Application of discrete choice experiments to enhance stakeholder engagement as a strategy for advancing implementation: a systematic review

Palliative care national plan implementation through stakeholder analysis

BACKGROUND

National palliative care plans depend upon stakeholder engagement to succeed. Assessing the capability, interest, and knowledge of stakeholders is a crucial step in the implementation of public health initiatives, as recommended by the World Health Organisation. However, utilising stakeholder analysis is a strategy underused in public palliative care.

OBJECTIVE

To conduct a stakeholder analysis characterising a diverse group of stakeholders involved in implementing a national palliative care plan in three rural regions of an upper-middle-income country.

METHODS

A descriptive cross-sectional study design, complemented by a quantitative stakeholder analysis approach, was executed through a survey designed to gauge stakeholders' levels of interest and capability in relation to five fundamental dimensions of public palliative care: provision of services, accessibility of essential medicines, palliative care education, financial support, and palliative care vitality. Stakeholders were categorised as promoters (high-power, high-interest), latent (high-power, low-interest), advocates (low-power, high-interest), and indifferent (low-power and low-interest). Stakeholder self-perceived category and knowledge level were also assessed.

RESULTS

Among the 65 surveyed stakeholders, 19 were categorised as promoters, 34 as advocates, 9 as latent, and 3 as indifferent. Stakeholders' self-perception of their category did not align with the results of the quantitative analysis. When evaluated by region and palliative care dimensions the distribution of stakeholders was nonuniform. Palliative care funding was the dimension with the highest number of stakeholders categorised as indifferent, and the lowest percentage of promoters. Stakeholders categorised as promoters consistently reported a low level of knowledge, regardless of the dimension, region, or their level of interest.

CONCLUSIONS

Assessing the capability, interest, and knowledge of stakeholders is a crucial step when implementing public health initiatives in palliative care. It allows for a data-driven decision-making process on how to delegate responsibilities, administer financial resources, and establish governance boards that remain engaged and work efficiently.

Cancer survivor preferences for breast cancer follow-up care: a discrete choice experiment

PURPOSE

To identify the key attributes of breast cancer follow-up care models preferred by cancer survivors in Australia.

METHODS

A discrete choice experiment (DCE) was conducted to elicit preferences for attributes of breast cancer follow-up care. Respondents were presented with two hypothetical scenarios, known as choice sets, and asked to select a preference. Respondents were individuals living in Australia who were diagnosed with breast cancer within the past five years prior to survey completion and were recruited through the Breast Cancer Network of Australia and other community or consumer networks. Latent class modelling (LCM) approach under a random utility framework was used for the analysis.

RESULTS

123 breast cancer survivors completed the DCE survey. LCA revealed two latent classes, those with older age and lower quality of life (class 1) and younger women with higher quality of life (class 2). Class 2 preferred a care team comprising specialists, nurses and GPs and emphasised the importance of shared survivorship care plans. Class 1 remained neutral regarding the team's composition but was notably concerned about the out-of-pocket costs per consultation, a finding not seen in Class 2.

CONCLUSIONS

Age and quality of life status are associated with patient preference for types and attributes of breast cancer follow-up care. The health system can work towards enhancing flexibility of follow-up care delivery, ultimately achieving person-centred care.

IMPLICATIONS FOR CANCER SURVIVORS

Efforts need to be made by policymakers to ensure consumer preferences are taken into consideration to implement tailored person-centred follow-up care pathways.

Decision-making in the multiphase optimization strategy: Applying decision analysis for intervention value efficiency to optimize an information leaflet to promote key antecedents of medication adherence

Advances in the multiphase optimization strategy (MOST) have suggested a new approach, decision analysis for intervention value efficiency (DAIVE), for selecting an optimized intervention based on the results of a factorial optimization trial. The new approach opens possibilities to select optimized interventions based on multiple valued outcomes. We applied DAIVE to identify an optimized information leaflet intended to support eventual adherence to adjuvant endocrine therapy for women with breast cancer. We used empirical performance data for five candidate leaflet components on three hypothesized antecedents of adherence: beliefs about the medication, objective knowledge about AET, and satisfaction with medication information. Using data from a 25 factorial trial (n = 1603), we applied the following steps: (i) We used Bayesian factorial analysis of variance to estimate main and interaction effects for the five factors on the three outcomes. (ii) We used posterior distributions for main and interaction effects to estimate expected outcomes for each leaflet version (32 total). (iii) We scaled and combined outcomes using a linear value function with predetermined weights indicating the relative importance of outcomes. (iv) We identified the leaflet that maximized the value function as the optimized leaflet, and we systematically varied outcome weights to explore robustness. The optimized leaflet included two candidate components, side-effects, and patient input, set to their higher levels. Selection was generally robust to weight variations consistent with the initial preferences for three outcomes. DAIVE enables selection of optimized interventions with the best-expected performance on multiple outcomes.

Driving factors in treatment decision-making of patients seeking medical assistance for infertility: a systematic review

BACKGROUND

ART differs in effectiveness, side-effects, administration, and costs. To improve the decision-making process, we need to understand what factors patients consider to be most important.

OBJECTIVE AND RATIONALE

We conducted this systematic review to assess which aspects of ART treatment (effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood) are most important in the decision-making of patients with an unfulfilled wish to have a child.

SEARCH METHODS

We searched studies indexed in Embase, PubMed, PsycINFO, and CINAHL prior to November 2023. Discrete choice experiments (DCEs), surveys, interviews, and conjoint analyses (CAs) about ART were included. Studies were included if they described two or more of the following attributes: effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood.Participants were men and women with an unfulfilled wish to have a child. From each DCE/CA study, we extracted the beta-coefficients and calculated the relative importance of treatment attributes or, in case of survey studies, extracted results. We assessed the risk of bias using the rating developed by the Grading of Recommendations Assessment, Development and Evaluation working group. Attributes were classified into effectiveness, safety, burden, costs, patient-centeredness, genetic parenthood, and others.

OUTCOMES

The search identified 938 studies of which 20 were included: 13 DCEs, three survey studies, three interview studies, and one conjoint analysis, with a total of 12 452 patients. Per study, 47-100% of the participants were women. Studies were assessed as having moderate to high risk of bias (critical: six studies, serious: four studies, moderate: nine studies, low: one study). The main limitation was the heterogeneity in the questionnaires and methodology utilized. Studies varied in the number and types of assessed attributes. Patients' treatment decision-making was mostly driven by effectiveness, followed by safety, burden, costs, and patient-centeredness. Effectiveness was rated as the first or second most important factor in 10 of the 12 DCE studies (83%) and the relative importance of effectiveness varied between 17% and 63%, with a median of 34% (moderate certainty of evidence). Of eight studies evaluating safety, five studies valued safety as the first or second most important factor (63%), and the relative importance ranged from 8% to 35% (median 23%) (moderate certainty of evidence). Cost was rated as first or second most important in five of 10 studies, and the importance relative to the other attributes varied between 5% and 47% (median 23%) (moderate certainty of evidence). Burden was rated as first or second by three of 10 studies (30%) and the relative importance varied between 1% and 43% (median 13%) (low certainty of evidence). Patient-centeredness was second most important in one of five studies (20%) and had a relative importance between 7% and 24% (median 14%) (low certainty of evidence). Results suggest that patients are prepared to trade-off some effectiveness for more safety, or less burden and patient-centeredness. When safety was evaluated, the safety of the child was considered more important than the mother's safety. Greater burden (cycle cancellations, number of injections, number of hospital visits, time) was more likely to be accepted by patients if they gained effectiveness, safety, or lower costs. Concerning patient-centeredness, information provision and physician attitude were considered most important, followed by involvement in decision-making, and treatment continuity by the same medical professional. Non-genetic parenthood did not have a clear impact on decision-making.

WIDER IMPLICATIONS

The findings of this review can be used in future preference studies and can help healthcare professionals in guiding patients' decision-making and enable a more patient-centered approach.

Unpacking overuse of androgen deprivation therapy for prostate cancer to inform de-implementation strategies

BACKGROUND

Many men with prostate cancer will be exposed to androgen deprivation therapy (ADT). While evidence-based ADT use is common, ADT is also used in cases with no or limited evidence resulting in more harm than benefit, i.e., overuse. Since there are risks of ADT (e.g., diabetes, osteoporosis), it is important to understand the behaviors facilitating overuse to inform de-implementation strategies. For these reasons, we conducted a theory-informed survey study, including a discrete choice experiment (DCE), to better understand ADT overuse and provider preferences for mitigating overuse.

METHODS

Our survey used the Action, Actor, Context, Target, Time (AACTT) framework, the Theoretical Domains Framework (TDF), the Capability, Opportunity, Motivation-Behavior (COM-B) Model, and a DCE to elicit provider de-implementation strategy preferences. We surveyed the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on the likelihood of stopping overuse as ADT monotherapy for localized prostate cancer ("yes"/"probably yes," "probably no"/"no"), and characterized corresponding Likert scale responses to seven COM-B statements. We used multivariable regression to identify associations between stopping ADT overuse and COM-B responses.

RESULTS

Our survey was completed by 84 respondents (13% response rate), with 27% indicating "probably no"/"no" to stopping ADT overuse. We found differences across respondents who said they would and would not stop ADT overuse in demographics and COM-B statements. Our model identified 2 COM-B domains (Opportunity-Social, Motivation-Reflective) significantly associated with a lower likelihood of stopping ADT overuse. Our DCE demonstrated in-person communication, multidisciplinary review, and medical record documentation may be effective in reducing ADT overuse.

CONCLUSIONS

Our study used a behavioral theory-informed survey, including a DCE, to identify behaviors and context underpinning ADT overuse. Specifying behaviors supporting and gathering provider preferences in addressing ADT overuse requires a stepwise, stakeholder-engaged approach to support evidence-based cancer care. From this work, we are pursuing targeted improvement strategies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03579680.

Using stated preference methods to facilitate knowledge translation in implementation science

Enhancing the arsenal of methods available to shape implementation strategies and bolster knowledge translation is imperative. Stated preference methods, including discrete choice experiments (DCE) and best-worst scaling (BWS), rooted in economics, emerge as robust, theory-driven tools for understanding and influencing the behaviors of both recipients and providers of innovation. This commentary outlines the wide-ranging application of stated preference methods across the implementation continuum, ushering in effective knowledge translation. The prospects for utilizing these methods within implementation science encompass (1) refining and tailoring intervention and implementation strategies, (2) exploring the relative importance of implementation determinants, (3) identifying critical outcomes for key decision-makers, and 4) informing policy prioritization. Operationalizing findings from stated preference research holds the potential to precisely align health products and services with the requisites of patients, providers, communities, and policymakers, thereby realizing equitable impact.

A systematic review of discrete choice experiments in stroke rehabilitation

OBJECTIVES

Existing research qualitatively explores consumer preferences for stroke rehabilitation interventions. However, it remains unclear which intervention characteristics are most important to consumers, and how these preferences may influence uptake and participation. Discrete choice experiments (DCE) provide a unique way to quantitatively measure preferences for health and health care. This study aims to explore how DCEs have been used in stroke rehabilitation and to identify reported consumer preferences for rehabilitation interventions.

MATERIAL AND METHODS

A systematic review of published stroke rehabilitation DCEs was completed (PROSPERO registration: CRD42021282578). Six databases (including CINAHL, MEDLINE, EconLIT) were searched from January 2000-March 2023. Data extracted included topic area, sample size, aim, attributes, design process, and preference outcomes. Descriptive and thematic analyses were conducted, and two methodological checklists applied to review quality.

RESULTS

Of 2,446 studies screened, five were eligible. Studies focused on exercise preference (n = 3), the structure and delivery of community services (n = 1), and self-management programs (n = 1). All had small sample sizes (range 50-146) and were of moderate quality (average score of 77%). Results indicated people have strong preferences for one-to-one therapy (over group-based), light-moderate intensity of exercise, and delivery by qualified therapists (over volunteers).

CONCLUSIONS

Few DCEs have been conducted in stroke rehabilitation, suggesting consumer preferences could be more rigorously explored. Included studies were narrow in the scope of attributes included, limiting their application to practice and policy. Further research is needed to assess the impact of differing service delivery models on uptake and participation.

Using decision analysis for intervention value efficiency to select optimized interventions in the multiphase optimization strategy

OBJECTIVE

Optimizing multicomponent behavioral and biobehavioral interventions presents a complex decision problem. To arrive at an intervention that is both effective and readily implementable, it may be necessary to weigh effectiveness against implementability when deciding which components to select for inclusion. Different components may have differential effectiveness on an array of outcome variables. Moreover, different decision-makers will approach this problem with different objectives and preferences. Recent advances in decision-making methodology in the multiphase optimization strategy (MOST) have opened new possibilities for intervention scientists to optimize interventions based on a wide variety of decision-maker preferences, including those that involve multiple outcome variables. In this study, we introduce decision analysis for intervention value efficiency (DAIVE), a decision-making framework for use in MOST that incorporates these new decision-making methods. We apply DAIVE to select optimized interventions based on empirical data from a factorial optimization trial.

METHOD

We define various sets of hypothetical decision-maker preferences, and we apply DAIVE to identify optimized interventions appropriate to each case.

RESULTS

We demonstrate how DAIVE can be used to make decisions about the composition of optimized interventions and how the choice of optimized intervention can differ according to decision-maker preferences and objectives.

CONCLUSIONS

We offer recommendations for intervention scientists who want to apply DAIVE to select optimized interventions based on data from their own factorial optimization trials. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Factors Influencing Patient Receptivity to Brief Alcohol Interventions in Primary Care: An Application of Conjoint Analysis

Background: Brief alcohol interventions (BAIs) are an evidence-based practice for addressing hazardous alcohol use in primary care settings. However, numerous barriers to implementation of BAIs in routine practice have been identified, including concerns about patient receptivity to BAIs. Despite this being a commonly identified barrier to BAI implementation, little BAI implementation research has focused on patient receptivity. Objectives: This study aimed to identify the treatment preferences of primary care patients who screened positive for hazardous alcohol use and to evaluate factors that may influence patients' receptivity to BAIs delivered in primary care. We conducted a mailed survey of primary care patients (N = 245) who screened positive for hazardous alcohol use on annual screening measures based on electronic medical record data. Patients completed measures assessing treatment preferences and a conjoint analysis questionnaire designed to evaluate the relative importance of three factors (focus of the BAI, tailoring of the BAI, and familiarity with the provider delivering the BAI) for patient receptivity. Results: Conjoint analysis results revealed that familiarity with provider (with patients preferring BAIs delivered by providers they have previously met) was the most important factor in predicting patients' receptivity to BAIs. Additionally, patients preferred to discuss alcohol use in the context of another concern (focus of the BAI) and preferred personalized information tailored based on their specific health concerns (tailoring of the BAI), although these factors were not statistically significant when accounting for familiarity with provider. Conclusions: Findings of the present study have potential to inform future research on implementation of BAIs.

Utilizing deliberative engagement for identifying implementation strategy priorities: lessons learned from an online deliberative forum with dental professionals

BACKGROUND

Selecting effective implementation strategies to support guideline-concordant dental care is a complex process. We are drawing on data collected during the DISGO study to reflect on barriers we encountered in implementing a deliberative engagement process for discussing implementation strategies relevant to the evidence-based guideline targeted in this intervention. The goal is to identify factors that may influence the success of deliberative engagement as a technique to involve healthcare staff in identifying priorities for implementation strategies.

METHODS

We drew on online chat transcripts from the deliberative engagement forums collected during the DISGO study. The chat transcripts were automatically generated for each discussion and captured the written exchanges between participants and moderators in all participating dental clinics. Chat transcripts were analyzed following a content analysis approach.

RESULTS

Our findings revealed barriers to the successful implementation of deliberative engagement in the context of the DISGO study. Participants were not familiar with the materials that had been prepared for the forum and lacked familiarity with the topic of deliberation. Participants also did not share divergent viewpoints and reinforced existing ideas rather than introducing new ideas.

CONCLUSIONS

In order to ensure that obstacles that were encountered in this study are not repeated, it is important to carefully consider how staff can effectively be prepared for the deliberations. Participants must be familiar with the content of the guideline, and most questions about the content and evidence should be answered before the deliberative engagement sessions. If perspectives among staff on a guideline are homogenous, briefing materials should introduce perspectives that complement existing views among staff. It is also necessary to create an environment in which staff are comfortable introducing opinions that may not be held by the majority of colleagues.

TRIAL REGISTRATION

This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 12/18/2020. https://clinicaltrials.gov/ct2/show/NCT04682730 .

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stakeholder Engagement in Designing Attributes for a Discrete Choice Experiment With Policy Implications: An Example of 2 Swiss Studies on Healthcare Delivery

OBJECTIVES

The use of discrete choice experiments (DCEs) has become increasingly popular in health policy development by involving and analyzing the preferences of target groups for different aspects of the policy intervention. In this article, we aim to contribute to the standardization of the process of attribute and attribute level development for DCEs with policy relevance. To do so, we propose and empirically illustrate a framework tool for the development and reporting of attributes and attribute levels, with the systematic engagement of relevant stakeholders.

METHODS

The framework tool was kept general to allow its use as a standard reporting approach on the development process of a DCE, involving relevant stakeholders at each stage. The proposed 3-stage process consists of (1) collection, (2) selection, and (3) refinement of the DCE attributes and attribute levels. The application of the framework tool is illustrated by 2 projects, Health2040 and COCONUTS-both concerning the preferences of the Swiss population for the future organization of healthcare.

RESULTS

By engaging stakeholders, we identified and included attributes and attribute levels that would not have been identified solely through the existing literature. In addition, including multiple stakeholders from different professional backgrounds ensured that the selected attributes and attribute levels were policy relevant, were applicable in practice, and reflected the opinions of multiple actors in healthcare.

CONCLUSION

The proposed framework helps to strengthen the standardization of the reporting on attribute and attribute level development with stakeholder engagement and to guide future research teams designing a DCE with policy implications.

Optimizing Dog Rabies Vaccination Services to the Public: A Discrete Choice Experiment in Guangdong, China

Vaccination for dogs is essential for controlling rabies and achieving the goal of eliminating dog-mediated rabies globally by 2030. This paper aims to investigate the preferences for public services regarding rabies vaccination, in an effort to optimize the existing rabies vaccination and prevention programs in China. The households investigated had significant preferences for dog rabies vaccination service attributes. The households can be classified into three types: resolute executors (52.13%), mischievous rebels (5.85%), and incentivized compliers (42.02%). The residence, the presence of children in the household, perception of the safety risks, and knowledge of rabies may be sources of heterogeneity. Supportive services on dog rabies vaccination should be made available, such as arranging weekend vaccination services, building mobile vaccination stations, providing home vaccination services, and increasing vaccine supply through multiple channels. Furthermore, multiple measures can be taken to increase rabies vaccination awareness among family members and facilitate dog management innovation to further increase the level of rabies prevention and control.

Measuring the Implementation Preferences of Emergency Medical Services Clinicians Using Discrete Choice Experiments

INTRODUCTION

Prehospital research and evidence-based guidelines (EBGs) have grown in recent decades, yet there is still a paucity of prehospital implementation research. While recent studies have revealed EMS agency leadership perspectives on implementation, the important perspectives and opinions of frontline EMS clinicians regarding implementation have yet to be explored in a systematic approach. The objective of this study was to measure the preferences of EMS clinicians for the process of EBG implementation and whether current agency practices align with those preferences.

METHODS

This study was a cross-sectional survey of National Registry of Emergency Medical Technicians registrants. Eligible participants were certified paramedics who were actively practicing EMS clinicians. The survey contained discrete choice experiments (DCEs) for three EBG implementation scenarios and questions about rank order preferences for various aspects of the implementation process. For the DCEs, we used multinomial logistic regression to analyze the implementation preference choices of EMS clinicians, and latent class analysis to classify respondents into groups by their preferences.

RESULTS

A total of 183 respondents completed the survey. Respondents had a median age of 39 years, were 74.9% male, 89.6% White, and 93.4% of non-Hispanic ethnicity. For all three DCE scenarios, respondents were significantly more likely to choose options with hospital feedback and individual-level feedback from EMS agencies. Respondents were significantly less likely to choose options with email/online only education, no feedback from hospitals, and no EMS agency feedback to clinicians. In general, respondents' preferences favored classroom-based training over in-person simulation. For all DCE questions, most respondents (66.2%-77.1%) preferred their survey DCE choice to their agency's current implementation practices. In the rank order preferences, most participants selected "knowledge of the underlying evidence behind the change" as the most important component of the process of implementation.

CONCLUSIONS

In this study of EMS clinicians' implementation preferences using DCEs, respondents preferred in-person education, feedback on hospital outcomes, and feedback on their individual performance. However, current practice at EMS agencies rarely matched those expressed EMS clinician preferences. Collectively, these results present opportunities for improving EMS implementation from the EMS clinician perspective.

Patient Preferences for Strategies to Improve Tuberculosis Diagnostic Services in Zambia

IMPORTANCE

Delayed engagement in tuberculosis (TB) services is associated with ongoing transmission and poor clinical outcomes.

OBJECTIVE

To assess whether patients with TB have differential preferences for strategies to improve the public health reach of TB diagnostic services.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was undertaken in which a discrete choice experiment (DCE) was administered between September 18, 2019, and January 17, 2020, to 401 adults (>18 years of age) with microbiologically confirmed TB in Lusaka, Zambia. The DCE had 7 attributes with 2 to 3 levels per attribute related to TB service enhancements. Latent class analysis was used to identify segments of participants with unique preferences. Multiscenario simulations were used to estimate shares of preferences for different TB service improvement strategies.

MAIN OUTCOMES AND MEASURES

The main outcomes were patient preference archetypes and estimated shares of preferences for different strategies to improve TB diagnostic services. Collected data were analyzed between January 3, 2022, to July 2, 2022.

RESULTS

Among 326 adults with TB (median [IQR] age, 34 [27-42] years; 217 [66.8%] male; 158 [48.8%] HIV positive), 3 groups with distinct preferences for TB service improvements were identified. Group 1 (192 participants [58.9%]) preferred a facility that offered same-day TB test results, shorter wait times, and financial incentives for testing. Group 2 (83 participants [25.4%]) preferred a facility that provided same-day TB results, had greater privacy, and was closer to home. Group 3 (51 participants [15.6%]) had no strong preferences for service improvements and had negative preferences for receiving telephone-based TB test results. Groups 1 and 2 were more likely to report at least a 4-week delay in seeking health care for their current TB episode compared with group 3 (29 [51.3%] in group 1, 95 [35.8%] in group 2, and 10 [19.6%] in group 3; P < .001). Strategies to improve TB diagnostic services most preferred by all participants were same-day TB test results alone (shares of preference, 69.9%) and combined with a small financial testing incentive (shares of preference, 79.3%), shortened wait times (shares of preference, 76.1%), or greater privacy (shares of preference, 75.0%). However, the most preferred service improvement strategies differed substantially by group.

CONCLUSIONS AND RELEVANCE

In this study, patients with TB had heterogenous preferences for TB diagnostic service improvements associated with differential health care-seeking behavior. Tailored strategies that incorporate features most valued by persons with undiagnosed TB, including same-day results, financial incentives, and greater privacy, may optimize reach by overcoming key barriers to timely TB care engagement.

Public Preferences for Policies to Promote COVID-19 Vaccination Uptake: A Discrete Choice Experiment in The Netherlands

OBJECTIVES

The COVID-19 pandemic forms an unprecedented public health, economic, and social crisis. Uptake of vaccination is critical for controlling the pandemic. Nevertheless, vaccination hesitancy is considerable, requiring policies to promote uptake. We investigate Dutch citizens' preferences for policies that aim to promote vaccination through facilitating choice of vaccination, profiling it as the norm, making vaccination more attractive through rewards, or punishing people who reject vaccination.

METHODS

We conducted a discrete choice experiment in which 747 respondents were asked to choose between policies to promote vaccination uptake and their impacts on the number of deaths, people with permanent health problems, households with income loss, and a tax increase.

RESULTS

Respondents generally had a negative preference for policies that promote vaccination. They particularly disliked policies that punish those who reject the vaccine and were more favorable toward policies that reward vaccination, such as awarding additional rights to vaccinated individuals through vaccination passports. Respondents who reject vaccination were in general much more negative about the policy options than respondents who consider accepting the vaccine. Nevertheless, vaccination passports are supported by both respondents who accept the vaccine, those who reject vaccination, and those who are unsure about vaccination.

CONCLUSIONS

This study provides concrete directions for governments attempting to increase the vaccination uptake in ways that are supported by the public. Our results could encourage policy makers to focus on policy options that make vaccination easier and reward people who take the vaccine, as especially the implementation of vaccination passports was supported.

Using decision analysis to support implementation planning in research and practice

BACKGROUND

The process of implementing evidence-based interventions, programs, and policies is difficult and complex. Planning for implementation is critical and likely plays a key role in the long-term impact and sustainability of interventions in practice. However, implementation planning is also difficult. Implementors must choose what to implement and how best to implement it, and each choice has costs and consequences to consider. As a step towards supporting structured and organized implementation planning, we advocate for increased use of decision analysis.

MAIN TEXT

When applied to implementation planning, decision analysis guides users to explicitly define the problem of interest, outline different plans (e.g., interventions/actions, implementation strategies, timelines), and assess the potential outcomes under each alternative in their context. We ground our discussion of decision analysis in the PROACTIVE framework, which guides teams through key steps in decision analyses. This framework includes three phases: (1) definition of the decision problems and overall objectives with purposeful stakeholder engagement, (2) identification and comparison of different alternatives, and (3) synthesis of information on each alternative, incorporating uncertainty. We present three examples to illustrate the breadth of relevant decision analysis approaches to implementation planning.

CONCLUSION

To further the use of decision analysis for implementation planning, we suggest areas for future research and practice: embrace model thinking; build the business case for decision analysis; identify when, how, and for whom decision analysis is more or less useful; improve reporting and transparency of cost data; and increase collaborative opportunities and training.

The development of task sharing policy and guidelines in Kenya

BACKGROUND

The global critical shortage of health workers prevents expansion of healthcare services and universal health coverage. Like most countries in sub-Saharan Africa, Kenya's healthcare workforce density of 13.8 health workers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doctors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP.

CASE PRESENTATION

The development and approval of Kenya's TSP occurred from February 2015 to May 2017. The U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United States President's Emergency Plan for AIDS Relief (PEPFAR) Advancing Children's Treatment initiative. After obtaining support from leadership in Kenya's MOH and health professional institutions, the TSP team conducted a desk review of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a Policy Advisory Committee was established to guide the process and worked collaboratively to form technical working groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in 2019 after a legal challenge from an association of medical laboratorians.

CONCLUSIONS

Task sharing may increase access to healthcare services in resource-limited settings. To advance task sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regulate practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure that task sharing is implemented appropriately to ensure quality outcomes.

Heterogeneity in preferences for outcomes of integrated care for persons with multiple chronic diseases: a latent class analysis of a discrete choice experiment

Purpose

For an integrated care programme to be successful, preferences of the stakeholders involved should be aligned. The aim of this study is to investigate to which extent outcomes beyond health are valued and to study the heterogeneity of preferences of those involved in integrated care.

Methods

A discrete choice experiment (DCE) was conducted to elicit preferences for eight Triple Aim outcomes, i.e., physical functioning, psychological well-being, social relationships & participation, enjoyment of life, resilience, person-centeredness, continuity of care and total health and social care costs. Stakeholders were recruited among Dutch persons with multi-morbidity, informal caregivers, professionals, payers, and policymakers. A Bayesian mixed-logit model was used to analyse the data. Subsequently, a latent class analysis was performed to identify stakeholders with similar preferences.

Results

739 stakeholders completed the DCE. Enjoyment of life was perceived as the most important outcome (relative importance: 0.221) across stakeholders, while total health and social care costs were perceived as least important (0.063). The latent class analysis identified four classes. The first class (19.9%) put most weight on experience with care outcomes. The second class (39%) favoured enjoyment of life. The third class (18%) focused relatively more on physical health. The fourth class (24%) had the least consistent preferences.

Conclusion

This study has highlighted the heterogeneity in views of stakeholders in integrated care on what is important in health(care) for persons with multi-morbidity. To accurately value integrated care a variety of outcomes beyond health–e.g., enjoyment of life and experience with care–should be taken into account.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03147-6.

Best-worst scaling methodology to evaluate constructs of the Consolidated Framework for Implementation Research: application to the implementation of pharmacogenetic testing for antidepressant therapy

Background

Despite the increased demand for pharmacogenetic (PGx) testing to guide antidepressant use, little is known about how to implement testing in clinical practice. Best–worst scaling (BWS) is a stated preferences technique for determining the relative importance of alternative scenarios and is increasingly being used as a healthcare assessment tool, with potential applications in implementation research. We conducted a BWS experiment to evaluate the relative importance of implementation factors for PGx testing to guide antidepressant use.

Methods

We surveyed 17 healthcare organizations that either had implemented or were in the process of implementing PGx testing for antidepressants. The survey included a BWS experiment to evaluate the relative importance of Consolidated Framework for Implementation Research (CFIR) constructs from the perspective of implementing sites.

Results

Participating sites varied on their PGx testing platform and methods for returning recommendations to providers and patients, but they were consistent in ranking several CFIR constructs as most important for implementation: patient needs/resources, leadership engagement, intervention knowledge/beliefs, evidence strength and quality, and identification of champions.

Conclusions

This study demonstrates the feasibility of using choice experiments to systematically evaluate the relative importance of implementation determinants from the perspective of implementing organizations. BWS findings can inform other organizations interested in implementing PGx testing for mental health. Further, this study demonstrates the application of BWS to PGx, the findings of which may be used by other organizations to inform implementation of PGx testing for mental health disorders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00300-7.

Sustainability of locally driven centres for those affected by dementia: a protocol for the get real with meeting centres realist evaluation

INTRODUCTION

Improving support for people with early to moderate dementia to live at home in their communities is a global public health goal. Community adult social care is not robust in many parts of the UK, however, with the pandemic increasing pressure on services for this population. Community-led interventions can play a key role in supporting people postdiagnosis, helping delay decline, but many interventions struggle to sustain beyond 1-2 years. Meeting Centres (MCs) are one such intervention, which many UK community groups find attractive and achievable. However, it is not understood how these communities can ensure they are putting in place strategies that will help them sustain in the longer term, beyond start-up phase.

METHODS AND ANALYSIS

This realist evaluation aims to understand the factors affecting sustainability of MCs in rural areas and learn lessons from MCs that have sustained beyond 3 years. Data will be collected using mixed methods: interviews and group discussions with stakeholders involved at every level in three case study locations in England and Wales, analysed with Soft Systems modelling; a Discrete Choice Experiment exploring what people across the UK value and are willing to pay for MCs, analysed with regression modelling. All data will be synthesised using a Realist logic of analysis to build a theoretical model of how, why, for whom, in what contexts and to what extent MCs can be successfully implemented for the long term.

ETHICS AND DISSEMINATION

As participants may lack capacity for informed consent, favourable ethical opinion was received from a Health Research Authority research ethics committee. Resulting recommendations will be of interest to stakeholders including those commissioning, planning, running, supporting or attending MCs, as well as policy-makers and healthcare professionals. Knowledge will be shared with emerging MCs to help accelerate scale up of this intervention.

Addressing health disparities through implementation science-a need to integrate an equity lens from the outset

There is increasing attention being given to opportunities and approaches to advance health equity using implementation science. To reduce disparities in health, it is crucial that an equity lens is integrated from the earliest stages of the implementation process. In this paper, we outline four key pre-implementation steps and associated questions for implementation researchers to consider that may help guide selection and design of interventions and associated implementation strategies that are most likely to reach and be effective in reducing health disparities among vulnerable persons and communities.

How can we discover the most valuable types of big data and artificial intelligence-based solutions? A methodology for the efficient development of the underlying analytics that improve care

BACKGROUND

Much has been invested in big data and artificial intelligence-based solutions for healthcare. However, few applications have been implemented in clinical practice. Early economic evaluations can help to improve decision-making by developers of analytics underlying these solutions aiming to increase the likelihood of successful implementation, but recommendations about their use are lacking. The aim of this study was to develop and apply a framework that positions best practice methods for economic evaluations alongside development of analytics, thereby enabling developers to identify barriers to success and to select analytics worth further investments.

METHODS

The framework was developed using literature, recommendations for economic evaluations and by applying the framework to use cases (chronic lymphocytic leukaemia (CLL), intensive care, diabetes). First, the feasibility of developing clinically relevant analytics was assessed and critical barriers to successful development and implementation identified. Economic evaluations were then used to determine critical thresholds and guide investment decisions.

RESULTS

When using the framework to assist decision-making of developers of analytics, continuing development was not always feasible or worthwhile. Developing analytics for progressive CLL and diabetes was clinically relevant but not feasible with the data available. Alternatively, developing analytics for newly diagnosed CLL patients was feasible but continuing development was not considered worthwhile because the high drug costs made it economically unattractive for potential users. Alternatively, in the intensive care unit, analytics reduced mortality and per-patient costs when used to identify infections (- 0.5%, - €886) and to improve patient-ventilator interaction (- 3%, - €264). Both analytics have the potential to save money but the potential benefits of analytics that identify infections strongly depend on infection rate; a higher rate implies greater cost-savings.

CONCLUSIONS

We present a framework that stimulates efficiency of development of analytics for big data and artificial intelligence-based solutions by selecting those applications of analytics for which development is feasible and worthwhile. For these applications, results from early economic evaluations can be used to guide investment decisions and identify critical requirements.

Primary Care Physician Perspectives on Recommending E-cigarettes to Smokers: a Best-Worst Discrete Choice Experiment

BACKGROUND

Recent clinical trials suggest that e-cigarettes may be more effective for smoking cessation than traditional cessation aids, yet primary care physician (PCP) practices regarding e-cigarette recommendations for smokers have not been studied in-depth.

OBJECTIVE

To identify factors influencing PCP recommendation of e-cigarettes for smoking cessation.

DESIGN

Discrete choice experiment and survey.

PARTICIPANTS

Florida PCPs.

MEASURES

The survey included a discrete choice experiment in which PCPs indicated whether they would recommend e-cigarettes for each of 8 hypothetical patient profiles with the following contrasting characteristics: e-cigarette use, interest in approved cessation methods, smoking intensity, prior experience with approved cessation medications, quit intention, age, and comorbidity. Responses were summarized using descriptive statistics and standardized scores (SS).

KEY RESULTS

The sample (n = 216) was predominately male (76%), white (66%), and non-Hispanic (78%), and most respondents had held their medical degree for 20+ years (77%). The response rate was 28.7%. Most PCPs thought e-cigarettes were at least somewhat effective for smoking cessation (66%) and lowering disease risk (65%); 31% perceived e-cigarettes to be equally/more effective than traditional cessation aids. PCPs were split regarding whether e-cigarettes were less (50%) or equally harmful (38%) as cigarettes. Yet, few were very confident in their ability to counsel patients on e-cigarettes risks (27%) or benefits (15%). PCPs recommended e-cigarettes in 27% of patient profiles they evaluated. The most important factors influencing the decision to recommend or not recommend e-cigarette were patients' prior use of nicotine replacement therapy with (SS = 0.22, 95% CI = 0.17-0.27) and without use of other medications for cessation (SS = 0.18, 95% CI = 0.13-0.23), and being middle age (50 years old) with chronic obstructive pulmonary disease (SS = 0.16, 95% CI = 0.10-0.23).

CONCLUSIONS

Considering the increased patient use of e-cigarettes and increasing use for cessation, this study highlights the need for guidelines and education to aid PCPs' counseling of patients about e-cigarette use.

The future of hospital quality of care policy: A multi-stakeholder discrete choice experiment in Flanders, Belgium

BACKGROUND

Collaboration between policymakers, patients and healthcare workers in hospital quality of care policy setting can improve the integration of new initiatives. The aim of this study was to quantify preferences for various characteristics of a future quality policy in a broad group of stakeholders.

MATERIALS AND METHODS

450 policymakers, clinicians, nurses, patient representatives and hospital board members in Flanders (Belgium) participated in five discrete choice experiments (DCE) on quality control, quality improvement, inspection, patient incidents and transparency. For each DCE, various attributes and levels were defined from a literature review and interviews with 12 international quality and patient safety experts.

RESULTS

For the attributes with the highest relative importance, participants exhibited a strong preference for quality control by an independent national organization and coordination of quality improvement initiatives at the level of hospital networks. The individual hospital was chosen over the government for setting up an action plan following patient complaints. Respondents also strongly preferred mandatory reporting of severe patient incidents and transparency by publicly reporting quality indicators at the hospital level.

CONCLUSIONS

A future quality model should focus on a multicomponent approach with external quality control, improvement actions on hospital network level and public transparency. DCEs provide an opportunity to incorporate the attitudes and views for individual components of a new policy recommendation.

Understanding the value of adhering to or adapting evidence-based interventions: a study protocol of a discrete choice experiment

Background

Whereas the value of an evidence-based intervention (EBI) is often determined by its effect on clinical outcomes, the value of implementing and using EBIs in practice is broader, reflecting qualities such as appropriateness, equity, costs, and impact. Reconciling these value conflicts involves a complicated decision process that has received very limited scholarly attention. Inspired by studies on decision-making, the objective of this project is to explore how practitioners appraise the values of different outcomes and to test how this appraisal influences their decisions surrounding the so-called fidelity–adaptation dilemma. This dilemma is related to the balance between using an EBI as it was designed (to ensure its effectiveness) and making appropriate adaptations (to ensure alignment with constraints and possibilities in the local context).

Methods

This project consists of three sub-studies. The participants will be professionals leading evidence-based parental programs in Sweden and, in Sub-study 1, parents and decision-makers. Sub-study 1 will use sequential focus groups and individual interviews to explore parameters that influence fidelity and adaptation decisions—the dilemmas encountered, available options, how outcomes are valued by practitioners as well as other stakeholders, and value trade-offs. Sub-study 2 is a discrete choice experiment that will test how value appraisals influence decision-making using data from Sub-study 1 as input. Sub-study 3 uses a mixed-method design, with findings from the two preceding sub-studies as input in focus group interviews to investigate how practitioners make sense of findings from optimal decision situations (experiment) and constrained, real-world decision situations.

Discussion

The project will offer unique insights into decision-making processes that influence how EBIs are used in practice. Such knowledge is needed for a more granular understanding of how practitioners manage the fidelity–adaptation dilemma and thus, ultimately, how the value of EBI implementation can be optimized. This study contributes to our knowledge of what happens once EBIs are adopted—that is, the gap between the way in which EBIs are intended to be used and the way in which they are used in practice.

Improving secure messaging: A framework for support, partnership & information-giving communicating electronically (SPICE)

BACKGROUND

Patient-centered communication benefits patients and is widely endorsed. However, it is primarily associated with face-to-face contexts, although patients are increasingly using electronic platforms, such as secure messaging in patient portals, to communicate with providers.

PURPOSE

Given the popularity of secure messaging and its ability to impact the patient-provider relationship, this study aimed to determine which attributes of patient-centered communication are most desired by cancer patients using secure messaging.

METHODS

A 2⁶ balanced incomplete block design discrete choice experiment was conducted using the best-worst scaling technique. Respondents were asked to select their most and least preferred attributes of two simulated patient-provider exchanges within each of eight choice sets.

RESULTS

210 respondents indicated that either level of partnership (high and low) and either level of information-giving (high and low) were most preferred, while response times greater than 24 hours and low levels of support were least favored.

CONCLUSIONS

Similar to face-to-face communication, patients value aspects of patient-centered communication in the secure messaging setting and desire them to be included in provider replies.

PRACTICE IMPLICATIONS

Patient-centered communication is important to patients using secure messaging. Providers should incorporate SPICE (Support, Partnership, and Information-giving while Communicating Electronically).

Whole genome sequencing in oncology: using scenario drafting to explore future developments

Background

In oncology, Whole Genome Sequencing (WGS) is not yet widely implemented due to uncertainties such as the required infrastructure and expertise, costs and reimbursements, and unknown pan-cancer clinical utility. Therefore, this study aimed to investigate possible future developments facilitating or impeding the use of WGS as a molecular diagnostic in oncology through scenario drafting.

Methods

A four-step process was adopted for scenario drafting. First, the literature was searched for barriers and facilitators related to the implementation of WGS. Second, they were prioritized by international experts, and third, combined into coherent scenarios. Fourth, the scenarios were implemented in an online survey and their likelihood of taking place within 5 years was elicited from another group of experts. Based on the minimum, maximum, and most likely (mode) parameters, individual Program Evaluation and Review Technique (PERT) probability density functions were determined. Subsequently, individual opinions were aggregated by performing unweighted linear pooling, from which summary statistics were extracted and reported.

Results

Sixty-two unique barriers and facilitators were extracted from 70 articles. Price, clinical utility, and turnaround time of WGS were ranked as the most important aspects. Nine scenarios were developed and scored on likelihood by 18 experts. The scenario about introducing WGS as a clinical diagnostic with a lower price, shorter turnaround time, and improved degree of actionability, scored the highest likelihood (median: 68.3%). Scenarios with low likelihoods and strong consensus were about better treatment responses to more actionable targets (26.1%), and the effect of centralizing WGS (24.1%).

Conclusions

Based on current expert opinions, the implementation of WGS as a clinical diagnostic in oncology is heavily dependent on the price, clinical utility (both in terms of identifying actionable targets as in adding sufficient value in subsequent treatment), and turnaround time. These aspects and the optimal way of service provision are the main drivers for the implementation of WGS and should be focused on in further research. More knowledge regarding these factors is needed to inform strategic decision making regarding the implementation of WGS, which warrants support from all relevant stakeholders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08214-8.

The FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare

BACKGROUND

Implementation strategies are necessary to ensure that evidence-based practices are successfully incorporated into routine clinical practice. Such strategies, however, are frequently modified to fit local populations, settings, and contexts. While such modifications can be crucial to implementation success, the literature on documenting and evaluating them is virtually nonexistent. In this paper, we therefore describe the development of a new framework for documenting modifications to implementation strategies.

DISCUSSION

We employed a multifaceted approach to developing the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS), incorporating multiple stakeholder perspectives. Development steps included presentations of initial versions of the FRAME-IS to solicit structured feedback from individual implementation scientists ("think-aloud" exercises) and larger, international groups of researchers. The FRAME-IS includes core and supplementary modules to document modifications to implementation strategies: what is modified, the nature of the modification (including the relationship to core elements or functions), the primary goal and rationale for the modification, timing of the modification, participants in the modification decision-making process, and how widespread the modification is. We provide an example of application of the FRAME-IS to an implementation project and provide guidance on how it may be used in future work.

CONCLUSION

Increasing attention is being given to modifications to evidence-based practices, but little work has investigated modifications to the implementation strategies used to implement such practices. To fill this gap, the FRAME-IS is meant to be a flexible, practical tool for documenting modifications to implementation strategies. Its use may help illuminate the pivotal processes and mechanisms by which implementation strategies exert their effects.

Exploring community engaged research experiences and preferences: a multi-level qualitative investigation

BACKGROUND

Community engagement may make research more relevant, translatable, and sustainable, hence improving the possibility of reducing health disparities. The purpose of this study was to explore strategies for community engagement adopted by research teams and identify areas for enhancing engagement in future community engaged research.

METHODS

The Community Engagement Program of the Johns Hopkins Institute for Clinical and Translational Research hosted a forum to engage researchers and community partners in group discussion to reflect on their diverse past and current experiences in planning, implementing, and evaluating community engagement in health research. A total of 50 researchers, research staff, and community partners participated in five concurrent semi-structured group interviews and a whole group wrap-up session. Group interviews were audiotaped, transcribed verbatim, and analyzed using content analysis.

RESULTS

Four themes with eight subthemes were identified. Main themes included: Community engagement is an ongoing and iterative process; Community partner roles must be well-defined and clearly communicated; Mutual trust and transparency are central to community engagement; and Measuring community outcomes is an evolving area. Relevant subthemes were: engaging community partners in various stages of research; mission-driven vs. "checking the box"; breadth and depth of engagement; roles of community partner; recruitment and selection of community partners; building trust; clear communication for transparency; and conflict in community engaged research.

CONCLUSION

The findings highlight the benefits and challenges of community engaged research. Enhanced capacity building for community engagement, including training and communication tools for both community and researcher partners, are needed.

Community stakeholder preferences for evidence-based practice implementation strategies in behavioral health: a best-worst scaling choice experiment

BACKGROUND

Community behavioral health clinicians, supervisors, and administrators play an essential role in implementing new psychosocial evidence-based practices (EBP) for patients receiving psychiatric care; however, little is known about these stakeholders' values and preferences for implementation strategies that support EBP use, nor how best to elicit, quantify, or segment their preferences. This study sought to quantify these stakeholders' preferences for implementation strategies and to identify segments of stakeholders with distinct preferences using a rigorous choice experiment method called best-worst scaling.

METHODS

A total of 240 clinicians, 74 clinical supervisors, and 29 administrators employed within clinics delivering publicly-funded behavioral health services in a large metropolitan behavioral health system participated in a best-worst scaling choice experiment. Participants evaluated 14 implementation strategies developed through extensive elicitation and pilot work within the target system. Preference weights were generated for each strategy using hierarchical Bayesian estimation. Latent class analysis identified segments of stakeholders with unique preference profiles.

RESULTS

On average, stakeholders preferred two strategies significantly more than all others-compensation for use of EBP per session and compensation for preparation time to use the EBP (P < .05); two strategies were preferred significantly less than all others-performance feedback via email and performance feedback via leaderboard (P < .05). However, latent class analysis identified four distinct segments of stakeholders with unique preferences: Segment 1 (n = 121, 35%) strongly preferred financial incentives over all other approaches and included more administrators; Segment 2 (n = 80, 23%) preferred technology-based strategies and was younger, on average; Segment 3 (n = 52, 15%) preferred an improved waiting room to enhance client readiness, strongly disliked any type of clinical consultation, and had the lowest participation in local EBP training initiatives; Segment 4 (n = 90, 26%) strongly preferred clinical consultation strategies and included more clinicians in substance use clinics.

CONCLUSIONS

The presence of four heterogeneous subpopulations within this large group of clinicians, supervisors, and administrators suggests optimal implementation may be achieved through targeted strategies derived via elicitation of stakeholder preferences. Best-worst scaling is a feasible and rigorous method for eliciting stakeholders' implementation preferences and identifying subpopulations with unique preferences in behavioral health settings.

Collaborating with health economists to advance implementation science: a qualitative study

Background

Implementation research infrequently addresses economic factors, despite the importance of understanding the costs of implementing evidence-based practices (EBPs). Though partnerships with health economists have the potential to increase attention to economic factors within implementation science, barriers to forming these collaborations have been noted. This study investigated the experiences of health economists and implementation researchers who have partnered across disciplines to inform strategies to increase such collaborations.

Methods

A purposeful sampling approach was used to identify eight health economists and eight implementation researchers with experience participating in cross-disciplinary research. We used semi-structured interviews to gather information about participants' experiences with collaborative research. Thematic analysis was conducted to identify core themes related to facilitators and barriers to collaborations.

Results

Health economists and implementation researchers voiced different perspectives on collaborative research, highlighting the importance of increasing cross-disciplinary understanding. Implementation researchers described a need to measure costs in implementation studies, whereas many health economists described that they seek to collaborate on projects that extend beyond conducting cost analyses. Researchers in both disciplines articulated motivations for collaborative research and identified strategies that promote successful collaboration, with varying degrees of convergence across these themes. Shared motivations included improving methodological rigor of research and making a real-world impact. Strategies to improve collaboration included starting partnerships early in the study design period, having a shared interest, and including health economists in the larger scope of the research.

Conclusions

Health economists and implementation researchers both conduct research with significant policy implications and have the potential to inform one another's work in ways that might more rapidly advance the uptake of EBPs. Collaborative research between health economists and implementation science has the potential to advance the field; however, researchers will need to work to bridge disciplinary differences. By beginning to develop strong working relationships; increasing their understanding of one another's disciplinary culture, methodology, and language; and increasing the role economists have within research design and execution, both implementation researchers and health economists can support successful collaborations and robust and informative research.

Individual-level determinants of waterpipe smoking demand in four Eastern-Mediterranean countries

The prevalence of waterpipe tobacco smoking in the Eastern Mediterranean Region is at alarmingly high levels, especially among young people. The objective of this research was to evaluate the preferences of young adult waterpipe smokers with respect to potential individual-level determinants of waterpipe smoking using discrete choice experiment methodology. Participants were young adult university students (18-29 years) who were ever waterpipe smokers, recruited from universities across four Eastern Mediterranean countries: Jordan, Oman, Palestine and the United Arab Emirates. The Internet-based discrete choice experiment, with 6 × 3 × 2 block design, evaluated preferences for choices of waterpipe smoking sessions, presented on hypothetical waterpipe café menus. Participants evaluated nine choice sets, each with five fruit-flavored options, a tobacco flavored option (non-flavored), and an opt-out option. Choices also varied based on nicotine content (0.0% vs. 0.05% vs. 0.5%) and price (low vs. high). Participants were randomized to receive menus with either a pictorial + text health-warning message or no message (between-subjects attribute). Multinomial logit regression models evaluated the influence of these attributes on waterpipe smoking choices. Across all four samples (n = 1859), participants preferred fruit-flavored varieties to tobacco flavor, lower nicotine content and lower prices. Exposure to the health warning did not significantly predict likelihood to opt-out. Flavor accounted for 81.4% of waterpipe smoking decisions. Limiting the use of fruit flavors in waterpipe tobacco, in addition to accurate nicotine content labeling and higher pricing may be effective at curbing the demand for waterpipe smoking among young adults.

The development of an Android platform to undertake a discrete choice experiment in a low resource setting

Background

Discrete choice experiment (DCE) is a quantitative technique which helps determine preferences from a definite set of choices. DCEs have been widely used to inform health services in high-income country settings and is gradually being used in low and middle-income countries (LMICs). There are challenges in deploying this method in LMIC settings due to the contextual, cultural and language related barriers. Most DCEs are conducted using paper-based tools. With mobile technology readily accessible across LMICs, we developed an Android-based platform to conduct a DCE among community health workers (CHWs) in rural India.

Methods

This paper describes the development of a DCE for low-literacy community health workers (CHWs) in low-resourced setting on an Android platform. We illustrate the process of identifying realistic and locally relevant attributes, finalising the tool and cognitively testing it among respondents with an average of 10 years of education using 'think aloud' and 'verbal probing' techniques. The Android application was tested in two rounds, first by the research team and second, by the CHWs. The 'think aloud' and 'verbal probing' techniques were essential in assessing the comprehension of the CHWs to the DCE choices.

Results

The CHWs did not take much time to familiarize themselves with the Android application. Compared to the paper based DCE, the time required for data collection using the Android application was reduced by 50%. We found the Android-based app to be more efficient and time saving as it reduced errors in data collection, eliminated the process of data entry and presented the data for analysis in real time.

Conclusion

Electronic administration of DCE on Android computer tablets to CHWs with basic education is more efficient, time-saving than paper-based survey designs once the application is provided. It is feasible to use technology to develop and implement DCEs among participants with basic education in resource poor settings.

Comparison of weighting methods used in multicriteria decision analysis frameworks in healthcare with focus on low- and middle-income countries

AIM

Criteria weighting is a key element of multicriteria decision analysis that is becoming extensively used in healthcare decision-making. In our narrative review we describe the advantages and disadvantages of various weighting methods.

METHODS

An assessment of the eight identified primary criteria weighting methods was compiled on domains including their resource requirements, and potential for bias.

RESULTS

In general, we found more complex methods to have less potential for bias; however, resource intensity and general participant burden is greater for these methods.

CONCLUSION

The selection of the most appropriate method depends on the decision-making context. The simple multiattribute rating technique (SMART) method combined with swing-weighting technique and the analytic hierarchy process methods may be the most feasible approaches for low- and middle-income countries.

Transforming Mental Health Delivery Through Behavioral Economics and Implementation Science: Protocol for Three Exploratory Projects

BACKGROUND

Efficacious psychiatric treatments are not consistently deployed in community practice, and clinical outcomes are attenuated compared with those achieved in clinical trials. A major focus for mental health services research is to develop effective and cost-effective strategies that increase the use of evidence-based assessment, prevention, and treatment approaches in community settings.

OBJECTIVE

The goal of this program of research is to apply insights from behavioral economics and participatory design to advance the science and practice of implementing evidence-based practice (EBP) for individuals with psychiatric disorders across the life span.

METHODS

Project 1 (Assisting Depressed Adults in Primary care Treatment [ADAPT]) is patient-focused and leverages decision-making heuristics to compare ways to incentivize adherence to antidepressant medications in the first 6 weeks of treatment among adults newly diagnosed with depression. Project 2 (App for Strengthening Services In Specialized Therapeutic Support [ASSISTS]) is provider-focused and utilizes normative pressure and social status to increase data collection among community mental health workers treating children with autism. Project 3 (Motivating Outpatient Therapists to Implement: Valuing a Team Effort [MOTIVATE]) explores how participatory design can be used to design organizational-level implementation strategies to increase clinician use of EBPs. The projects are supported by a Methods Core that provides expertise in implementation science, behavioral economics, participatory design, measurement, and associated statistical approaches.

RESULTS

Enrollment for project ADAPT started in 2018; results are expected in 2020. Enrollment for project ASSISTS will begin in 2019; results are expected in 2021. Enrollment for project MOTIVATE started in 2018; results are expected in 2019. Data collection had begun for ADAPT and MOTIVATE when this protocol was submitted.

CONCLUSIONS

This research will advance the science of implementation through efforts to improve implementation strategy design, measurement, and statistical methods. First, we will test and refine approaches to collaboratively design implementation strategies with stakeholders (eg, discrete choice experiments and innovation tournaments). Second, we will refine the measurement of mechanisms related to heuristics used in decision making. Third, we will develop new ways to test mechanisms in multilevel implementation trials. This trifecta, coupled with findings from our 3 exploratory projects, will lead to improvements in our knowledge of what causes successful implementation, what variables moderate and mediate the effects of those causal factors, and how best to leverage this knowledge to increase the quality of care for people with psychiatric disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03441399; https://www.clinicaltrials.gov/ct2/show/NCT03441399 (Archived by WebCite at http://www.webcitation.org/74dRbonBD).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12121.

De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT)

Background

Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial.

Methods/design

This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies.

Discussion

Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring.

Trial registration

ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.

Evidence-Based Dentistry: Two Decades and Beyond

BACKGROUND

In 1999, the American Dental Association proffered a definition of the term evidence-based dentistry, which is still very much used to this day. It stated that "… evidence-based dentistry is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences." Concerted research during the past 2 decades have defined and characterized the protocols that obtain the qualitative and quantitative consensus of the best evidence base. This component of evidence-based dentistry, which is referred to as evidence-based dental research, is brought about as comparative effectiveness research with the research synthesis design. The best evidence base is judiciously used to generate evidence-based clinical practice guidelines, which in turn inform evidence-based dental practice.

DISCUSSION

At this juncture, the complexity of the construct of evidence-based dentistry dictates several avenues of current and future inquiry and development. The most urgent and important of these is undoubtedly to craft and validate novel didactic and practical methodologies to teach evidence-based dentistry-both research and practice-to the next generation of dental researchers and clinical dentists and to optimize the integration of evidence-based dentistry in the dental curriculum. Secondarily, but certainly not of lesser importance, is the need to open and expand new research opportunities in subdomains critical to successful evidence-based dental practice, such as stakeholder engagement, teledentistry, patient-centered care, individual patient data analysis, and health literacy of the patients and caregivers.

CONCLUSIONS

The course that has led evidence-based dentistry from its infancy in 1999 to a state of relative recognition, if not acceptance across academic and private clinical dentistry in the United States and abroad that the field enjoys today, has been arduous. The concerted efforts by researchers and clinicians were aided considerably by the political environment, which, during the years, proffered funding to the Agency for Healthcare Research and Quality and the Patient-Centered Outcome Research Institute. These have been significant catalysts of the field of comparative effectiveness research and evidence-based research in medicine and dentistry and have fostered and defended the pursuit of evidence-based endeavors in translational health care. The road ahead does not promise to be easier in next 2 decades. In fact, it has become all the murkier and more complicated now as phrases such as science based and evidence based have presently been banned and declared politically incorrect.

Coordination of the Environmental influences on Child Health Outcomes program: so the whole is greater than the sum of its parts

PURPOSE OF REVIEW

The Environmental influences on Child Health Outcomes (ECHO) program's mission is to enhance the health of children for generations to come. In this manuscript, we describe the structure of the ECHO Coordinating Center (ECHO-CC) and its role in developing the infrastructure for the ECHO program.

RECENT FINDINGS

The ECHO-CC supports ECHO's mission by developing the framework of the ECHO program, coordinating multiple levels of membership in the ECHO community, developing ECHO policies and procedures, and fostering communication and engagement inside and outside of ECHO.

SUMMARY

The ECHO-CC has used a number of innovative methods for organization, communication, and engagement to enable the ECHO program to become greater than the sum of its parts.