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada. .,The Institute for Clinical evaluative Sciences, Ottawa, ON, Canada.
| | | | - William Hogg
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, 113-43, rue Bruyère St, K1N 5C7, Annex E, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,The Institute for Clinical evaluative Sciences, Ottawa, ON, Canada
| | - Jatinderpreet Singh
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, 113-43, rue Bruyère St, K1N 5C7, Annex E, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Clare Liddy
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, 113-43, rue Bruyère St, K1N 5C7, Annex E, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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Moussa L, Garcia-Cardenas V, Benrimoj SI. Change Facilitation Strategies Used in the Implementation of Innovations in Healthcare Practice: A Systematic Review. JOURNAL OF CHANGE MANAGEMENT 2019. [DOI: 10.1080/14697017.2019.1602552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Lydia Moussa
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | | | - Shalom I. Benrimoj
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
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Machline-Carrion MJ, Soares RM, Damiani LP, Campos VB, Sampaio B, Yamashita J, Fonseca FH, Izar MC, Amodeo C, Pontes-Neto OM, de Melo Barros PG, Lopes RD, Brandão da Silva N, Guimarães HP, Piegas L, Stein AT, Berwanger O. Rationale and design for a cluster randomized quality-improvement trial to increase the uptake of evidence-based therapies for patients at high cardiovascular risk: The BRIDGE-Cardiovascular Prevention trial. Am Heart J 2019; 207:40-48. [PMID: 30415082 DOI: 10.1016/j.ahj.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Translating evidence into clinical practice in the management of high cardiovascular risk patients is challenging. Few quality improvement interventions have rigorously evaluated their impact on both patient care and clinical outcomes. OBJECTIVES The main objectives are to evaluate the impact of a multifaceted educational intervention on adherence to local guidelines for the prescription of statins, antiplatelets and angiotensin converting enzyme inhibitors or angiotensin II receptor blockers for high cardiovascular risk patients, as well as on the incidence of major cardiovascular events. DESIGN We designed a pragmatic two arm cluster randomized trial involving 40 clusters. Clusters are randomized to receive a multifaceted quality improvement intervention or to routine practice (control). The multifaceted intervention includes: reminders, care algorithms, training of a case manager, audit and feedback reports, and distribution of educational materials to health care providers. The primary endpoint is the adherence to combined evidence-based therapies (statins, antiplatelet therapy and angiotensin converting enzyme inhibitors or angiotensin receptor blockers) at 12 months after the intervention period in patients without contra-indications for these medications. All analyses follow the intention-to-treat principle and take the cluster design into account using linear mixed logistic regression modeling. SUMMARY If proven effective, this multifaceted intervention would have wide utility as a means of promoting optimal usage of evidence-based interventions for the management of high cardiovascular risk patients.
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Wang A, Pollack T, Kadziel LA, Ross SM, McHugh M, Jordan N, Kho AN. Impact of Practice Facilitation in Primary Care on Chronic Disease Care Processes and Outcomes: a Systematic Review. J Gen Intern Med 2018; 33:1968-1977. [PMID: 30066117 PMCID: PMC6206351 DOI: 10.1007/s11606-018-4581-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/08/2018] [Accepted: 07/06/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND More than 100 million individuals in the USA have been diagnosed with a chronic disease, yet chronic disease care has remained fragmented and of inconsistent quality. Improving chronic disease management has been challenging for primary care and internal medicine practitioners. Practice facilitation provides a comprehensive approach to chronic disease care. The objective is to evaluate the impact of practice facilitation on chronic disease outcomes in the primary care setting. METHODS This systematic review examined North American studies from PubMed, EMBASE, and Web of Science (database inception to August 2017). Investigators independently extracted and assessed the quality of the data on chronic disease process and clinical outcome measures. Studies implemented practice facilitation and reported quantifiable care processes and patient outcomes for chronic disease. Each study and their evidence were assessed for risk of bias and quality according to the Cochrane Collaboration and the Grade Collaboration tool. RESULTS This systematic review included 25 studies: 12 randomized control trials and 13 prospective cohort studies. Across all studies, practices and their clinicians were aware of the implementation of practice facilitation. Improvements were observed in most studies for chronic diseases including asthma, cancer (breast, cervical, and colorectal), cardiovascular disease (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, myocardial infarction, and peripheral vascular disease), and type 2 diabetes. Mixed results were observed for chronic kidney disease and chronic illness care. DISCUSSION Overall, the results suggest that practice facilitation may improve chronic disease care measures. Across all studies, practices were aware of practice facilitation. These findings lend support for the potential expansion of practice facilitation in primary care. Future work will need to investigate potential opportunities for practice facilitation to improve chronic disease outcomes in other health care settings (e.g., specialty and multi-specialty practices) with standardized measures.
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Affiliation(s)
- Andrew Wang
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Teresa Pollack
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren A Kadziel
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Samuel M Ross
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Megan McHugh
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil Jordan
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Departments of Psychiatry & Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
| | - Abel N Kho
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Ludden T, Shade L, Reeves K, Welch M, Taylor YJ, Mohanan S, McWilliams A, Halladay J, Donahue K, Coyne-Beasley T, Dolor RJ, Bray P, Tapp H. Asthma dissemination around patient-centered treatments in North Carolina (ADAPT-NC): a cluster randomized control trial evaluating dissemination of an evidence-based shared decision-making intervention for asthma management. J Asthma 2018; 56:1087-1098. [PMID: 30252544 DOI: 10.1080/02770903.2018.1514630] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objective: To compare three dissemination approaches for implementing an asthma shared decision-making (SDM) intervention into primary care practices. Methods: We randomized thirty practices into three study arms: (1) a facilitator-led approach to implementing SDM; (2) a one-hour lunch-and-learn training on SDM; and (3) a control group with no active intervention. Patient perceptions of SDM were assessed in the active intervention arms using a one-question anonymous survey. Logistic regression models compared the frequency of asthma exacerbations (emergency department (ED) visits, hospitalizations, and oral steroid prescriptions) between the three arms. Results: We collected 705 surveys from facilitator-led sites and 523 from lunch-and-learn sites. Patients were more likely to report that they participated equally with the provider in making the treatment decision in the facilitator-led sites (75% vs. 66%, p = 0.001). Comparisons of outcomes for patients in the facilitator-led (n = 1,658) and lunch-and-learn (n = 2,613) arms respectively vs. control (n = 2,273) showed no significant differences for ED visits (Odds Ratio [OR] [95%CI] = 0.77[0.57-1.04]; 0.83[0.66-1.07]), hospitalizations (OR [95%CI] = 1.30[0.59-2.89]; 1.40 [0.68-3.06]), or oral steroids (OR [95%CI] =0.95[0.79-1.15]; 1.03[0.81-1.06]). Conclusion: Facilitator-led dissemination was associated with a significantly higher proportion of patients sharing equally in decision-making with the provider compared to a traditional lunch-and-learn approach. While there was no significant difference in health outcomes between the three arms, the results were most likely confounded by a concurrent statewide asthma initiative and the pragmatic implementation of the intervention. These results offer support for the use of structured approaches such as facilitator-led dissemination of complex interventions into primary care practices.
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Affiliation(s)
- Thomas Ludden
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Lindsay Shade
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Kelly Reeves
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Madelyn Welch
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Sveta Mohanan
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Jacqueline Halladay
- University of North Carolina Department of Family Medicine, Chapel Hill, NC, USA.,Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, USA
| | - Katrina Donahue
- University of North Carolina Department of Family Medicine, Chapel Hill, NC, USA.,Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, USA
| | - Tamera Coyne-Beasley
- University of North Carolina Department of Family Medicine, Chapel Hill, NC, USA.,Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, USA
| | - Rowena J Dolor
- Division General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Paul Bray
- Vidant Medical Group, Greenville, NC, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
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Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care. J Gen Intern Med 2018; 33:1142-1154. [PMID: 29728892 PMCID: PMC6025666 DOI: 10.1007/s11606-018-4435-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 08/10/2017] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs). METHODS The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results. RESULTS The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]). DISCUSSION Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.
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35
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Bachmann MO, Bateman ED, Stelmach R, Cruz ÁA, Pacheco de Andrade M, Zonta R, Zepeda J, Natal S, Cornick R, Wattrus C, Anderson L, Lombard C, Fairall LR. Integrating primary care of chronic respiratory disease, cardiovascular disease and diabetes in Brazil: Practical Approach to Care Kit (PACK Brazil): study protocol for randomised controlled trials. J Thorac Dis 2018; 10:4667-4677. [PMID: 30174920 PMCID: PMC6105957 DOI: 10.21037/jtd.2018.07.34] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/03/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Multimorbidity is increasing common in Brazilian adults. Comorbid chronic lung disease, cardiovascular disease and diabetes are often inaccurately diagnosed or ineffectively treated. The Global Alliance against Chronic Respiratory Diseases (GARD) aims to strengthen health systems to prevent and control non-communicable diseases through primary health care. The Practical Approach to Care Kit (PACK Adult) is a clinical decision support tool that provides evidence-supported algorithmic guidelines for screening, diagnosis and treatment of chronic diseases, and is widely used in South Africa. It was adapted for Brazil by family physicians in the Florianopolis City Health Department, which trains clinic doctors and nurses to use it. METHODS Effectiveness of PACK Adult training will be evaluated in two pragmatic cluster randomised trials, one enrolling adults with chronic lower respiratory diseases and the other enrolling adults with cardiovascular disease or diabetes. Forty-eight municipal clinics in Florianopolis were randomly allocated to intervention or control arms. In intervention arm clinics, doctors and nurses will receive educational outreach training and the PACK Adult clinical decision support tool. In control arm clinics, doctors and nurses will receive only the tool. Trial outcomes will be measured using patients' electronic medical records during 12 months after completion of basic training. Primary outcomes for the respiratory trial are appropriate prescribing, spirometry and diagnosis rates. Primary outcomes for the cardiovascular trial are testing for cardiovascular risk and diabetes, and systolic blood pressure. Educational outreach to primary care professionals could improve respiratory, cardiovascular and diabetes care in Brazil. TRIAL REGISTRATION NCT02786030 and NCT02795910 (https://clinicaltrials.gov/).
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Affiliation(s)
- Max O. Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | | | | | | | | | - Sonia Natal
- Federal University of Santa Catarina, Florianopolis, Brazil
| | - Ruth Cornick
- University of Cape Town, Cape Town, South Africa
| | | | | | - Carl Lombard
- Medical Research Council, Cape Town, South Africa
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36
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Lynch EA, Chesworth BM, Connell LA. Implementation—The Missing Link in the Research Translation Pipeline: Is It Any Wonder No One Ever Implements Evidence-Based Practice? Neurorehabil Neural Repair 2018; 32:751-761. [DOI: 10.1177/1545968318777844] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the exponential growth in the evidence base for stroke rehabilitation, there is still a paucity of knowledge about how to consistently and sustainably deliver evidence-based stroke rehabilitation therapies in clinical practice. This means that people with stroke will not consistently benefit from research breakthroughs, simply because clinicians do not always have the skills, authority, knowledge or resources to be able to translate the findings from a research trial and apply these in clinical practice. This “point of view” article by an interdisciplinary, international team illustrates the lack of available evidence to guide the translation of evidence to practice in rehabilitation, by presenting a comprehensive and systematic content analysis of articles that were published in 2016 in leading clinical stroke rehabilitation journals commonly read by clinicians. Our review confirms that only a small fraction (2.5%) of published stroke rehabilitation research in these journals evaluate the implementation of evidence-based interventions into health care practice. We argue that in order for stroke rehabilitation research to contribute to enhanced health and well-being of people with stroke, journals, funders, policy makers, researchers, clinicians, and professional associations alike need to actively support and promote (through funding, conducting, or disseminating) implementation and evaluation research.
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Affiliation(s)
- Elizabeth A. Lynch
- University of Adelaide, Adelaide, South Australia, Australia
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Parkville, Victoria, Australia
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37
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Brown B, Young J, Smith DP, Kneebone AB, Brooks AJ, Egger S, Xhilaga M, Dominello A, O'Connell DL, Haines M. A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial. Implement Sci 2018. [PMID: 29530071 PMCID: PMC5848547 DOI: 10.1186/s13012-018-0733-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations. METHODS Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals' and study Sites' practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists' attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability. RESULTS Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%). CONCLUSIONS The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists' attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.
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Affiliation(s)
- Bernadette Brown
- Sax Institute, Haymarket, Australia. .,School of Public Health, University of Sydney, Camperdown, Australia.
| | - Jane Young
- School of Public Health, University of Sydney, Camperdown, Australia
| | - David P Smith
- School of Public Health, University of Sydney, Camperdown, Australia.,Cancer Research Division, Cancer Council NSW, Sydney, Australia.,Griffith Health Institute, Griffith University, Gold Coast, QLD, Australia
| | - Andrew B Kneebone
- Department of Radiation Oncology, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, University of Sydney, Camperdown, Australia
| | - Andrew J Brooks
- NSW Agency for Clinical Innovation, Sydney, Australia.,Westmead Private Hospital, Westmead, Australia.,Westmead Clinical School, University of Sydney, Camperdown, Australia
| | - Sam Egger
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | - Miranda Xhilaga
- Prostate Cancer Foundation of Australia, Melbourne, Australia
| | - Amanda Dominello
- Sax Institute, Haymarket, Australia.,School of Public Health, University of Sydney, Camperdown, Australia
| | - Dianne L O'Connell
- School of Public Health, University of Sydney, Camperdown, Australia.,Cancer Research Division, Cancer Council NSW, Sydney, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Mary Haines
- Sax Institute, Haymarket, Australia.,School of Public Health, University of Sydney, Camperdown, Australia
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38
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Haines TP, Hemming K. Stepped-wedge cluster-randomised trials: level of evidence, feasibility and reporting. J Physiother 2018; 64:63-66. [PMID: 29289591 DOI: 10.1016/j.jphys.2017.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/22/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Terry P Haines
- School of Primary and Allied Health Care, Monash University, Frankston, Australia; Institute of Allied Health Research, University of Birmingham, Birmingham, UK
| | - Karla Hemming
- Institute of Allied Health Research, University of Birmingham, Birmingham, UK
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39
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Liddy C, Rowan M, Valiquette-Tessier SC, Drosinis P, Crowe L, Hogg W. Experiences of practice facilitators working on the Improved Delivery of Cardiovascular Care project: Retrospective case study. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2018; 64:e23-e32. [PMID: 29358265 PMCID: PMC5962976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To examine the barriers to and facilitators of practice facilitation experienced by participants in the Improving Delivery of Cardiovascular Care (IDOCC) project. DESIGN Case studies of practice facilitators' narrative reports. SETTING Eastern Ontario. PARTICIPANTS Primary care practices that participated in the IDOCC project. MAIN OUTCOME MEASURES Cases were identified by calculating sum scores in order to determine practices' performance relative to their peers. Two case exemplars were selected that scored within ± 1 SD of the total mean score, and a qualitative analysis of practice facilitators' narrative reports was conducted using a 5-factor implementation framework to identify barriers and facilitators. Narratives were divided into 3 phases: planning, implementation, and sustainability. RESULTS Barriers and facilitators fluctuated over the intervention's 3 phases. Site A reported more barriers (n = 47) than facilitators (n = 38), while site B reported a roughly equal number of barriers (n = 144) and facilitators (n = 136). In both sites, the most common barriers involved organizational and provider factors and the most common facilitators were associated with innovation and structural factors. CONCLUSION Both practices encountered various barriers and facilitators throughout the IDOCC's 3 phases. The case studies reveal the complex interactions of these factors over time, and provide insight into the implementation of practice facilitation programs.
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Affiliation(s)
- Clare Liddy
- Clinician Investigator at the C.T. Lamont Primary Health Care Research Centre of the Bruyère Research Institute and Associate Professor in the Department of Family Medicine at the University of Ottawa in Ontario.
| | - Margo Rowan
- Principal Lead of Rowan Research and Evaluation and Assistant Professor in the Department of Family Medicine at the University of Ottawa
| | | | - Paul Drosinis
- Research assistant at the C.T. Lamont Primary Health Care Research Centre of the Bruyère Research Institute
| | - Lois Crowe
- Research Manager at the C.T. Lamont Primary Health Care Research Centre of the Bruyère Research Institute
| | - William Hogg
- Professor in the Department of Family Medicine at the University of Ottawa and Senior Research Advisor at the C.T. Lamont Primary Health Care Research Centre of the Bruyère Research Institute
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40
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Weiner BJ, Rohweder CL, Scott JE, Teal R, Slade A, Deal AM, Jihad N, Wolf M. Using Practice Facilitation to Increase Rates of Colorectal Cancer Screening in Community Health Centers, North Carolina, 2012-2013: Feasibility, Facilitators, and Barriers. Prev Chronic Dis 2017; 14:E66. [PMID: 28817791 PMCID: PMC5566800 DOI: 10.5888/pcd14.160454] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Practice facilitation involves trained individuals working with practice staff to conduct quality improvement activities and support delivery of evidence-based clinical services. We examined the feasibility of using practice facilitation to assist federally qualified health centers (FQHCs) to increase colorectal cancer screening rates in North Carolina. Methods The intervention consisted of 12 months of facilitation in 3 FQHCs. We conducted chart audits to obtain data on changes in documented recommendation for colorectal cancer screening and completed screening. Key informant interviews provided qualitative data on barriers to and facilitators of implementing office systems. Results Overall, the percentage of eligible patients with a documented colorectal cancer screening recommendation increased from 15% to 29% (P < .001). The percentage of patients up to date with colorectal cancer screening rose from 23% to 34% (P = .03). Key informants in all 3 clinics said the implementation support from the practice facilitator was critical for initiating or improving office systems and that modifying the electronic medical record was the biggest challenge and most time-consuming aspect of implementing office systems changes. Other barriers were staff turnover and reluctance on the part of local gastroenterology practices to perform free or low-cost diagnostic colonoscopies for uninsured or underinsured patients. Conclusion Practice facilitation is a feasible, acceptable, and promising approach for supporting universal colorectal cancer screening in FQHCs. A larger-scale study is warranted.
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Affiliation(s)
- Bryan J Weiner
- Department of Global Health, University of Washington, 1510 San Juan Rd, Seattle, WA 98195.
| | | | - Jennifer E Scott
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Randall Teal
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alecia Slade
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Allison M Deal
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Naima Jihad
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Marti Wolf
- North Carolina Community Health Center Association, Raleigh, North Carolina
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41
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Karmali KN, Persell SD, Perel P, Lloyd-Jones DM, Berendsen MA, Huffman MD. Risk scoring for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2017; 3:CD006887. [PMID: 28290160 PMCID: PMC6464686 DOI: 10.1002/14651858.cd006887.pub4] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The current paradigm for cardiovascular disease (CVD) emphasises absolute risk assessment to guide treatment decisions in primary prevention. Although the derivation and validation of multivariable risk assessment tools, or CVD risk scores, have attracted considerable attention, their effect on clinical outcomes is uncertain. OBJECTIVES To assess the effects of evaluating and providing CVD risk scores in adults without prevalent CVD on cardiovascular outcomes, risk factor levels, preventive medication prescribing, and health behaviours. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2016, Issue 2), MEDLINE Ovid (1946 to March week 1 2016), Embase (embase.com) (1974 to 15 March 2016), and Conference Proceedings Citation Index-Science (CPCI-S) (1990 to 15 March 2016). We imposed no language restrictions. We searched clinical trial registers in March 2016 and handsearched reference lists of primary studies to identify additional reports. SELECTION CRITERIA We included randomised and quasi-randomised trials comparing the systematic provision of CVD risk scores by a clinician, healthcare professional, or healthcare system compared with usual care (i.e. no systematic provision of CVD risk scores) in adults without CVD. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies, extracted data, and evaluated study quality. We used the Cochrane 'Risk of bias' tool to assess study limitations. The primary outcomes were: CVD events, change in CVD risk factor levels (total cholesterol, systolic blood pressure, and multivariable CVD risk), and adverse events. Secondary outcomes included: lipid-lowering and antihypertensive medication prescribing in higher-risk people. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data using 95% confidence intervals. We used a fixed-effects model when heterogeneity (I²) was at least 50% and a random-effects model for substantial heterogeneity (I² > 50%). We evaluated the quality of evidence using the GRADE framework. MAIN RESULTS We identified 41 randomised controlled trials (RCTs) involving 194,035 participants from 6422 reports. We assessed studies as having high or unclear risk of bias across multiple domains. Low-quality evidence evidence suggests that providing CVD risk scores may have little or no effect on CVD events compared with usual care (5.4% versus 5.3%; RR 1.01, 95% confidence interval (CI) 0.95 to 1.08; I² = 25%; 3 trials, N = 99,070). Providing CVD risk scores may reduce CVD risk factor levels by a small amount compared with usual care. Providing CVD risk scores reduced total cholesterol (MD -0.10 mmol/L, 95% CI -0.20 to 0.00; I² = 94%; 12 trials, N = 20,437, low-quality evidence), systolic blood pressure (MD -2.77 mmHg, 95% CI -4.16 to -1.38; I² = 93%; 16 trials, N = 32,954, low-quality evidence), and multivariable CVD risk (SMD -0.21, 95% CI -0.39 to -0.02; I² = 94%; 9 trials, N = 9549, low-quality evidence). Providing CVD risk scores may reduce adverse events compared with usual care, but results were imprecise (1.9% versus 2.7%; RR 0.72, 95% CI 0.49 to 1.04; I² = 0%; 4 trials, N = 4630, low-quality evidence). Compared with usual care, providing CVD risk scores may increase new or intensified lipid-lowering medications (15.7% versus 10.7%; RR 1.47, 95% CI 1.15 to 1.87; I² = 40%; 11 trials, N = 14,175, low-quality evidence) and increase new or increased antihypertensive medications (17.2% versus 11.4%; RR 1.51, 95% CI 1.08 to 2.11; I² = 53%; 8 trials, N = 13,255, low-quality evidence). AUTHORS' CONCLUSIONS There is uncertainty whether current strategies for providing CVD risk scores affect CVD events. Providing CVD risk scores may slightly reduce CVD risk factor levels and may increase preventive medication prescribing in higher-risk people without evidence of harm. There were multiple study limitations in the identified studies and substantial heterogeneity in the interventions, outcomes, and analyses, so readers should interpret results with caution. New models for implementing and evaluating CVD risk scores in adequately powered studies are needed to define the role of applying CVD risk scores in primary CVD prevention.
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Affiliation(s)
- Kunal N Karmali
- Departments of Medicine (Cardiology), Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, USA, 60611
| | - Stephen D Persell
- Department of Medicine-General Internal Medicine and Geriatrics, Northwestern University, 750 N Lake Shore Drive, Rubloff Building 10th Floo, Chicago, Illinois, USA, 60611
| | - Pablo Perel
- Department of Population Health, London School of Hygiene & Tropical Medicine, Room 134b Keppel Street, London, UK, WC1E 7HT
| | - Donald M Lloyd-Jones
- Departments of Preventive Medicine and Medicine (Cardiology), Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, USA, 60611
| | - Mark A Berendsen
- Galter Health Sciences Library, Northwestern University, 303 E. Chicago Avenue, Chicago, IL, USA, 60611
| | - Mark D Huffman
- Departments of Preventive Medicine and Medicine (Cardiology), Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, USA, 60611
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Liddy C, Rowan M, Valiquette-Tessier SC, Drosinis P, Crowe L, Hogg W. Improved Delivery of Cardiovascular Care (IDOCC): Findings from Narrative Reports by Practice Facilitators. Prev Med Rep 2017; 5:214-219. [PMID: 28271017 PMCID: PMC5330620 DOI: 10.1016/j.pmedr.2016.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/10/2016] [Accepted: 12/19/2016] [Indexed: 11/26/2022] Open
Abstract
Practice facilitation can help family physicians adopt
evidence-based guidelines. However, many practices struggle to effectively implement
practice changes that result in meaningful improvement. Building on our previous
research, we examined the barriers to and enablers of implementation perceived by
practice facilitators (PF) in helping practices to adopt the Improved Delivery of
Cardiovascular Care (IDOCC) program, which took place at 84 primary care practices in
Ottawa, Canada between April 2008 and March 2012. We conducted a qualitative analysis
of PFs’ narrative reports using a multiple case study design. We used a combined
purposeful sampling approach to identify cases that 1) reflected experiences typical
of the broader sample and 2) presented sufficient breadth of experience from each
project step and family practice model. Sampling continued until data saturation was
reached. Team members conducted a qualitative analysis of reports using an open and
axial coding style and a constant comparative approach. Barriers and enablers were
divided into five constructs: structural, organizational, provider, patient, and
innovation. Narratives from 13 practice sites were reviewed. A total of 8 barriers
and 11 enablers were consistently identified across practices. Barriers were most
commonly reported at the organizational (n = 3)
and structural level, (n = 2) while enablers were
most common at the innovation level (n = 6).
While physicians responded positively to PFs’ presence and largely supported their
recommendations for practice change, organizational and structural aspects such as
lack of time, minimal staff engagement, and provider reimbursement remained too great
for practices to successfully implement practice-level changes. Trial Registration: ClinicalTrials.gov,
NCT00574808 Eight Barriers and 11 enablers to practice facilitation
emerged across constructs. Barriers were most common at the structural (n = 3) and organizational (n = 2) levels. The majority of enablers occurred at the innovation level
(n = 6). The Chaudoir framework provided a comprehensive picture of
barriers and enablers.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Margo Rowan
- Rowan Research & Evaluation, Ottawa, Ontario, Canada
| | | | - Paul Drosinis
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Lois Crowe
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - William Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
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Cheong AT, Liew SM, Khoo EM, Mohd Zaidi NF, Chinna K. Are interventions to increase the uptake of screening for cardiovascular disease risk factors effective? A systematic review and meta-analysis. BMC FAMILY PRACTICE 2017; 18:4. [PMID: 28095788 PMCID: PMC5240221 DOI: 10.1186/s12875-016-0579-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/26/2016] [Indexed: 11/29/2022]
Abstract
Background Cardiovascular disease (CVD) is the leading cause of death globally. However, many individuals are unaware of their CVD risk factors. The objective of this systematic review is to determine the effectiveness of existing intervention strategies to increase uptake of CVD risk factors screening. Methods A systematic search was conducted through Pubmed, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials. Additional articles were located through cross-checking of the references list and bibliography citations of the included studies and previous review papers. We included intervention studies with controlled or baseline comparison groups that were conducted in primary care practices or the community, targeted at adult populations (randomized controlled trials, non-randomized trials with controlled groups and pre- and post-intervention studies). The interventions were targeted either at individuals, communities, health care professionals or the health-care system. The main outcome of interest was the relative risk (RR) of screening uptake rates due to the intervention. Results We included 21 studies in the meta-analysis. The risk of bias for randomization was low to medium in the randomized controlled trials, except for one, and high in the non-randomized trials. Two analyses were performed; optimistic (using the highest effect sizes) and pessimistic (using the lowest effect sizes). Overall, interventions were shown to increase the uptake of screening for CVD risk factors (RR 1.443; 95% CI 1.264 to 1.648 for pessimistic analysis and RR 1.680; 95% CI 1.420 to 1.988 for optimistic analysis). Effective interventions that increased screening participation included: use of physician reminders (RR ranged between 1.392; 95% CI 1.192 to 1.625, and 1.471; 95% CI 1.304 to 1.660), use of dedicated personnel (RR ranged between 1.510; 95% CI 1.014 to 2.247, and 2.536; 95% CI 1.297 to 4.960) and provision of financial incentives for screening (RR 1.462; 95% CI 1.068 to 2.000). Meta-regression analysis showed that the effect of CVD risk factors screening uptake was not associated with study design, types of population nor types of interventions. Conclusions Interventions using physician reminders, using dedicated personnel to deliver screening, and provision of financial incentives were found to be effective in increasing CVD risk factors screening uptake. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0579-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A T Cheong
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - S M Liew
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - E M Khoo
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - N F Mohd Zaidi
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - K Chinna
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Deri Armstrong C, Taljaard M, Hogg W, Mark AE, Liddy C. Practice facilitation for improving cardiovascular care: secondary evaluation of a stepped wedge cluster randomized controlled trial using population-based administrative data. Trials 2016; 17:434. [PMID: 27596224 PMCID: PMC5011906 DOI: 10.1186/s13063-016-1547-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Practice facilitation (PF), a multifaceted approach in which facilitators (external health care professionals) help family physicians to improve their adoption of best practices, has been highly successful. Improved Delivery of Cardiovascular Care (IDOCC) was an innovative PF trial designed to improve evidence-based care for people who have, or are at risk of, cardiovascular disease (CVD). The intervention was found to be ineffective as assessed by a patient-level composite score based on chart reviews from a subsample of patients (N = 5292). Here, we used population-based administrative data to examine IDOCC's effect on CVD-related hospitalizations. METHODS IDOCC used a pragmatic, stepped wedge cluster randomized controlled design involving primary care providers recruited across Eastern Ontario, Canada. IDOCC's effect on CVD-related hospitalizations was assessed in the 2 years of active intervention and post-intervention years. Marginal and mixed-effects regression analyses were used to account for the study design and to control for patient, physician, and practice characteristics. Secondary and subgroup analyses investigated robustness. RESULTS Our sample included 262,996 patient/year observations representing 54,085 unique patients who had, or were at risk of, CVD, from 70 practices. There was a strong decreasing secular trend in CVD-related hospitalizations but no statistically significant effect of IDOCC. Relative to patients in the control condition, patients in the intervention condition were estimated to have 4 % lower odds of CVD-related hospitalizations (adjOR = 0.96, 99 % CI 0.83 to 1.11). The nonsignificant result persisted across robustness analyses. CONCLUSIONS Clinical outcomes from administrative databases were examined to form a more complete picture of the (in)effectiveness of a large-scale quality improvement intervention. IDOCC did not have a significant effect on CVD hospitalizations, suggesting that the results from the primary composite adherence score analysis were neither due to choice of outcome nor relatively short follow-up period. TRIAL REGISTRATION ClinicalTrials.gov NCT00574808 , registered on 14 December 2007.
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Affiliation(s)
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - William Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Amy E Mark
- Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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Esserman D, Allore HG, Travison TG. The Method of Randomization for Cluster-Randomized Trials: Challenges of Including Patients with Multiple Chronic Conditions. ACTA ACUST UNITED AC 2016; 5:2-7. [PMID: 27478520 PMCID: PMC4963011 DOI: 10.6000/1929-6029.2016.05.01.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cluster-randomized clinical trials (CRT) are trials in which the unit of randomization is not a participant but a group (e.g. healthcare systems or community centers). They are suitable when the intervention applies naturally to the cluster (e.g. healthcare policy); when lack of independence among participants may occur (e.g. nursing home hygiene); or when it is most ethical to apply an intervention to all within a group (e.g. school-level immunization). Because participants in the same cluster receive the same intervention, CRT may approximate clinical practice, and may produce generalizable findings. However, when not properly designed or interpreted, CRT may induce biased results. CRT designs have features that add complexity to statistical estimation and inference. Chief among these is the cluster-level correlation in response measurements induced by the randomization. A critical consideration is the experimental unit of inference; often it is desirable to consider intervention effects at the level of the individual rather than the cluster. Finally, given that the number of clusters available may be limited, simple forms of randomization may not achieve balance between intervention and control arms at either the cluster- or participant-level. In non-clustered clinical trials, balance of key factors may be easier to achieve because the sample can be homogenous by exclusion of participants with multiple chronic conditions (MCC). CRTs, which are often pragmatic, may eschew such restrictions. Failure to account for imbalance may induce bias and reducing validity. This article focuses on the complexities of randomization in the design of CRTs, such as the inclusion of patients with MCC, and imbalances in covariate factors across clusters.
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Affiliation(s)
- Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Heather G Allore
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Thomas G Travison
- Department of Medicine, Harvard Medical School, Cambridge, Massachusetts, USA; Hebrew SeniorLife Institute for Aging Research, Roslindale, Massachusetts, USA
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