Studying de-implementation in health: an analysis of funded research grants

Low-value health care, de-implementation, and implications for nursing research: A discussion paper

Globally, the nursing profession constitutes the largest proportion of the health workforce; however, it is challenged by widespread workforce shortages relative to need. Strategies to promote recruitment of the nursing workforce are well-established, with a lesser focus on strategies to alleviate the burden on the existing workforce. This burden may be exacerbated by the impact of low-value health care, characterised as health care that provides little or no benefit for patients, or has the potential to cause harm. Low-value health care is a global problem, a major contributor to the waste of healthcare resources, and a key focus of health system reform. Evidence of variation in low-value health care has been identified across countries and system levels. Research on low-value health care has largely focused on the medical profession, with a paucity of research examining either low-value health care or the de-implementation of low-value health care from a nursing perspective. The objective of this paper is to provide a scholarly discussion of the literature around low-value health care and de-implementation, with the purpose of identifying implications for nursing research. With increasing pressures on the global nursing workforce, research identifying low-value health care and developing approaches to de-implement this care, is crucial.

Navigating the field of implementation science towards maturity: challenges and opportunities

BACKGROUND

The field of implementation science has significantly expanded in size and scope over the past two decades, although work related to understanding implementation processes have of course long preceded the more systematic efforts to improve integration of evidence-based interventions into practice settings. While this growth has had significant benefits to research, practice, and policy, there are some clear challenges that this period of adolescence has uncovered.

MAIN BODY

This invited commentary reflects on the development of implementation science, its rapid growth, and milestones in its establishment as a viable component of the biomedical research enterprise. The authors reflect on progress in research and training, and then unpack some of the consequences of rapid growth, as the field has grappled with the competing challenges of legitimacy among the research community set against the necessary integration and engagement with practice and policy partners. The article then enumerates a set of principles for the field's next developmental stage and espouses the aspirational goal of a "big tent" to support the next generation of impactful science.

CONCLUSION

For implementation science to expand its relevance and impact to practice and policy, researchers must not lose sight of the original purpose of the field-to support improvements in health and health care at scale, the importance of building a community of research and practice among key partners, and the balance of rigor, relevance, and societal benefit.

Testing Theory-Based Messages to Encourage Women at Average Risk for Breast Cancer to Consider Biennial Mammography Screening

BACKGROUND

The US Preventive Services Task Force does not recommend routine annual mammography screening for women aged 40-49 at average risk. Little research has been done to develop theory-based communication interventions to facilitate informed decision-making about reducing potentially low-value mammography screening.

PURPOSE

Evaluate the effects of theory-based persuasive messages on women's willingness to consider delaying screening mammography until age 50 or have mammograms biennially.

METHODS

We conducted a randomized controlled communication experiment online with a population-based sample of U.S. women aged 40-49 (N = 383) who screened to be at average risk for breast cancer. Women were randomly assigned to the following messaging summaries: annual mammography risks in 40s (Arm 1, n = 124), mammography risks plus family history-based genetic risk (Arm 2, n = 120), and mammography risks, genetic risk, and behavioral alternatives (Arm 3, n = 139). Willingness to delay screening or reduce screening frequency was assessed post-experiment by a set of 5-point Likert scale items.

RESULTS

Women in Arm 3 reported significantly greater willingness to delay screening mammography until age 50 (mean = 0.23, SD = 1.26) compared with those in Arm 1 (mean = -0.17, SD = 1.20; p = .04). There were no significant arm differences in willingness to reduce screening frequency. Exposure to the communication messages significantly shifted women's breast cancer-related risk perceptions without increasing unwarranted cancer worry across all three arms.

CONCLUSIONS

Providing women with screening information and options may help initiate challenging discussions with providers about potentially low-value screening.

Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial

BACKGROUND

While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care.

METHODS

We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios.

DISCUSSION

On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm.

TRIAL REGISTRATION

This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).

Mapping European Association of Urology Guideline Practice Across Europe: An Audit of Androgen Deprivation Therapy Use Before Prostate Cancer Surgery in 6598 Cases in 187 Hospitals Across 31 European Countries

BACKGROUND

Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation "Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer" was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available.

OBJECTIVE

To assess current ADT use before prostate cancer surgery in Europe.

DESIGN, SETTING, AND PARTICIPANTS

This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence.

RESULTS AND LIMITATIONS

We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0-32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0-43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated.

CONCLUSIONS

EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued.

PATIENT SUMMARY

Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.

Beyond implementation: Uncovering the parallels between de-implementation and antimicrobial stewardship

De-implementation is defined as the process of discontinuing, removing, reducing, or replacing a harmful, ineffective, or low-value clinical practice or intervention. The goal of de-implementation strategies is to minimize patient harm, maximize use of resources, and reduce healthcare costs and inequities. Both antibiotic and diagnostic stewardship programs focus on reducing low-value interventions (tests or antimicrobials). Stewardship interventions commonly involve de-implementation and deprescribing strategies. This commentary explores unique aspects of deimplementing low-value testing and unnecessary antimicrobial use, similarities between de-implementation and stewardship approaches, multilevel factors that impact de-implementation, and opportunities for future research.

National Cancer Institute-Funded Social Risk Research in Cancer Care Delivery: Opportunities for Future Research

BACKGROUND

Cancer patients and survivors with food insecurity, housing instability, and transportation-related barriers face challenges in access and utilization of quality cancer care thereby adversely impacting their health outcomes. This portfolio analysis synthesized and described National Cancer Institute (NCI)-supported social risk research focused on assessing food insecurity, housing instability, and transportation-related barriers among individuals diagnosed with cancer.

METHODS

We conducted a query using the National Institutes of Health iSearch tool to identify NCI-awarded extramural research and training grants (2010-2022). Grant abstracts, specific aims, and research strategies were coded for research characteristics, study population, and outcomes.

RESULTS

Of the 30 grants included in this analysis, most assessed transportation-related barriers as patient-level social needs. Grants focused on community-level social risks, food insecurity, and housing instability were largely absent. Most grants included activities that identified the presence of social risks and/or needs (n = 24), connected patients to social care resources (n = 10), and engaged community members or organizations to inform the research study (n = 9). Of the grants, 18 focused on a single type of cancer, primarily breast cancer, and more than half focused on the treatment and survivorship phases.

CONCLUSIONS

In the last decade, there has been limited NCI-funded social risk research grants focused on food insecurity and housing instability. Findings highlight opportunities for future cancer care delivery research, including community and health system-level approaches that integrate social and clinical care to address social risks and social needs. Such efforts can help improve outcomes of populations that experience cancer health and health-care disparities.

De-Implementation of Detrimental Feeding Practices in Childcare: Mixed Methods Evaluation of Community Partner Selected Strategies

This pilot evaluated strategies to decrease detrimental feeding practices in early care and education, which are hypothesized to compete with evidence-based feeding and obesity prevention practices. This study made two key comparisons: (1) a between-site comparison of sites receiving (a) no implementation or de-implementation strategies (i.e., Basic Support; B), (b) implementation strategies only (i.e., Enhanced Support; E), and (c) implementation and de-implementation strategies (i.e., De-implementation + Enhanced Support; D + E) and (2) a within-site pre-post comparison among sites with D + E. At nutrition lessons, the D + E group had more Positive Comments (Hedege’s g = 0.60) and higher Role Model fidelity (Hedege’s g = 1.34) compared to the E group. At meals, assistant teachers in the D + E group had higher Positive Comments than in the B group (g = 0.72). For within-group comparisons, the D + E group decreased Negative Comments (t(19) = 2.842, p = 0.01), increased Positive Comments (t(20) = 2.314, p = 0.031), and improved use of the program mascot at nutrition lessons (t(21) = 3.899, p = 0.001). At meals, lead teachers’ Negative Comments decreased (t(22) = 2.73, p = 0.01). Qualitative data identified strengths and opportunities for iteration. Despite a COVID interruption, mid-point comparisons and qualitative feedback suggest promise of the de-implementation strategy package.

FAST: A Framework to Assess Speed of Translation of Health Innovations to Practice and Policy

The 17-year time span between discovery and application of evidence in practice has become a unifying challenge for implementation science and translational science more broadly. Further, global pandemics and social crises demand timely implementation of rapidly accruing evidence to reduce morbidity and mortality. Yet speed remains an understudied metric in implementation science. Prevailing evaluations of implementation lack a temporal aspect, and current approaches have not yielded rapid implementation. In this paper, we address speed as an important conceptual and methodological gap in implementation science. We aim to untangle the complexities of studying implementation speed, offer a framework to assess speed of translation (FAST), and provide guidance to measure speed in evaluating implementation. To facilitate specification and reporting on metrics of speed, we encourage consideration of stakeholder perspectives (e.g., comparison of varying priorities), referents (e.g., speed in attaining outcomes, transitioning between implementation phases), and observation windows (e.g., time from intervention development to first patient treated) in its measurement. The FAST framework identifies factors that may influence speed of implementation and potential effects of implementation speed. We propose a research agenda to advance understanding of the pace of implementation, including identifying accelerators and inhibitors to speed.

Testing Function Focused Care for Acute Care using the Evidence Integration Triangle: Protocol description

This manuscript provides the protocol for a National Institute of Aging-funded cluster randomized clinical trial that focuses on helping nurses in acute care to engage patients with dementia in physical activity while hospitalized using an approach referred to as function-focused care. Physical activity is defined as bodily movement produced by skeletal muscles resulting in the expenditure of energy and includes functional tasks such as bathing and dressing, leisure activity, ambulation, and moderate and vigorous intensity physical activity such as dancing, bike riding, or walking upstairs. The development of Function Focused Care for Acute Care (FFC-AC) was based on the Social Ecological Model and Social Cognitive Theory and includes four steps: (1) Environment and Policy Assessments; (2) Education; (3) Establishing Patient Goals; and (4) Mentoring and Motivating of Staff (all levels of nursing staff), Patients, and Families. Function-focused care activities include motivating older patients to participate in bed mobility; personal care activities such as bathing, dressing, ambulating as they are able; and other types of physical activities. The integration of the intervention among the nurses on the units is guided by the Evidence Integration Triangle (EIT), which includes the participation of a stakeholder team and practical outcome measures. The intervention is therefore referred to as FFC-AC-EIT. In addition to describing the protocol developed to test the effectiveness and feasibility of FFC-AC-EIT, a description of ways to overcome some of the barriers and challenges that can be encountered with this study is provided.

Choosing Wisely: An idea worth sustaining

OBJECTIVES

To evaluate the sustainability potential of Choosing Wisely (CW) to address unnecessary medical care at Ontario community hospitals.

DATA SOURCES/STUDY SETTING

Ontario community hospitals and their affiliated family health teams (FHTs).

STUDY DESIGN

A mixed-methods study involving the administration of a validated sustainability survey to CW implementation teams followed by their participation in focus groups.

DATA COLLECTION/EXTRACTION METHODS

Survey data were collected using an Excel file with an embedded, automated scoring system. We collated individual survey scores and generated aggregate team scores. We also performed descriptive statistics for quantitative data (frequencies, means). Qualitative data were triangulated with quantitative assessments to support data interpretations using the meta-matrix method.

PRINCIPAL FINDINGS

Fifteen CW implementation teams across four Ontario community hospitals and six affiliated primary care FHTs participated. CW priority areas investigated were de-prescribing of proton pump inhibitors (PPIs) and reducing Pre-Op testing and BUN/Urea lab testing. Survey results showed steady improvements in sustainability scores from baseline to final follow-up among most implementation teams: 10% increase for PPI de-prescribing (six FHTs) and 2% increase (three hospital teams); 18% increase in BUN/Urea lab testing (three hospital teams). Regardless of site or CW priority area, common facilitators were fit with existing processes and workflows, leadership support, and optimized team communication; common challenges were lack of awareness and buy-in, leadership engagement or a champion, and lack of fit with existing workflow and culture. All teams identified at least one challenge for which they co-designed and implemented a plan to maximize the sustainability potential of their CW initiative.

CONCLUSIONS

Evaluating the sustainability potential of an innovation such as Choosing Wisely is critical to ensuring that they have the best potential for impact. Our work highlights that implementation teams can be empowered to influence implementation efforts and to realize positive outcomes for their health care services and patients.

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

BACKGROUND

Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.

METHODS

We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).

DISCUSSION

De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05020418.

"It's good to feel like you're doing something": a qualitative study examining state health department employees' views on why ineffective programs continue to be implemented in the USA

Background

Mis-implementation, the inappropriate continuation of programs or policies that are not evidence-based or the inappropriate termination of evidence-based programs and policies, can lead to the inefficient use of scarce resources in public health agencies and decrease the ability of these agencies to deliver effective programs and improve population health. Little is known about why mis-implementation occurs, which is needed to understand how to address it. This study sought to understand the state health department practitioners’ perspectives about what makes programs ineffective and the reasons why ineffective programs continue.

Methods

Eight state health departments (SHDs) were selected to participate in telephone-administered qualitative interviews about decision-making around ending or continuing programs. States were selected based on geographic representation and on their level of mis-implementation (low and high) categorized from our previous national survey. Forty-four SHD chronic disease staff participated in interviews, which were audio-recorded and transcribed verbatim. Transcripts were consensus coded, and themes were identified and summarized. This paper presents two sets of themes, related to (1) what makes a program ineffective and (2) why ineffective programs continue to be implemented according to SHD staff.

Results

Participants considered programs ineffective if they were not evidence-based or if they did not fit well within the population; could not be implemented well due to program restraints or a lack of staff time and resources; did not reach those who could most benefit from the program; or did not show the expected program outcomes through evaluation. Practitioners described several reasons why ineffective programs continued to be implemented, including concerns about damaging the relationships with partner organizations, the presence of program champions, agency capacity, and funding restrictions.

Conclusions

The continued implementation of ineffective programs occurs due to a number of interrelated organizational, relational, human resources, and economic factors. Efforts should focus on preventing mis-implementation since it limits public health agencies’ ability to conduct evidence-based public health, implement evidence-based programs effectively, and reduce the high burden of chronic diseases. The use of evidence-based decision-making in public health agencies and supporting adaptation of programs to improve their fit may prevent mis-implementation. Future work should identify effective strategies to reduce mis-implementation, which can optimize public health practice and improve population health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00252-4.

A scoping review of de-implementation frameworks and models

BACKGROUND

Reduction or elimination of inappropriate, ineffective, or potentially harmful healthcare services and public health programs can help to ensure limited resources are used effectively. Frameworks and models (FM) are valuable tools in conceptualizing and guiding the study of de-implementation. This scoping review sought to identify and characterize FM that can be used to study de-implementation as a phenomenon and identify gaps in the literature to inform future model development and application for research.

METHODS

We searched nine databases and eleven journals from a broad array of disciplines (e.g., healthcare, public health, public policy) for de-implementation studies published between 1990 and June 2020. Two raters independently screened titles and abstracts, and then a pair of raters screened all full text records. We extracted information related to setting, discipline, study design, methodology, and FM characteristics from included studies.

RESULTS

The final search yielded 1860 records, from which we screened 126 full text records. We extracted data from 27 articles containing 27 unique FM. Most FM (n = 21) were applicable to two or more levels of the Socio-Ecological Framework, and most commonly assessed constructs were at the organization level (n = 18). Most FM (n = 18) depicted a linear relationship between constructs, few depicted a more complex structure, such as a nested or cyclical relationship. Thirteen studies applied FM in empirical investigations of de-implementation, while 14 articles were commentary or review papers that included FM.

CONCLUSION

De-implementation is a process studied in a broad array of disciplines, yet implementation science has thus far been limited in the integration of learnings from other fields. This review offers an overview of visual representations of FM that implementation researchers and practitioners can use to inform their work. Additional work is needed to test and refine existing FM and to determine the extent to which FM developed in one setting or for a particular topic can be applied to other contexts. Given the extensive availability of FM in implementation science, we suggest researchers build from existing FM rather than recreating novel FM.

REGISTRATION

Not registered.

Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer

BACKGROUND

Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel's Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development.

METHODS

We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices.

RESULTS

Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT.

CONCLUSIONS

Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03579680.

A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

BACKGROUND

There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse.

METHODS

This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process.

RESULTS

Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening.

CONCLUSIONS

Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

De-implementing and sustaining an intervention to eliminate nursing home resident bed and chair alarms: interviews on leadership and staff perspectives

Background

Improving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation. We know little about de-implementation in this setting. Relatively recent policy changes reclassified resident position-change (bed and chair) alarms, which monitor resident movement, as restraints. This created an optimal environment in which to study impressions of an alarm de-implementation and sustainment intervention.

Methods

This cross-sectional interview study focused on understanding participants’ experience of a quality improvement program in the Department of Veterans Affairs Community Living Centers (nursing homes). The program’s goal was to improve resident outcomes and staff communication and teamwork through, among other foci, eliminating resident position-change alarms. The Community Living Centers were located in geographically dispersed areas of the continental United States. Interview participants were leadership and staff members from seven Community Living Centers. We conducted in-depth, semi-structured qualitative interviews using a convenience sample and used a thematic analytic approach.

Results

We conducted seventeen interviews. We identified five main themes: Initiating De-implementation (compelling participants with evidence, engaging local leadership, and site-level education and training), Changing Expectations (educating staff and family members), Using Contrasting Approaches (gradual or abrupt elimination of alarms), Witnessing Positive Effects of De-implementation (reduction in resident falls, improved resident sleep, reduction in distressing behaviors, and increased resident engagement), and Staying the Course (sustainment of the initiative).

Conclusions

Findings highlight how participants overcame barriers and successfully eliminated resident position-change alarms and sustained the de-implementation through using convincing evidence for the initiative, local leadership involvement and support, and staff and family member education and engagement. These findings and the resulting three-phase process to support nursing homes' de-implementation efforts expand the de-implementation science knowledge base and provide a promising framework for other nursing home-based de-implementation initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00195-w.

Approaches for Ending Ineffective Programs: Strategies From State Public Health Practitioners

Background: Public health agencies are increasingly concerned with ensuring they are maximizing limited resources by delivering evidence-based programs to enhance population-level chronic disease outcomes. Yet, there is little guidance on how to end ineffective programs that continue in communities. The purpose of this analysis is to identify what strategies public health practitioners perceive to be effective in de-implementing, or reducing the use of, ineffective programs. Methods: From March to July 2019, eight states were selected to participate in qualitative interviews from our previous national survey of US state health department (SHD) chronic disease practitioners on program decision making. This analysis examined responses to a question about "…advice for others who want to end an ineffective program." Forty-five SHD employees were interviewed via phone. Interviews were audio-recorded, and the conversations were transcribed verbatim. All transcripts were consensus coded, and themes were identified and summarized. Results: Participants were program managers or section directors who had on average worked 11 years at their agency and 15 years in public health. SHD employees provided several strategies they perceived as effective for de-implementation. The major themes were: (1) collect and rely on evaluation data; (2) consider if any of the programs can be saved; (3) transparently communicate and discuss program adjustments; (4) be tactful and respectful of partner relationships; (5) communicate in a way that is meaningful to your audience. Conclusions: This analysis provides insight into how experienced SHD practitioners recommend ending ineffective programs which may be useful for others working at public health agencies. As de-implementation research is limited in public health settings, this work provides a guiding point for future researchers to systematically assess these strategies and their effects on public health programming.

Future directions for implementation science at the National Cancer Institute: Implementation Science Centers in Cancer Control

The National Cancer Institute (NCI) Cancer Moonshot initiative seeks to accelerate cancer research for the USA. One of the scientific priorities identified by the Moonshot's Blue Ribbon Panel (BRP) of scientific experts was the implementation of evidence-based approaches. In September 2019, the NCI launched the Implementation Science Centers in Cancer Control (ISC3 or "Centers") initiative to advance this Moonshot priority. The vision of the ISC3 is to promote the development of research centers to build capacity and research in high-priority areas of cancer control implementation science (e.g., scale-up and spread, sustainability and adaptation, and precision implementation), build implementation laboratories within community and clinical settings, improve the state of measurement and methods, and improve the adoption, implementation, and sustainment of evidence-based cancer control interventions. This paper highlights the research agenda, vision, and strategic direction for these Centers and encourages transdisciplinary scientists to learn more about opportunities to collaborate with these Centers.

De-implementing low-value care in endocrinology

Low-value care exposes patients to ineffective, costly, and potentially harmful care. In endocrinology, low-value care practices are common in the care of patients with highly prevalent conditions. There is an urgent need to move past the identification of these practices to an active process of de-implementation. However, clinicians, researchers, and other stakeholders might lack familiarity with the frameworks and processes that can help guide successful de-implementation. To address this gap and support the de-implementation of low-value care, we provide a summary of low-value care practices in endocrinology and a primer on the fundamentals of de-implementation science. Our goal is to increase awareness of low-value care within endocrinology and suggest a path forward for addressing low-value care using principles of de-implementation science.

Identifying Low Value Malnutrition Care Activities for De-Implementation and Systematised, Interdisciplinary Alternatives-A Multi-Site, Nominal Group Technique Approach

Malnutrition risk is identified in over one-third of inpatients; reliance on dietetics-delivered nutrition care for all “at-risk” patients is unsustainable, inefficient, and ineffective. This study aimed to identify and prioritise low-value malnutrition care activities for de-implementation and articulate systematised interdisciplinary opportunities. Nine workshops, at eight purposively sampled hospitals, were undertaken using the nominal group technique. Participants were asked “What highly individualised malnutrition care activities do you think we could replace with systematised, interdisciplinary malnutrition care?” and “What systematised, interdisciplinary opportunities do you think we should do to provide more effective and efficient nutrition care in our ward/hospital?” Sixty-three participants were provided five votes per question. The most voted de-implementation activities were low-value nutrition reviews (32); education by dietitian (28); assessments by dietitian for patients with malnutrition screening tool score of two (22); assistants duplicating malnutrition screening (19); and comprehensive, individualised nutrition assessments where unlikely to add value (15). The top voted alternative opportunities were delegated/skill shared interventions (55), delegated/skill shared education (24), abbreviated malnutrition care processes where clinically appropriate (23), delegated/skill shared supportive food/fluids (14), and mealtime assistance (13). Findings highlight opportunities to de-implement perceived low-value malnutrition care activities and replace them with systems and skill shared alternatives across hospital settings.

Feasibility of a pharmacy-led intervention to de-implement non-guideline-concordant proton pump inhibitor use

Background

Proton pump inhibitors (PPIs) are among the most prescribed medications and are often used unnecessarily. PPIs are used for the treatment of heartburn and acid-related disorders. Emerging evidence indicates that PPIs are associated with serious adverse events, such as increased risk of Clostridioides difficile infection. In this study, we designed and piloted a PPI de-implementation intervention among hospitalized non-intensive care unit patients.

Methods

Using the Systems Engineering Initiative for Patient Safety (SEIPS) model as the framework, we developed an intervention with input from providers and patients. On a bi-weekly basis, a trainee pharmacist reviewed a random sample of eligible patients’ charts to assess if PPI prescriptions were guideline-concordant; a recommendation to de-implement non-guideline-concordant PPI therapy was sent when applicable. We used convergent parallel mixed-methods design to evaluate the feasibility and outcomes of the intervention.

Results

During the study period (September 2019 to August 2020), 2171 patients with an active PPI prescription were admitted. We randomly selected 155 patient charts for review. The mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥5 years. The average time (minutes) needed to complete the intervention was as follows: 5 to assess if the PPI was guideline-concordant, 5 to provide patient education, and 7 to follow-up with patients post-discharge. After intervention initiation, the week-to-week mean number of PPI prescriptions decreased by 0.5 (S<0.0001). Barriers and facilitators spanned the 5 elements of the SEIPS model and included factors such as providers’ perception that PPIs are low priority medications and patients’ willingness to make changes to their PPI therapy if needed, respectively. Ready access to pharmacists was another frequently reported facilitator to guideline-concordant PPI. Providers recommended a PPI de-implementation intervention that is specific and tells them exactly what they need to do with a PPI treatment.

Conclusion

In a busy inpatient setting, we developed a feasible way to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess any unintended consequences. We documented barriers, facilitators, and provider recommendations that should be considered before implementing such an intervention on a large scale.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00161-6.

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration

IMPORTANCE

The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.

OBJECTIVE

To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.

EXPOSURES

A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.

MAIN OUTCOMES AND MEASURES

Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).

RESULTS

A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.

CONCLUSIONS AND RELEVANCE

Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

An Overview of Research Opportunities to Increase the Impact of Nutrition Intervention Research in Early Childhood and Education Care Settings According to the RE-AIM Framework

Objective: To highlight opportunities for future nutrition intervention research within early childhood and education care (ECEC) settings, with a focus on generating evidence that has applicability to real-world policy and practice. Methods: An overview of opportunities to progress the field was developed by the authors using a collaborative writing approach and informed by recent research in the field. The group developed a list of recommendations aligned with the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Pairs of authors drafted individual sections of the manuscript, which were then reviewed by a separate pair. The first and senior author consolidated all sections of the manuscript and sought critical input on the draft iterations of the manuscript. Results: Interventions that employ digital platforms (reach) in ECEC settings, as well as research in the family day care setting (effectiveness) were identified as areas of opportunities. Research understanding the determinants of and effective strategies for dissemination (adoption), the implementation of nutrition programs, in addition to de-implementation (implementation) of inappropriate nutrition practices, is warranted. For maintenance, there is a need to better understand sustainability and the sustainment of interventions, in addition to undertaking policy-relevant research. Conclusions: The ECEC setting is prime for innovative and practical nutrition intervention research.

Current state of funded National Institutes of Health grants focused on individuals living with advanced and metastatic cancers: a portfolio analysis

PURPOSE

The National Cancer Institute has supported cancer survivorship science for many years, yet few funded studies have examined the needs of individuals living with cancer that is advanced or has metastasized. This report analyzes currently active National Institutes of Health (NIH) grants focused on survivorship for patients living with advanced or metastatic cancers to identify emerging research topics in this population and gaps in current science.

METHODS

A search of all NIH research grants that received funding in Fiscal Year 2020 focused on this population was conducted, excluding grants with a primary focus on end-of-life care, tumor progression or staging and grants for which the only outcome was survival.

RESULTS

A total of 25 active grants met the inclusion criteria. Most were funded using the R01 grant mechanism and included a range of cancer types and topics such as palliative/supportive care, psychosocial support, health services, and symptom sequelae.

CONCLUSIONS

Although currently funded grants focus on several important topics, gaps in the portfolio remain. There is a need to enhance the grant portfolio of research studies focused on the longitudinal examination of unmet needs, models of care delivery, impact of innovative therapies, and the impact of financial hardship for individuals living with advanced or metastatic cancer.

IMPLICATIONS FOR CANCER SURVIVORS

This review of current NIH studies suggests a need for expanded research on individuals living with advanced or metastatic cancer. Moving forward, enhancing research focused on key gap areas will be critical to improve care and outcomes for this growing population.

Prognostic models will be victims of their own success, unless…

Predictive analytics have begun to change the workflows of healthcare by giving insight into our future health. Deploying prognostic models into clinical workflows should change behavior and motivate interventions that affect outcomes. As users respond to model predictions, downstream characteristics of the data, including the distribution of the outcome, may change. The ever-changing nature of healthcare necessitates maintenance of prognostic models to ensure their longevity. The more effective a model and intervention(s) are at improving outcomes, the faster a model will appear to degrade. Improving outcomes can disrupt the association between the model's predictors and the outcome. Model refitting may not always be the most effective response to these challenges. These problems will need to be mitigated by systematically incorporating interventions into prognostic models and by maintaining robust performance surveillance of models in clinical use. Holistically modeling the outcome and intervention(s) can lead to resilience to future compromises in performance.

Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis

Background

Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.

Objectives

Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.

Design

A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.

Participants

In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.

Data sources

Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.

Results

The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.

Limitations

Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.

Conclusions

This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.

Study registration

This study is registered as PROSPERO CRD42017081030.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

Patterns and correlates of mis-implementation in state chronic disease public health practice in the United States

BACKGROUND

Much of the disease burden in the United States is preventable through application of existing knowledge. State-level public health practitioners are in ideal positions to affect programs and policies related to chronic disease, but the extent to which mis-implementation occurring with these programs is largely unknown. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones.

METHODS

A 2018 comprehensive survey assessing the extent of mis-implementation and multi-level influences on mis-implementation was reported by state health departments (SHDs). Questions were developed from previous literature. Surveys were emailed to randomly selected SHD employees across the Unites States. Spearman's correlation and multinomial logistic regression were used to assess factors in mis-implementation.

RESULTS

Half (50.7%) of respondents were chronic disease program managers or unit directors. Forty nine percent reported that programs their SHD oversees sometimes, often or always continued ineffective programs. Over 50% also reported that their SHD sometimes or often ended effective programs. The data suggest the strongest correlates and predictors of mis-implementation were at the organizational level. For example, the number of organizational layers impeded decision-making was significant for both continuing ineffective programs (OR=4.70; 95% CI=2.20, 10.04) and ending effective programs (OR=3.23; 95% CI=1.61, 7.40).

CONCLUSION

The data suggest that changing certain agency practices may help in minimizing the occurrence of mis-implementation. Further research should focus on adding context to these issues and helping agencies engage in appropriate decision-making. Greater attention to mis-implementation should lead to greater use of effective interventions and more efficient expenditure of resources, ultimately to improve health outcomes.

Better Service by Doing Less: Introducing De-implementation Research in HIV

The course of HIV research has led to a multitude of interventions to prevent and treat HIV. With the arrival of more effective interventions comes the need to end, or de-implement, less effective interventions. PURPOSE OF REVIEW: To describe the state of de-implementation research in HIV and provide a rationale for expanded research in this area. RECENT FINDINGS: Existing studies have identified a set of HIV-specific interventions appropriate for de-implementing and described the persistence of interventions that should be ended. However, to our knowledge, strategies to successfully promote appropriate de-implementation of HIV-specific interventions have not been examined. De-implementing interventions that are no longer needed is an opportunity to improve the quality and effectiveness of HIV services. Opportunities to expand this field of research abound.

Rugged landscapes: complexity and implementation science

BACKGROUND

Mis-implementation-defined as failure to successfully implement and continue evidence-based programs-is widespread in public health practice. Yet the causes of this phenomenon are poorly understood.

METHODS

We develop an agent-based computational model to explore how complexity hinders effective implementation. The model is adapted from the evolutionary biology literature and incorporates three distinct complexities faced in public health practice: dimensionality, ruggedness, and context-specificity. Agents in the model attempt to solve problems using one of three approaches-Plan-Do-Study-Act (PDSA), evidence-based interventions (EBIs), and evidence-based decision-making (EBDM).

RESULTS

The model demonstrates that the most effective approach to implementation and quality improvement depends on the underlying nature of the problem. Rugged problems are best approached with a combination of PDSA and EBI. Context-specific problems are best approached with EBDM.

CONCLUSIONS

The model's results emphasize the importance of adapting one's approach to the characteristics of the problem at hand. Evidence-based decision-making (EBDM), which combines evidence from multiple independent sources with on-the-ground local knowledge, is a particularly potent strategy for implementation and quality improvement.

Implementation science and periodontal practice: Translation of evidence into periodontology

The advent of evidence-based practice in the 1990s led to the development of processes and resources to support the use of high-quality research in the provision of health care. As the evidence-based approach to health care continues to evolve, it has become apparent that mere creation and access to scientific knowledge is not sufficient to facilitate its routine adoption in health care. Throughout any health care system, there are inherent barriers preventing the adoption and routine use of new evidence in patient care. These barriers include provider-level factors, such as knowledge and access to new evidence, as well as each provider's attitudes and beliefs around adopting and applying the evidence with their patients. Importantly, there are also health care system-level barriers that, even among willing providers, prevent the easy adoption of new evidence and routine application in patient care. In addition to barriers, there are facilitators that help promote adoption of evidence into practice. Understanding and addressing barriers and facilitators to promote adoption of evidence into practice has led to the growth of a new field known as implementation science. Successful application of implementation science in all areas of health care, including periodontology, will help bridge the gap between what are known from clinical research to be effective treatments and what treatments should be applied routinely in clinical practice. This article reviews key concepts in implementation science and how its application in periodontology can facilitate the translation of high-quality evidence into routine periodontal practice and improved patient outcomes.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

BACKGROUND AND OBJECTIVES

International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics.

METHODS

We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR).

RESULTS

In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently.

CONCLUSIONS

The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Iterative Decision-making for Evaluation of Adaptations (IDEA): A decision tree for balancing adaptation, fidelity, and intervention impact

BACKGROUND

Evidence-based practices (EBPs) are frequently adapted to maximize outcomes while maintaining fidelity to core EBP elements. Many step-by-step frameworks for adapting EBPs have been developed, but these models may not account for common complexities in the adaptation process. In this paper, we introduce the Iterative Decision-making for Evaluation of Adaptations (IDEA), a tool to guide adaptations that addresses these issues.

FRAMEWORK DESIGN AND USE

Adapting EBPs requires attending to key contingencies incorporated into the IDEA, including: the need for adaptations; fidelity to core EBP elements; the timeframe in which to make adaptations; the potential to collect pilot data; key clinical and implementation outcomes; and stakeholder viewpoints. We use two examples to illustrate application of the IDEA.

CONCLUSIONS

The IDEA is a practical tool to guide EBP adaptation that incorporates important decision points and the dynamism of ongoing adaptation. Its use may help implementation scientists, clinicians, and administrators maximize EBP impact.

The increasing value of eHealth in the delivery of patient-centred cancer care

The increasing use of eHealth has ushered in a new era of patient-centred cancer care that moves beyond the traditional in-person care model to real-time, dynamic, and technology-assisted assessments and interventions. eHealth has the potential to better the delivery of cancer care through improved patient-provider communication, enhanced symptom and toxicity assessment and management, and optimised patient engagement across the cancer care continuum. In this Review, we provide a brief, narrative appraisal of the peer reviewed literature over the past 10 years related to the uses of patient-centred eHealth to improve cancer care delivery. These uses include the addressal of symptom management, health-related quality of life, and other patient-reported outcomes across cancer care. In addition, we discuss the challenges of, and opportunities for, accessibility, scalability, and implementation of these technologies, important areas for further development, and future research directions.

Defining and conceptualizing outcomes for de-implementation: key distinctions from implementation outcomes

BACKGROUND

Increasingly, scholars argue that de-implementation is a distinct concept from implementation; factors contributing to stopping a current practice might be distinct from those that encourage adoption of a new one. One such distinction is related to de-implementation outcomes. We offer preliminary analysis and guidance on de-implementation outcomes, including how they may differ from or overlap with implementation outcomes, how they may be conceptualized and measured, and how they could be measured in different settings such as clinical care vs. community programs.

CONCEPTUALIZATION OF OUTCOMES

We conceptualize each of the outcomes from Proctor and colleagues' taxonomy of implementation outcomes for de-implementation research. First, we suggest key considerations for researchers assessing de-implementation outcomes, such as considering how the cultural or historical significance to the practice may impact de-implementation success and, as others have stated, the importance of the patient in driving healthcare overuse. Second, we conceptualize de-implementation outcomes, paying attention to a number of factors such as the importance of measuring outcomes not only of the targeted practice but of the de-implementation process as well. Also, the degree to which a practice should be de-implemented must be distinguished, as well as if there are thresholds that certain outcomes must reach before action is taken. We include a number of examples across all outcomes, both from clinical and community settings, to demonstrate the importance of these considerations. We also discuss how the concepts of health disparities, cultural or community relevance, and altruism impact the assessment of de-implementation outcomes.

CONCLUSION

We conceptualized existing implementation outcomes within the context of de-implementation, noted where there are similarities and differences to implementation research, and recommended a clear distinction between the target for de-implementation and the strategies used to promote de-implementation. This critical analysis can serve as a building block for others working to understand de-implementation processes and de-implement practices in real-world settings.

Civic engagement and mental health system strengthening in Indonesia: a qualitative examination of the views of health professionals and national key stakeholders

BACKGROUND

Mental health services in Indonesia are developing rapidly in response to national and global health policy to support people living with psychosis. This presents a unique opportunity for civic engagement, the active involvement of patients, carers and communities in mental health care, to shape emergent services. In-depth explorations of the views of professionals and other key stakeholders in mental health care on the use of civic engagement in Indonesia are lacking which contributes to a limited understanding of its potential in this regard. The study aimed to explore contemporary professionals' and other key stakeholders' perspectives on the current use of and potential for civic engagement to strengthen mental health systems in Indonesia.

METHODS

Qualitative interviews were undertaken and analysed using thematic analysis underpinned by a critical realist approach. Eighteen multi-disciplinary professionals and lay health workers involved in mental health care in Jakarta and Bogor and 10 national key stakeholders were recruited.

RESULTS

Despite high levels of awareness of and support for civic engagement amongst mental health professionals and policy makers combined with a nascent grass roots movement, analysis revealed unstructured and insufficient mechanisms for civic engagement which resulted in ad-hoc and mostly superficial levels of involvement activity. Civic engagement was thought to require a marked shift in existing practices as well as organisational and societal cultures. Challenging stigma is a key feature of civic engagement and our analysis highlights the relevance of social contact methods which are locally and culturally contextualised in this regard. Our findings point to a need to expand current definitions of civic engagement which focus on indivdiual enablement to ones that also encompass environmental and organisational enablement to optimise the future use of civic engagement in mental health settings.

CONCLUSIONS

Key mental health stakeholders have identified that central aspects of Indonesian culture are well aligned to the ethos of civic engagement which has the potential to facilitate the enactment of recent global health policy. However, full realisation is likely to be impeded by prevailing paternalistic cultures in mental health services and high levels of stigma and discrimination towards those with mental illness in Indonesia without intervention.

Perspectives on program mis-implementation among U.S. local public health departments

BACKGROUND

Public health resources are limited and best used for effective programs. This study explores associations of mis-implementation in public health (ending effective programs or continuing ineffective programs) with organizational supports for evidence-based decision making among U.S. local health departments.

METHODS

The national U.S. sample for this cross-sectional study was stratified by local health department jurisdiction population size. One person was invited from each randomly selected local health department: the leader in chronic disease, or the director. Of 600 selected, 579 had valid email addresses; 376 completed the survey (64.9% response). Survey items assessed frequency of and reasons for mis-implementation. Participants indicated agreement with statements on organizational supports for evidence-based decision making (7-point Likert).

RESULTS

Thirty percent (30.0%) reported programs often or always ended that should have continued (inappropriate termination); organizational supports for evidence-based decision making were not associated with the frequency of programs ending. The main reason given for inappropriate termination was grant funding ended (86.0%). Fewer (16.4%) reported programs often or always continued that should have ended (inappropriate continuation). Higher perceived organizational supports for evidence-based decision making were associated with less frequent inappropriate continuation (odds ratio = 0.86, 95% confidence interval 0.79, 0.94). All organizational support factors were negatively associated with inappropriate continuation. Top reasons were sustained funding (55.6%) and support from policymakers (34.0%).

CONCLUSIONS

Organizational supports for evidence-based decision making may help local health departments avoid continuing programs that should end. Creative mechanisms of support are needed to avoid inappropriate termination. Understanding what influences mis-implementation can help identify supports for de-implementation of ineffective programs so resources can go towards evidence-based programs.

De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations.

OBJECTIVE

We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative.

DESIGN

We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys.

PARTICIPANTS

We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems.

MAIN MEASURES

Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared.

KEY RESULTS

Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate.

CONCLUSIONS

Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.

Increasing implementation science literacy to address the research-to-practice gap in school psychology

Many evidence-based practices have not achieved their potential to broadly impact student outcomes as schools struggle with their adoption and implementation. This costly and consequential implementation gap must be addressed within school psychology through the focused study of implementation processes and outcomes. Implementation science is a multidisciplinary, translational field focused on increasing the usage and implementation of evidence-based practices into typical practice to improve outcomes. Despite the rapid development of the field of implementation science over the past decade it has been underexamined in school psychology research. As a step toward decreasing the implementation gap, the purpose of this introductory article is to increase school psychology researchers' implementation literacy. Specifically, this article provides an overview of implementation science, including (a) key terminology; (b) theories, models, and frameworks designed to explain, describe, or illustrate implementation processes or constructs; (c) strategies to support implementation across levels (e.g., provider, organization); (d) measures to capture implementation and related context; and (e) utilized research designs. By increasing school psychology researchers' implementation literacy, it is hoped that future research will attend to and evaluate implementation process and outcomes and thus facilitate the adoption and implementation of evidence-based practices to improve student outcomes.

A four-stage process for intervention description and guide development of a practice-based intervention: refining the Namaste Care intervention implementation specification for people with advanced dementia prior to a feasibility cluster randomised trial

Background

Some interventions are developed from practice, and implemented before evidence of effect is determined, or the intervention is fully specified. An example is Namaste Care, a multi-component intervention for people with advanced dementia, delivered in care home, community, hospital and hospice settings. This paper describes the development of an intervention description, guide and training package to support implementation of Namaste Care within the context of a feasibility trial. This allows fidelity to be determined within the trial, and for intervention users to understand how similar their implementation is to that which was studied.

Methods

A four-stage approach: a) Collating existing intervention materials and drawing from programme theory developed from a realist review to draft an intervention description. b) Exploring readability, comprehensibility and utility with staff who had not experienced Namaste Care. c) Using modified nominal group techniques with those with Namaste Care experience to refine and prioritise the intervention implementation materials. d) Final refinement with a patient and public involvement panel.

Results

Eighteen nursing care home staff, one carer, one volunteer and five members of our public involvement panel were involved across the study steps. A 16-page A4 booklet was designed, with flow charts, graphics and colour coded information to ease navigation through the document. This was supplemented by infographics, and a training package. The guide describes the boundaries of the intervention and how to implement it, whilst retaining the flexible spirit of the Namaste Care intervention.

Conclusions

There is little attention paid to how best to specify complex interventions that have already been organically implemented in practice. This four-stage process may have utility for context specific adaptation or description of existing, but untested, interventions. A robust, agreed, intervention and implementation description should enable a high-quality future trial. If an effect is determined, flexible practice implementation should be enabled through having a clear, evidence-based guide.

International survey of De-implementation of initiating parenteral nutrition early in Paediatric intensive care units

BACKGROUND

Initiating parenteral nutrition (PN) within 24 h in critically ill children is inferior to withholding PN during the first week, as was found in the PEPaNIC study. The aims of this study were to investigate de-implementation of early initiation of PN at PICUs worldwide, and to identify factors influencing de-implementation.

METHODS

A cross-sectional online survey was conducted (May - October 2017), consisting of 41 questions addressing current PN practices, the degree of de-implementation, and factors affecting de-implementation.

RESULTS

We analysed 81 responses from 39 countries. Of these 81 respondents, 53 (65%) were aware of the findings of the PEPaNIC study, and 43 (53%) have read the article. In these 43 PICUs, PN was completely withheld during the first week in 10 PICUs, of which 5 already withheld PN (12%), and 5 de-implemented early initiation of PN (12%). Partial de-implementation was reported by 17 (40%) and no de-implementation by 16 (37%). Higher de-implementation rates were observed when the interpreted level of evidence and grade of recommendation of PEPaNIC was high. Predominant reasons for retaining early initiation of PN were concerns on withholding amino acids, the safety in undernourished children and neonates, and the long-term consequences. Furthermore, the respondents were waiting for updated guidelines.

CONCLUSIONS

One year after the publication of the PEPaNIC trial, only two-thirds of the respondents was aware of the study results. Within this group, early initiation of PN was de-implemented completely in 12% of the PICUs, while 40% asserted partial de-implementation. Increasing the awareness, addressing the intervention-specific questions and more frequently revising international guidelines might help to accelerate de-implementation of ineffective, unproven or harmful healthcare.

Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis

BACKGROUND

Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments.

METHODS

We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge.

FINDINGS

Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50).

INTERPRETATION

Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis.

FUNDING

None.

Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice

BACKGROUND

The Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians' knowledge, self-efficacy, and practice related to implementing CO-OP.

METHODS

A single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.

RESULTS

Sixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).

Promoting Health Equity through De-Implementation Research

Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias.

Commentary: Increasing the Connectivity Between Implementation Science and Public Health: Advancing Methodology, Evidence Integration, and Sustainability

Gaps remain between the outcomes of biomedical research and their application within clinical and community settings. The field of implementation science, also referred to as dissemination and implementation research, is intended to improve the adoption, uptake, and sustainability of evidence-based health interventions. The articles in this volume's symposium on implementation science and public health identify important directions in the effort to maximize the impact of research on public and population health. Leading researchers present reviews of the use of quasi-experimental designs in implementation science, the movement toward enhancing evidence-based public health, and intervention sustainability. Each article presents lessons learned from prior research and recommendations for the next generation of studies. Collectively, the symposium offers a road map for future implementation science that seeks to optimize public health.

Studying de-implementation in health: an analysis of funded research grants

BACKGROUND

Studying de-implementation-defined herein as reducing or stopping the use of a health service or practice provided to patients by healthcare practitioners and systems-has gained traction in recent years. De-implementing ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices is important for mitigating patient harm, improving processes of care, and reducing healthcare costs. A better understanding of the state-of-the-science is needed to guide future objectives and funding initiatives. To this end, we characterized de-implementation research grants funded by the United States (US) National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ).

METHODS

We used systematic methods to search, identify, and describe de-implementation research grants funded across all 27 NIH Institutes and Centers (ICs) and AHRQ from fiscal year 2000 through 2017. Eleven key terms and three funding opportunity announcements were used to search for research grants in the NIH Query, View and Report (QVR) system. Two coders identified eligible grants based on inclusion/exclusion criteria. A codebook was developed, pilot tested, and revised before coding the full grant applications of the final sample.

RESULTS

A total of 1277 grants were identified through the QVR system; 542 remained after removing duplicates. After the multistep eligibility assessment and review process, 20 grant applications were coded. Many grants were funded by NIH (n = 15), with fewer funded by AHRQ, and a majority were funded between fiscal years 2015 and 2016 (n = 11). Grant proposals focused on de-implementing a range of health services and practices (e.g., medications, therapies, screening tests) across various health areas (e.g., cancer, cardiovascular disease) and delivery settings (e.g., hospitals, nursing homes, schools). Grants proposed to use a variety of study designs and research methods (e.g., experimental, observational, mixed methods) to accomplish study aims.

CONCLUSIONS

Based on the systematic portfolio analysis of NIH- and AHRQ-funded research grants over the past 17 years, relatively few have focused on studying the de-implementation of ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices provided to patients by healthcare practitioners and systems. Strategies for raising the profile and growing the field of research on de-implementation are discussed.