A pragmatic method for costing implementation strategies using time-driven activity-based costing

Developing a Program Costs Checklist of Digital Health Interventions: A Scoping Review and Empirical Case Study

INTRODUCTION

The rate of development and complexity of digital health interventions (DHIs) in recent years has to some extent outpaced the methodological development in economic evaluation and costing. Particularly, the choice of cost components included in intervention or program costs of DHIs have received scant attention. The aim of this study was to build a literature-informed checklist of program cost components of DHIs. The checklist was next tested by applying it to an empirical case, Mamma Mia, a DHI developed to prevent perinatal depression.

METHOD

A scoping review with a structured literature search identified peer-reviewed literature from 2010 to 2022 that offers guidance on program costs of DHIs. Relevant guidance was summarized and extracted elements were organized into categories of main cost components and their associated activities following the standard three-step approach, that is, activities, resource use and unit costs.

RESULTS

Of the 3448 records reviewed, 12 studies met the criteria for data extraction. The main cost categories identified were development, research, maintenance, implementation and health personnel involvement (HPI). Costs are largely considered to be context-specific, may decrease as the DHI matures and vary with number of users. The five categories and their associated activities constitute the checklist. This was applied to estimate program costs per user for Mamma Mia Self-Guided and Blended, the latter including additional guidance from public health nurses during standard maternal check-ups. Excluding research, the program cost per mother was more than double for Blended compared with Self-Guided (€140.5 versus €56.6, 2022 Euros) due to increased implementation and HPI costs. Including research increased the program costs to €190.8 and €106.9, respectively. One-way sensitivity analyses showed sensitivity to changes in number of users, lifespan of the app, salaries and license fee.

CONCLUSION

The checklist can help increase transparency of cost calculation and improve future comparison across studies.

Cost-effectiveness of a Novel Hypoglycaemia Programme: The 'HARPdoc vs BGAT' RCT

AIMS

To assess the cost-effectiveness of HARPdoc (Hypoglycaemia Awareness Restoration Programme for adults with type 1 diabetes and problematic hypoglycaemia despite optimised care), focussed upon cognitions and motivation, versus BGAT (Blood Glucose Awareness Training), focussed on behaviours and education, as adjunctive treatments for treatment-resistant problematic hypoglycaemia in type 1 diabetes, in a randomised controlled trial.

METHODS

Eligible adults were randomised to either intervention. Quality of life (QoL, measured using EQ-5D-5L); cost of utilisation of health services (using the adult services utilization schedule, AD-SUS) and of programme implementation and curriculum delivery were measured. A cost-utility analysis was undertaken using quality-adjusted life years (QALYs) as a measure of trial participant outcome and cost-effectiveness was evaluated with reference to the incremental net benefit (INB) of HARPdoc compared to BGAT.

RESULTS

Over 24 months mean total cost per participant was £194 lower for HARPdoc compared to BGAT (95% CI: -£2498 to £1942). HARPdoc was associated with a mean incremental gain of 0.067 QALYs/participant over 24 months post-randomisation: an equivalent gain of 24 days in full health. The mean INB of HARPdoc compared to BGAT over 24 months was positive: £1521/participant, indicating comparative cost-effectiveness, with an 85% probability of correctly inferring an INB > 0.

CONCLUSIONS

Addressing health cognitions in people with treatment-resistant hypoglycaemia achieved cost-effectiveness compared to an alternative approach through improved QoL and reduced need for medical services, including hospital admissions. Compared to BGAT, HARPdoc offers a cost-effective adjunct to educational and technological solutions for problematic hypoglycaemia.

Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing

STUDY OBJECTIVE

Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding.

METHODS

We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care.

RESULTS

The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively.

CONCLUSION

Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.

Estimating the cost of Rh testing and prophylaxis in early pregnancy: A time-driven activity-based costing study

OBJECTIVE

To estimate the cost of Rhesus (Rh) testing and prophylaxis for first-trimester vaginal bleeding in the ambulatory setting.

STUDY DESIGN

We used time-driven, activity-based costing to analyze tasks associated with Rh testing and prophylaxis of first-trimester vaginal bleeding at one hospital-based outpatient and two independent reproductive health clinics. At each site, we observed 10 patients undergoing Rh-typing and two patients undergoing Rh prophylaxis. We computed the costs of blood Rh-typing by both fingerstick and phlebotomy, cost of locating previous blood type in the electronic health record (available for 69.8% of hospital-based patients), and costs associated with Rh immune globulin prophylaxis. All costs are reported in 2021 US dollars.

RESULTS

The hospital-based clinic reviewed the electronic health record to confirm Rh-status (cost, $26.18 per patient) and performed a phlebotomy, at $47.11 per patient, if none was recorded. The independent clinics typed blood by fingerstick, at a per-patient cost of $4.07. Rh-immune globulin administration costs, including the medication, were similar across facilities, at a mean of $145.66 per patient. Projected yearly costs for testing and prophylaxis were $55,831 for the hospital-based clinic, which was the lowest-volume site, $47,941 for Clinic A, which saw 150 patients/month, and $185,654 for Clinic B, which saw 600 patients/month.

CONCLUSIONS

Rh testing and prophylaxis for first-trimester vaginal bleeding generates considerable costs for outpatient facilities, even for Rh-positive patients with a prior blood type on record.

IMPLICATIONS

Rh testing and prophylaxis for first-trimester bleeding generate considerable costs even for Rh-positive patients and those with a previously known blood type. These findings highlight the need to reconsider this practice, which is no longer supported by evidence and already safely waived in multiple medical settings in the United States and around the world.

Economic evaluations performed alongside randomized implementation trials in clinical settings: a systematic review

BACKGROUND

Economic evaluations alongside implementation trials compare the outcomes and costs of competing implementation strategies to identify the most efficient strategies. The aims of this systematic review were to investigate how economic evaluations are performed in randomized implementation trials in clinical settings and to assess the quality of these evaluations.

METHODS

A systematic literature review was conducted on 23 March 2023 to identify studies that reported on economic evaluations embedded in randomized implementation trials in clinical settings. A systematic search was applied across seven databases, and references of relevant reviews were screened for additional studies. The Drummond Checklist was used to assess the quality and risk of bias of included economic evaluations. Study characteristics and quality assessments were tabulated and described.

RESULTS

Of the 6,550 studies screened for eligibility, 10 met the inclusion criteria. Included studies were published between 1990 and 2022 and from North America, the United Kingdom, Europe, and Africa. Most studies were conducted in the primary and out-patient care setting. Implementation costs included materials, staffing, and training, and the most common approach to collecting implementation costs was obtaining expense and budget reports. Included studies scored medium to high in terms of economic methodological quality.

CONCLUSIONS

Economic evidence is particularly useful for healthcare funders and service providers to inform the prioritization of implementation efforts in the context of limited resources and competing demands. The relatively small number of studies identified may be due to lack of guidance on how to conduct economic evaluations alongside implementation trials and the lack of standardized terminology used to describe implementation strategies in clinical research. We discuss these methodological gaps and present recommendations for embedding economic evaluations in implementation trials. First, reporting implementation strategies used in clinical trials and aligning these strategies with implementation outcomes and costs are an important advancement in clinical research. Second, economic evaluations of implementation trials should follow guidelines for standard clinical trial economic evaluations and adopt an appropriate costing and data collection approach. Third, hybrid trial designs are recommended to generate evidence for effective and cost-effective implementation strategies alongside clinical effectiveness and cost-effectiveness.

TRIAL REGISTRATION

The review was prospectively registered with PROSPERO (CRD42023410186).

Addressing COVID-19 vaccine hesitancy in rural community pharmacies: a protocol for a stepped wedge randomized clinical trial

BACKGROUND

Uptake of COVID-19 vaccines remains problematically low in the USA, especially in rural areas. COVID-19 vaccine hesitancy is associated with lower uptake, which translates to higher susceptibility to SARS-CoV-2 variants in communities where vaccination coverage is low. Because community pharmacists are among the most accessible and trusted health professionals in rural areas, this randomized clinical trial will examine implementation strategies to support rural pharmacists in delivering an adapted evidence-based intervention to reduce COVID-19 vaccine hesitancy.

METHODS

We will use an incomplete stepped wedge trial design in which we will randomize 30 rural pharmacies (unit of analysis) to determine the effectiveness and incremental cost-effectiveness of a standard implementation approach (consisting of online training that describes the vaccine hesitancy intervention, live webinar, and resource website) compared to adding on a virtual facilitation approach (provided by a trained facilitator in support of the delivery of the vaccine hesitancy counseling intervention by pharmacists). The intervention (ASORT) has been adapted from an evidence-based vaccine communication intervention for HPV vaccines through a partnership with rural pharmacies in a practice-based research network in seven southern US states. ASORT teaches pharmacists how to identify persons eligible for COVID-19 vaccination (including a booster), solicit and address vaccine concerns in a non-confrontational way, recommend the vaccine, and repeat the steps later if needed. The primary trial outcome is fidelity to the ASORT intervention, which will be determined through ratings of recordings of pharmacists delivering the intervention. The secondary outcome is the effectiveness of the intervention, determined by rates of patients who agree to be vaccinated after receiving the intervention. Other secondary outcomes include feasibility, acceptability, adoption, reach, and cost. Cost-effectiveness and budget impact analyses will be conducted to maximize the potential for future dissemination and sustainability. Mixed methods will provide triangulation, expansion, and explanation of quantitative findings.

DISCUSSION

This trial contributes to a growing evidence base on vaccine hesitancy interventions and virtual-only facilitation of evidenced-based practices in community health settings. The trial will provide the first estimate of the relative value of different implementation strategies in pharmacy settings.

TRIAL REGISTRATION

NCT05926544 (clinicaltrials.gov); 07/03/2023.

Is it possible to automate the discovery of process maps for the time-driven activity-based costing method? A systematic review

OBJECTIVES

The main objective of this manuscript was to identify the methods used to create process maps for care pathways that utilized the time-driven activity-based costing method.

METHODS

This is a systematic mapping review. Searches were performed in the Embase, PubMed, CINAHL, Scopus, and Web of Science electronic literature databases from 2004 to September 25, 2022. The included studies reported practical cases from healthcare institutions in all medical fields as long as the time-driven activity-based costing method was employed. We used the time-driven activity-based costing method and analyzed the created process maps and a qualitative approach to identify the main fields.

RESULTS

A total of 412 studies were retrieved, and 70 articles were included. Most of the articles are related to the fields of orthopedics and childbirth-related to hospital surgical procedures. We also identified various studies in the field of oncology and telemedicine services. The main methods for creating the process maps were direct observational practices, complemented by the involvement of multidisciplinary teams through surveys and interviews. Only 33% of the studies used hospital documents or healthcare data records to integrate with the process maps, and in 67% of the studies, the created maps were not validated by specialists.

CONCLUSIONS

The application of process mining techniques effectively automates models generated through clinical pathways. They are applied to the time-driven activity-based costing method, making the process more agile and contributing to the visualization of high degrees of variations encountered in processes, thereby making it possible to enhance and achieve continual improvements in processes.

Randomized-controlled trial of a whole-family obesity prevention and treatment intervention designed for low-income Hispanic families: HeLP the healthy living program

BACKGROUND

Low-income Hispanic families face marked disparities in obesity, but interventions for obesity prevention and treatment have rarely been designed with this population as a focus. Hispanic culture is characterized by Familism, a value that prioritizes familial respect, cooperation, and togetherness. We describe the rationale and design of a trial of the Healthy Living Program (HeLP), a bilingual whole-family behavioral obesity prevention and treatment intervention designed around the value Familism and addressing food insecurity.

METHODS/DESIGN

This two-group randomized comparative effectiveness trial will compare the effects of HeLP versus a primary care counseling intervention (Recommended Treatment of Obesity in Primary Care, or RTOP) on decreasing body mass index (BMI; kg/m2) in Hispanic children 2-16 years of age with obesity and preventing BMI increase among siblings without obesity. 164 families per arm will be recruited from primary care practices. Families randomized to HeLP will participate in 12 two-hour sessions, followed by booster sessions. HeLP sessions include family meals and instruction in parenting skills, nutrition, culinary skills, fitness, and mindfulness delivered at community recreation centers by bilingual health educators and athletic trainers. Families randomized to RTOP will be offered individual visits in primary care every 3 months throughout the 18-month follow-up period. Secondary outcomes include changes to objectively measured child fitness, the home environment related to nutrition, physical activity, and media usage, food insecurity, child eating behaviors, quality of life, parent BMI and waist circumference, and implementation outcomes.

DISCUSSION

This protocol paper describes the rationale and planned methods for the comparative effectiveness trial.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT05041855 (6/13/2023).

Implementation costs of sugary drink policies in the United States

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

The Longitudinal Implementation Strategy Tracking System (LISTS): feasibility, usability, and pilot testing of a novel method

BACKGROUND

Systematic approaches are needed to accurately characterize the dynamic use of implementation strategies and how they change over time. We describe the development and preliminary evaluation of the Longitudinal Implementation Strategy Tracking System (LISTS), a novel methodology to document and characterize implementation strategies use over time.

METHODS

The development and initial evaluation of the LISTS method was conducted within the Improving the Management of SymPtoms during And following Cancer Treatment (IMPACT) Research Consortium (supported by funding provided through the NCI Cancer MoonshotSM). The IMPACT Consortium includes a coordinating center and three hybrid effectiveness-implementation studies testing routine symptom surveillance and integration of symptom management interventions in ambulatory oncology care settings. LISTS was created to increase the precision and reliability of dynamic changes in implementation strategy use over time. It includes three components: (1) a strategy assessment, (2) a data capture platform, and (3) a User's Guide. An iterative process between implementation researchers and practitioners was used to develop, pilot test, and refine the LISTS method prior to evaluating its use in three stepped-wedge trials within the IMPACT Consortium. The LISTS method was used with research and practice teams for approximately 12 months and subsequently we evaluated its feasibility, acceptability, and usability using established instruments and novel questions developed specifically for this study.

RESULTS

Initial evaluation of LISTS indicates that it is a feasible and acceptable method, with content validity, for characterizing and tracking the use of implementation strategies over time. Users of LISTS highlighted several opportunities for improving the method for use in future and more diverse implementation studies.

CONCLUSIONS

The LISTS method was developed collaboratively between researchers and practitioners to fill a research gap in systematically tracking implementation strategy use and modifications in research studies and other implementation efforts. Preliminary feedback from LISTS users indicate it is feasible and usable. Potential future developments include additional features, fewer data elements, and interoperability with alternative data entry platforms. LISTS offers a systematic method that encourages the use of common data elements to support data analysis across sites and synthesis across studies. Future research is needed to further adapt, refine, and evaluate the LISTS method in studies with employ diverse study designs and address varying delivery settings, health conditions, and intervention types.

Increasing antiretroviral therapy adherence and retention in care among adults living with HIV in Philadelphia: a study protocol for a stepped-wedge cluster-randomised type 2 hybrid effectiveness-implementation trial of managed problem-solving plus (MAPS+) delivered by community health workers

INTRODUCTION

To end the HIV epidemic in Philadelphia, implementation of evidence-based practices (EBP) to increase viral suppression and retention in HIV care is critical. Managed problem solving (MAPS), an EBP for antiretroviral therapy adherence, follows a problem-solving approach to empower people living with HIV (PWH) to manage their health. To overcome barriers to care experienced by PWH in Philadelphia, the EBP was adapted to include a focus on care retention and delivery by community health workers (CHWs). The adapted intervention is MAPS+. To maximise the clinical impact and reach of the intervention, evaluation of the effectiveness and implementation of MAPS+ is necessary.

METHODS AND ANALYSIS

This manuscript describes the protocol for a stepped-wedge cluster-randomised type 2 hybrid effectiveness-implementation trial in 10 clinics in Philadelphia. This research incorporates innovative approaches to accomplish three objectives: (1) to evaluate the effectiveness of the CHW-led MAPS+ intervention to improve viral suppression and retention in care 1 year after the individual implementation period (N=390 participants), (2) to examine the effect of the menu of implementation strategies on reach and implementation cost and (3) to examine processes, mechanisms, and sustainment of the implementation strategies for MAPS+ (N=56 participants). Due to various factors (eg, COVID-19), protocol modifications have occurred.

ETHICS AND DISSEMINATION

The institutional review board (IRB) at the city of Philadelphia serves as the primary IRB; initial approval was granted on 21 December 2020. The University of Pennsylvania and Northwestern University executed reliance agreements. A safety monitoring committee comprised experts in implementation science, biostatistics and infectious diseases oversee this study. This research will offer insights into achieving the goals to end the HIV epidemic in Philadelphia as well as implementation efforts of MAPS+ and other behavioural interventions aimed at increasing medication adherence and retention in care. Dissemination will include deliverables (eg, peer-reviewed manuscripts and lay publications) to reach multiple constituents.

TRIAL REGISTRATION NUMBER

NCT04560621.

Costs to Implement a Pediatric Weight Management Program Across 3 Distinct Contexts

BACKGROUND

The Connect for Health program is an evidence-based program that aligns with national recommendations for pediatric weight management and includes clinical decision support, educational handouts, and community resources. As implementation costs are a major driver of program adoption and maintenance decisions, we assessed the costs to implement the Connect for Health program across 3 health systems that primarily serve low-income communities with a high prevalence of childhood obesity.

METHODS

We used time-driven activity-based costing methods. Each health system (site) developed a process map and a detailed report of all implementation actions taken, aligned with major implementation requirements (eg, electronic health record integration) or strategies (eg, providing clinician training). For each action, sites identified the personnel involved and estimated the time they spent, allowing us to estimate the total costs of implementation and breakdown costs by major implementation activities.

RESULTS

Process maps indicated that the program integrated easily into well-child visits. Overall implementation costs ranged from $77,103 (Prisma Health) to $84,954 (Denver Health) to $142,721 (Massachusetts General Hospital). Across implementation activities, setting up the technological aspects of the program was a major driver of costs. Other cost drivers included training, engaging stakeholders, and audit and feedback activities, though there was variability across systems based on organizational context and implementation choices.

CONCLUSIONS

Our work highlights the major cost drivers of implementing the Connect for Health program. Accounting for context-specific considerations when assessing the costs of implementation is crucial, especially to facilitate accurate projections of implementation costs in future settings.

The Costs of Implementing a Conversation Aid for Uterine Fibroids in Multiple Health Care Settings

BACKGROUND

Health care organizations considering adopting a conversation aid (CA), a type of patient decision aid innovation, need information about the costs of implementation.

OBJECTIVES

The aims of this study were to: (1) calculate the costs of introducing a CA in a study of supported implementation in 5 gynecologic settings that manage individuals diagnosed with uterine fibroids and (2) estimate the potential costs of future clinical implementation efforts in hypothetical settings.

RESEARCH DESIGN

We used time-driven activity-based costing to estimate the costs of CA implementation at multiple steps: integration with an electronic health record, preimplementation, implementation, and sustainability. We then estimated costs for 2 disparate hypothetical implementation scenarios.

SUBJECTS AND DATA COLLECTION

We conducted semistructured interviews with participants and examined internal documentation.

RESULTS

We interviewed 41 individuals, analyzed 51 documents and 100 emails. Overall total implementation costs over ∼36 months of activities varied significantly across the 5 settings, ranging from $14,157 to $69,134. Factors influencing costs included size/complexity of the setting, urban/rural location, practice culture, and capacity to automate patient identification. Initial investments were substantial, comprising mostly personnel time. Settings that embedded CA use into standard workflows and automated identification of appropriate patients had the lowest initial investment and sustainability costs. Our estimates of the costs of sustaining implementation were much lower than initial investments and mostly attributable to CA subscription fees.

CONCLUSION

Initiation and implementation of the interventions require significant personnel effort. Ongoing costs to maintain use are much lower and are a small fraction of overall organizational operating costs.

The Price of Practice Change: Assessing the Cost of Integrating Research Findings Into Clinical Practice

BACKGROUND

Clinicians, health care administrators, and implementation scientists know that it takes intentional effort, resources, and implementation strategies to integrate research findings into routine clinical practice. An oft-cited concern for those considering whether and how to implement an evidence-based program is how much it will cost to implement the change. Yet information about the cost of implementation is not often available to health care decision-makers. Teams that received Implementation Award funding from PCORI are conducting implementation projects to promote the uptake of evidence-based practices in health care settings. As part of their implementation efforts, a number of teams have examined the costs of implementation. In this Topical Collection, 5 teams will report their findings on implementation costs and discuss their methods for data collection and analysis.

DISCUSSION

The teams' costing efforts provide specific information about the costs sites can expect to incur in promoting the uptake of specific evidence-based programs. In addition, the papers illuminate 3 key features of the teams' approaches to measuring the cost of implementation: (1) the use of specific micro-costing methods with time-driven activity-based costing serving as the most popular method; (2) different ways to categorize and organize costs, including a site-based and non-site-based framework; and (3) cost collection challenges experienced by the teams.

CONCLUSION

The cost of implementation is a critical consideration for organizations seeking to improve practice in accordance with research findings. This Topical Collection describes detailed approaches to providing this type of cost information and highlights insights to be gained from a rigorous focus on implementation cost.

Economic Evaluation of Novel Models of Care for Patients With Acute Medical Problems

Importance

During COVID-19, Singapore simultaneously experienced a dengue outbreak, and acute hospitals were under pressure to lower bed occupancy rates. This led to new models of care to treat patients with acute, low-severity medical conditions either at home, in a hospital-at-home (HaH) model, or in a clinic-style setting sited at the emergency department in an ambulatory care team (ACT) model, but a reliable cost analysis for these models is lacking.

Objective

To compare personnel costs of HaH and ACT with inpatient care.

Design, Setting, and Participants

In this economic evaluation study, time-driven activity-based costing was used to compare the personnel cost of inpatient care with treating dengue via HaH and treating chest pain via ACT. Participants were patients with nonsevere dengue and chest pain unrelated to a coronary event admitted via the emergency department to the internal medicine service of a tertiary hospital in Singapore.

Exposures

HaH for dengue and ACT for chest pain.

Main Outcomes and Measures

A process map was created for the patient journey for a typical patient with each condition. The amount of time personnel spent on delivering care was estimated and the cost per minute determined based on their wages in 2022. The total cost of care was calculated by multiplying the time spent by the per-minute cost of the personnel resource and summing all costs.

Results

Compared with inpatient care, HaH used 50% less nursing time (418 minutes, 95% uncertainty interval [UI], 370 to 465 minutes) but 80% more medical time (303 minutes, 95% UI, 270 to 338 minutes) per case of dengue. If implemented nationally, HaH would save an estimated 56 828 SGD per year (95% UI, -169 497 to 281 412 SGD [US $41 856; 95% UI, -$124 839 to $207 268]). The probability that HaH is cost saving was 69.2%. Compared with inpatient care, ACT used 15% less nursing time (296 minutes, 95% UI, 257 to 335 minutes) and 50% less medical time (57 minutes, 95% UI, 46 to 69 minutes) per case of chest pain. If implemented nationally, ACT would save an estimated 1 561 185 SGD per year (95% UI, 1 040 666 to 2 086 518 SGD [US $1 149 862; 95% UI, $766 483 to $1 536 786]). The probability that ACT is cost saving was 100%.

Conclusions and Relevance

This economic evaluation found that the HaH and ACT models decreased the overall personnel cost of care. Reorganizing hospital resources may help hospitals reap the benefits of reduced hospital-acquired infections, improved patient recovery, and reduced hospital bed occupancy rates.

Challenges and recommendations for measuring time devoted to implementation and intervention activities in health equity-focused, resource-constrained settings: a qualitative analysis

BACKGROUND

There is little guidance for conducting health equity-focused economic evaluations of evidence-based practices in resource-constrained settings, particularly with respect to staff time use. Investigators must balance the need for low-touch, non-disruptive cost data collection with the need for data on providing services to priority subpopulations.

METHODS

This investigation took place within a pilot study examining the implementation of a bundled screening intervention combining screening for social determinants of health and colorectal cancer at four federally qualified health centers (FQHCs) in the Boston metropolitan area. Methods for collecting data on personnel costs for implementation and intervention activities, including passive (automatic) and active (non-automatic, requiring staff time and effort) data collection, as well as three alternate wordings for self-reporting time-use, were evaluated qualitatively using data collected through interviews with FQHC staff (including clinicians, population health staff, and community health workers) and assessments of data completeness.

RESULTS

Passive data collection methods were simple to execute and resulted in no missing data, but missed implementation and intervention activities that took place outside planned meetings. Active cost data collection using spreadsheets was simple for users when applied to care processes already tracked in this fashion and yielded accurate time use data. However, for tasks where this was not typical, and when tasks were broken up over multiple sessions, spreadsheets were more challenging to use. Questions asking about time use for a typical rather than specific time period, and for typical patients, yielded the most reliable and actionable data. Still, even the best-performing question had substantial variability in time use estimates. Participants noted that patient characteristics of interest for equity-focused research, including language spoken, adverse social determinants of health, and issues related to poverty or mental health, all contributed significantly to this variability.

CONCLUSIONS

Passively collected time use data are the least burdensome and should be pursued in research efforts when possible, but should be accompanied by qualitative assessments to ensure the data are an accurate reflection of effort. When workflows are already tracked by active data collection, these are also strong data collection methods. Self-reported time use will be most accurate when questions inquire about "typical" tasks and specific types of patients.

Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder

BACKGROUND

The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program.

METHODS

We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data.

RESULTS

The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages.

CONCLUSIONS

Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.

Programmatic Costs of Project ImPACT for Children with Autism: A Time-Driven Activity Based Costing Study

Programmatic cost assessment of clinical interventions can inform future dissemination and implementation efforts. We conducted a randomized trial of Project ImPACT (Improving Parents As Communication Teachers) in which community early intervention (EI) providers coached caregivers in techniques to improve young children's social communication skills. We estimated implementation and intervention costs while demonstrating an application of Time-Driven Activity-Based Costing (TDABC). We defined Project ImPACT implementation and intervention as processes that can be broken down successively into a set of procedures. We created process maps for both implementation and intervention delivery. We determined resource use and costs, per unit procedure in the first year of the program, from a payer perspective. We estimated total implementation cost per clinician and per site, intervention cost per child, and provided estimates of total hours spent and associated costs for implementation strategies, intervention activities and their detailed procedures. Total implementation cost was $43,509 per clinic and $14,503 per clinician. Clinician time (60%) and coach time (12%) were the most expensive personnel resources. Implementation coordination and monitoring (47%), ongoing consultation (26%) and clinician training (19%) comprised most of the implementation cost, followed by fidelity assessment (7%), and stakeholder engagement (1%). Per-child intervention costs were $2619 and $9650, respectively, at a dose of one hour per week and four hours per week Project ImPACT. Clinician and clinic leader time accounted for 98% of per child intervention costs. Highest cost intervention activity was ImPACT delivery to parents (89%) followed by assessment for child's ImPACT eligibility (10%). The findings can be used to inform funding and policy decision-making to enhance early intervention options for young children with autism. Uncompensated time costs of clinicians are large which raises practical and ethical concerns and should be considered in planning of implementation initiatives. In program budgeting, decisionmakers should anticipate resource needs for coordination and monitoring activities. TDABC may encourage researchers to assess costs more systematically, relying on process mapping and gathering prospective data on resource use and costs concurrently with their collection of other trial data.

A coordinated approach for managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication Therapy Management (pMTM) randomized controlled trial

BACKGROUND

Children with medical complexity (CMC) often rely upon the use of multiple medications to sustain quality of life and control substantial symptom burden. Pediatric polypharmacy (≥ 5 concurrent medications) is prevalent and increases the risk of medication-related problems (MRPs). Although MRPs are associated with pediatric morbidity and healthcare utilization, polypharmacy is infrequently assessed during routine clinical care for CMC. The aim of this randomized controlled trial is to determine if a structured pharmacist-led Pediatric Medication Therapy Management (pMTM) intervention reduces MRP counts, as well as the secondary outcomes of symptom burden and acute healthcare utilization.

METHODS

This is a hybrid type 2 randomized controlled trial assessing the effectiveness of pMTM compared to usual care in a large, patient-centered medical home for CMC. Eligible patients include all children ages 2-18 years old, with ≥ 1 complex chronic condition, and with ≥ 5 active medications, as well as their English-speaking primary caregivers. Child participants and their primary parental caregivers will be randomized to pMTM or usual care before a non-acute primary care visit and followed for 90 days. Using generalized linear models, the overall effectiveness of the intervention will be evaluated using total MRP counts at 90 days following pMTM intervention or usual care visit. Following attrition, a total of 296 CMC will contribute measurements at 90 days, which provides > 90% power to detect a clinically significant 1.0 reduction in total MRPs with an alpha level of 0.05. Secondary outcomes include Parent-Reported Outcomes of Symptoms (PRO-Sx) symptom burden scores and acute healthcare visit counts. Program replication costs will be assessed using time-driven activity-based scoring.

DISCUSSION

This pMTM trial aims to test hypotheses that a patient-centered medication optimization intervention delivered by pediatric pharmacists will result in lower MRP counts, stable or improved symptom burdens, and fewer cumulative acute healthcare encounters at 90 days following pMTM compared to usual care. The results of this trial will be used to quantify medication-related outcomes, safety, and value for a high-utilization group of CMC, and outcomes may elucidate the role of integrated pharmacist services as a key component of outpatient complex care programs for this priority pediatric population.

TRIAL REGISTRATION

This trial was prospectively registered at clinicaltrials.gov (NCT05761847) on Feb 25, 2023.

Financial Impact of a Culturally Sensitive Hispanic Kidney Transplant Program on Increasing Living Donation

BACKGROUND

In the United States, Hispanic/Latinx patients receive disproportionately fewer living donor kidney transplants (LDKTs) than non-Hispanic White patients. Northwestern Medicine's culturally targeted Hispanic Kidney Transplant Program (HKTP) was found to increase LDKTs in Hispanic patients at 1 of 2 transplant programs with greater implementation fidelity.

METHODS

We conducted a budget impact analysis to evaluate HKTP's impact on program financial profiles from changes in volume of LDKTs and deceased donor kidney transplants (DDKTs) in 2017 to 2019. We estimated HKTP programmatic costs, and kidney transplant (KT) program costs and revenues. We forecasted transplant volumes, HKTP programmatic costs, and KT program costs and revenues for 2022-2024.

RESULTS

At both programs, HKTP programmatic costs had <1% impact on total KT program costs, and HKTP programmatic costs comprised <1% of total KT program revenues in 2017-2019. In particular, the total volume of Hispanic KTs and HKTP LDKTs increased at both sites. Annual KT program revenues of HKTP LDKTs and DDKTs increased by 226.9% at site A and by 1042.9% at site B when comparing 2019-2017. Forecasted HKTP LDKT volume showed an increase of 36.4% (site A) and 33.3% (site B) with a subsequent increase in KT program revenues of 42.3% (site A) and 44.3% (site B) among HKTP LDKTs and DDKTs.

CONCLUSIONS

HKTP programmatic costs and KT evaluation costs are potentially recoverable by reimbursement of organ acquisition costs and offset by increases in total KT program revenues of LDKTs; transplant programs may find implementation of the HKTP financially manageable.

Implementation costs of hospital-based computerised decision support systems: a systematic review

BACKGROUND

The importance of accurately costing implementation strategies is increasingly recognised within the field of implementation science. However, there is a lack of methodological guidance for costing implementation, particularly within digital health settings. This study reports on a systematic review of costing analyses conducted alongside implementation of hospital-based computerised decision support systems.

METHODS

PubMed, Embase, Scopus and CINAHL databases were searched between January 2010 and August 2021. Two reviewers independently screened and selected original research studies that were conducted in a hospital setting, examined the implementation of a computerised decision support systems and reported implementation costs. The Expert Recommendations for Implementing Change Framework was used to identify and categorise implementation strategies into clusters. A previously published costing framework was applied to describe the methods used to measure and value implementation costs. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

Titles and abstracts of 1836 articles were screened, with nine articles eligible for inclusion in the review. Implementation costs were most frequently reported under the 'evaluative and iterative strategies' cluster, followed by 'provide interactive assistance'. Labour was the largest implementation-related cost in the included papers, irrespective of implementation strategy. Other reported costs included consumables, durable assets and physical space, which was mostly associated with stakeholder training. The methods used to cost implementation were often unclear. There was variation across studies in the overall quality of reporting.

CONCLUSIONS

A relatively small number of papers have described computerised decision support systems implementation costs, and the methods used to measure and value these costs were not well reported. Priorities for future research should include establishing consistent terminology and appropriate methods for estimating and reporting on implementation costs.

TRIAL REGISTRATION

The review protocol is registered with PROSPERO (ID: CRD42021272948).

Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project

BACKGROUND

Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs.

METHODS

For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months.

DISCUSSION

This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention.

TRIAL REGISTRATION

Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618.

Economic evaluation of implementation science outcomes in low- and middle-income countries: a scoping review

BACKGROUND

Historically, the focus of cost-effectiveness analyses has been on the costs to operate and deliver interventions after their initial design and launch. The costs related to design and implementation of interventions have often been omitted. Ignoring these costs leads to an underestimation of the true price of interventions and biases economic analyses toward favoring new interventions. This is especially true in low- and middle-income countries (LMICs), where implementation may require substantial up-front investment. This scoping review was conducted to explore the topics, depth, and availability of scientific literature on integrating implementation science into economic evaluations of health interventions in LMICs.

METHODS

We searched Web of Science and PubMed for papers published between January 1, 2010, and December 31, 2021, that included components of both implementation science and economic evaluation. Studies from LMICs were prioritized for review, but papers from high-income countries were included if their methodology/findings were relevant to LMIC settings.

RESULTS

Six thousand nine hundred eighty-six studies were screened, of which 55 were included in full-text review and 23 selected for inclusion and data extraction. Most papers were theoretical, though some focused on a single disease or disease subset, including: mental health (n = 5), HIV (n = 3), tuberculosis (n = 3), and diabetes (n = 2). Manuscripts included a mix of methodology papers, empirical studies, and other (e.g., narrative) reviews. Authorship of the included literature was skewed toward high-income settings, with 22 of the 23 papers featuring first and senior authors from high-income countries. Of nine empirical studies included, no consistent implementation cost outcomes were measured, and only four could be mapped to an existing costing or implementation framework. There was also substantial heterogeneity across studies in how implementation costs were defined, and the methods used to collect them.

CONCLUSION

A sparse but growing literature explores the intersection of implementation science and economic evaluation. Key needs include more research in LMICs, greater consensus on the definition of implementation costs, standardized methods to collect such costs, and identifying outcomes of greatest relevance. Addressing these gaps will result in stronger links between implementation science and economic evaluation and will create more robust and accurate estimates of intervention costs.

TRIAL REGISTRATION

The protocol for this manuscript was published on the Open Science Framework. It is available at: https://osf.io/ms5fa/ (DOI: 10.17605/OSF.IO/32EPJ).

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial

Background

Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown.

Methods

The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16–19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16–19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems).

Discussion

The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease.

Trial registration

ClinicalTrials.gov,NCT05132322. Registered on November 10, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01246-z.

Required sample size to detect mediation in 3-level implementation studies

Background

Statistical tests of mediation are important for advancing implementation science; however, little research has examined the sample sizes needed to detect mediation in 3-level designs (e.g., organization, provider, patient) that are common in implementation research. Using a generalizable Monte Carlo simulation method, this paper examines the sample sizes required to detect mediation in 3-level designs under a range of conditions plausible for implementation studies.

Method

Statistical power was estimated for 17,496 3-level mediation designs in which the independent variable (X) resided at the highest cluster level (e.g., organization), the mediator (M) resided at the intermediate nested level (e.g., provider), and the outcome (Y) resided at the lowest nested level (e.g., patient). Designs varied by sample size per level, intraclass correlation coefficients of M and Y, effect sizes of the two paths constituting the indirect (mediation) effect (i.e., X→M and M→Y), and size of the direct effect. Power estimates were generated for all designs using two statistical models—conventional linear multilevel modeling of manifest variables (MVM) and multilevel structural equation modeling (MSEM)—for both 1- and 2-sided hypothesis tests.

Results

For 2-sided tests, statistical power to detect mediation was sufficient (≥0.8) in only 463 designs (2.6%) estimated using MVM and 228 designs (1.3%) estimated using MSEM; the minimum number of highest-level units needed to achieve adequate power was 40; the minimum total sample size was 900 observations. For 1-sided tests, 808 designs (4.6%) estimated using MVM and 369 designs (2.1%) estimated using MSEM had adequate power; the minimum number of highest-level units was 20; the minimum total sample was 600. At least one large effect size for either the X→M or M→Y path was necessary to achieve adequate power across all conditions.

Conclusions

While our analysis has important limitations, results suggest many of the 3-level mediation designs that can realistically be conducted in implementation research lack statistical power to detect mediation of highest-level independent variables unless effect sizes are large and 40 or more highest-level units are enrolled. We suggest strategies to increase statistical power for multilevel mediation designs and innovations to improve the feasibility of mediation tests in implementation research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01235-2.

Cost-effectiveness and cost-utility of hypertension and hyperlipidemia collaborative management between pharmacies and primary care in portugal alongside a trial compared with usual care (USFarmácia®)

Background: There is little experience in the economic evaluation of pharmacy/primary care collaborative health interventions using interprofessional technology-driven communication under real-world conditions. This study aimed to conduct cost-effectiveness and cost-utility analyses of a collaborative care intervention in hypertension and hyperlipidemia management between pharmacies and primary care versus usual (fragmented) care alongside a trial.

Methods: An economic evaluation was conducted alongside a 6-month pragmatic quasi-experimental controlled trial. Data sources included primary care clinical software; pharmacy dispensing software; patient telephone surveys; and published literature. The target population was adult patients on hypertension and/or lipid-lowering medication. The perspective was societal. We collected patient-level data on resource use to estimate trial costs. Effect outcomes included blood pressure (BP) and quality-adjusted life years (QALYs). Bootstrapping was used to estimate uncertainty around the incremental cost-effectiveness and cost-utility ratios. Cost-effectiveness planes and acceptability curves were estimated.

Results: The intervention was not shown to have reasonable levels of cost-effectiveness or cost-utility when compared to usual care as denoted by the levels of uncertainty expressed in wide confidence intervals. The probability of the intervention being cost-effective is 28% at the threshold of €20,000 per QALY gained and 57% at the threshold of €500 per mmHg systolic BP decrease.

Conclusion: Considering the limitations of the trial which affected effectiveness and economic outcomes, our results are not generalizable for community pharmacy and primary care in Portugal. This research offers, however, valuable lessons on methods and strategies that can be used in future economic evaluations of collaborative public health interventions with the potential for reimbursement.

Clinical trial registration:https://www.isrctn.com/ISRCTN13410498, identifier ISRCTN13410498

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.

Comparing output from two methods of participatory design for developing implementation strategies: traditional contextual inquiry vs. rapid crowd sourcing

Background

Participatory design methods are a key component of designing tailored implementation strategies. These methods vary in the resources required to execute and analyze their outputs. No work to date has examined the extent to which the output obtained from different approaches to participatory design varies.

Methods

We concurrently used two separate participatory design methods: (1) field observations and qualitative interviews (i.e., traditional contextual inquiry) and (2) rapid crowd sourcing (an innovation tournament). Our goal was to generate and compare information to tailor implementation strategies to increase the use of evidence-based data collection practices among one-to-one aides working with children with autism. Each method was executed and analyzed by study team members blinded to the output of the other method. We estimated the personnel time and monetary costs associated with each method to further facilitate comparison.

Results

Observations and interviews generated nearly double the number of implementation strategies (n = 26) than did the innovation tournament (n = 14). When strategies were classified into implementation strategies from the Expert Recommendations for Implementing Change (ERIC) taxonomy, there was considerable overlap in the content of identified strategies. However, strategies derived from observations and interviews were more specific than those from the innovation tournament. Five strategies (13%) reflected content unique to observations and interviews and 3 (8%) strategies were unique to the innovation tournament. Only observations and interviews identified implementation strategies related to adapting and tailoring to context; only the innovation tournament identified implementation strategies that used incentives. Observations and interviews required more than three times the personnel hours than the innovation tournament, but the innovation tournament was more costly overall due to the technological platform used.

Conclusions

There was substantial overlap in content derived from observations and interviews and the innovation tournament, although there was greater specificity in the findings from observations and interviews. However, the innovation tournament yielded unique information. To select the best participatory design approach to inform implementation strategy design for a particular context, researchers should carefully consider unique advantages of each method and weigh the resources available to invest in the process.

Scoping review of costs of implementation strategies in community, public health and healthcare settings

OBJECTIVES

To identify existing evidence concerning the cost of dissemination and implementation (D&I) strategies in community, public health and health service research, mapped with the 'Expert Recommendations for Implementing Change' (ERIC) taxonomy.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus and the Cochrane Library were searched to identify any English language reports that had been published between January 2008 and December 2019 concerning the cost of D&I strategies.

DATA EXTRACTION

We matched the strategies identified in each article using ERIC taxonomies; further classified them into five areas (eg, dissemination, implementation, integration, capacity building and scale-up); and extracted the corresponding costs (total costs and cots per action target and per evidence-based programme (EBP) participant). We also recorded the reported level of costing methodology used for cost assessment of D&I strategies.

RESULTS

Of the 6445 articles identified, 52 studies were eligible for data extraction. Lack of D&I strategy cost data was the predominant reason (55% of the excluded studies) for study exclusion. Predominant topic, setting, country and research design in the included studies were mental health (19%), primary care settings (44%), the US (35%) and observational (42%). Thirty-five (67%) studies used multicomponent D&I strategies (ranging from two to five discrete strategies). The most frequently applied strategies were Conduct ongoing training (50%) and Conduct educational meetings (23%). Adoption (42%) and reach (27%) were the two most frequently assessed outcomes. The overall costs of Conduct ongoing training ranged from $199 to $105 772 ($1-$13 973 per action target and $0.02-$412 per EBP participant); whereas the cost of Conduct educational meetings ranged from $987 to $1.1-$2.9 million/year ($33-$54 869 per action target and $0.2-$146 per EBP participant). The wide range of costs was due to the varying scales of the studies, intended audiences/diseases and the complexities of the strategy components. Most studies presented limited information on costing methodology, making interpretation difficult.

CONCLUSIONS

The quantity of published D&I strategy cost analyses is increasing, yet guidance on conducting and reporting of D&I strategy cost analysis is necessary to facilitate and promote the application of comparative economic evaluation in the field of D&I research.

Implementation initiatives to improve low back pain care in Australia: a scoping review

OBJECTIVE

This scoping review aimed to comprehensively review strategies for implementation of low back pain (LBP) guidelines, policies and models of care in the Australian healthcare system.

METHODS

A literature search was conducted in MEDLINE, EMBASE, CINAHL, Amed and Web of Science to identify studies that aimed to implement or integrate evidence-based interventions/practices to improve LBP care within Australian settings.

RESULTS

Twenty-five studies met the inclusion criteria. Most studies targeted primary care settings (n = 13). Other settings included tertiary care (n = 4), community (n = 4), pharmacies (n = 3). One study targeted both primary and tertiary care settings (n = 1). Only 40% of the included studies reported an underpinning framework, model or theory. Implementation strategies most frequently used were evaluative and iterative strategies (n = 14, 56%) and train and educate stakeholders (n = 13, 52%), followed by engage consumers (n = 6, 24%), develop stakeholder relationships (n = 4, 16%), change in infrastructure (n = 4, 16%) and support clinicians (n = 3, 12%). The most common implementation outcomes considered were acceptability (n = 11, 44%) and adoption (n = 10, 40%), followed by appropriateness (n = 7, 28%), cost (n = 3, 12%), feasibility (n = 1, 4%) and fidelity (n = 1, 4%). Barriers included time constraints, funding, and teamwork availability. Facilitators included funding and collaboration between stakeholders.

CONCLUSIONS

Implementation research targeting LBP appears to be a young field, mostly focusing on training and educating stakeholders in primary care. Outcomes on sustainability and penetration of evidence-based interventions are lacking. There is a need for implementation research guided by established frameworks that consider interrelationships between organisational and system contexts beyond the clinician-patient dyad.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations

BACKGROUND

Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care.

METHODS

The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective.

RESULTS

Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate.

CONCLUSIONS

As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03590470 ).

Protocol for the process evaluation of a counselling intervention designed to educate cancer patients on complementary and integrative health care and promote interprofessional collaboration in this area (the CCC-Integrativ study)

Background

Conducting a process evaluation is essential to understand how health interventions work in different healthcare settings. Particularly in the case of complex interventions, it is important to find out whether the intervention could be carried out as planned and which factors had a beneficial or hindering effect on its implementation. The aim of this study is to present the detailed protocol of the process evaluation embedded in the controlled implementation study CCC-Integrativ aiming to implement an interprofessional counselling program for cancer patients on complementary and integrative health care (CIH).

Methods

This mixed methods study will draw upon the “Consolidated Framework for Implementation Research” (CFIR) combined with the concept of “intervention fidelity” to evaluate the quality of the interprofessional counselling sessions, to explore the perspective of the directly and indirectly involved healthcare staff, as well as to analyze the perceptions and experiences of the patients. The qualitative evaluation phase consists of analyzing audio-recorded counselling sessions, as well as individual and group interviews with the involved persons. The quantitative evaluation phase applies questionnaires which are distributed before (T0), at the beginning (T1), in the middle (T2) and at the end (T3) of the intervention delivery.

Discussion

This protocol provides an example of how a process evaluation can be conducted parallel to a main study investigating and implementing a complex intervention. The results of this mixed methods research will make it possible to identify strengths and weaknesses of the team-based intervention, and to target more specifically the key factors and structures required to implement healthcare structures to meet patients’ unmet needs in the context of CIH. To our knowledge, this study is the first applying the CFIR framework in the context of interprofessional CIH counselling, and its results are expected to provide comprehensive and multidisciplinary management of cancer patients with complex supportive healthcare needs.

Extending analytic methods for economic evaluation in implementation science

Background

Economic evaluations of the implementation of health-related evidence-based interventions (EBIs) are conducted infrequently and, when performed, often use a limited set of quantitative methods to estimate the cost and effectiveness of EBIs. These studies often underestimate the resources required to implement and sustain EBIs in diverse populations and settings, in part due to inadequate scoping of EBI boundaries and underutilization of methods designed to understand the local context. We call for increased use of diverse methods, especially the integration of quantitative and qualitative approaches, for conducting and better using economic evaluations and related insights across all phases of implementation.

Main body

We describe methodological opportunities by implementation phase to develop more comprehensive and context-specific estimates of implementation costs and downstream impacts of EBI implementation, using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We focus specifically on the implementation of complex interventions, which are often multi-level, resource-intensive, multicomponent, heterogeneous across sites and populations, involve many stakeholders and implementation agents, and change over time with respect to costs and outcomes. Using colorectal cancer (CRC) screening EBIs as examples, we outline several approaches to specifying the “boundaries” of EBI implementation and analyzing implementation costs by phase of implementation. We describe how systems mapping and stakeholder engagement methods can be used to clarify EBI implementation costs and guide data collection—particularly important when EBIs are complex. In addition, we discuss the use of simulation modeling with sensitivity/uncertainty analyses within implementation studies for projecting the health and economic impacts of investment in EBIs. Finally, we describe how these results, enhanced by careful data visualization, can inform selection, adoption, adaptation, and sustainment of EBIs.

Conclusion

Health economists and implementation scientists alike should draw from a larger menu of methods for estimating the costs and outcomes associated with complex EBI implementation and employ these methods across the EPIS phases. Our prior experiences using qualitative and systems approaches in addition to traditional quantitative methods provided rich data for informing decision-making about the value of investing in CRC screening EBIs and long-term planning for these health programs. Future work should consider additional opportunities for mixed-method approaches to economic evaluations.

Pragmatic considerations and approaches for measuring staff time as an implementation cost in health systems and clinics: key issues and applied examples

Background

As the field of implementation science wrestles with the need for system decision-makers to anticipate the budget impact of implementing new programs, there has been a push to report implementation costs more transparently. For this purpose, the method of time-driven activity-based costing (TDABC) has been heralded as a pragmatic advance. However, a recent TDABC review found that conventional methods for estimating staff time remain resource-intensive and called for simpler alternatives. Our objective was to conceptually compare conventional and emerging TDABC approaches to measuring staff time.

Methods

Our environmental scan of TDABC methods identified several categories of approaches for staff time estimation; across these categories, staff time was converted to cost as a pro-rated fraction of salary/benefits. Conventional approaches used a process map to identify each step of program delivery and estimated the staff time used at each step in one of 3 ways: (a) uniform estimates of time needed for commonly occurring tasks (self-report), (b) retrospective “time diary” (self-report), or (c) periodic direct observation. In contrast, novel semi-automated electronic health record (EHR) approaches “nudge” staff to self-report time for specific process map step(s)—serving as a contemporaneous time diary. Also, novel EHR-based automated approaches include timestamps to track specific steps in a process map. We compared the utility of these TDABC approach categories according to the 5 R’s model that measures domains of interest to system decision-makers: relevance, rapidity, rigor, resources, and replicability, and include two illustrative case examples.

Results

The 3 conventional TDABC staff time estimation methods are highly relevant to settings but have limited rapidity, variable rigor, are rather resource-intensive, and have varying replicability. In contrast to conventional TDABC methods, the semi-automated and automated EHR-based approaches have high rapidity, similar rigor, similar replicability, and are less resource-intensive, but have varying relevance to settings.

Conclusions

This synthesis and evaluation of conventional and emerging methods for staff time estimation by TDABC provides the field of implementation science with options beyond the current approaches. The field remains pressed to innovatively and pragmatically measure costs of program delivery that rate favorably across all of the 5 R’s domains.

Using economic evaluations in implementation science to increase transparency in costs and outcomes for organizational decision-makers

Background

Economic evaluations frequently are utilized to compare the value of different interventions in medicine and health in concrete terms. Implementation science also would benefit from the incorporation of economic evaluations, but such studies are rare in the literature. The National Cancer Institute has supported a special collection of articles focusing on economic evaluations in implementation science. Even when interventions are supported by substantial evidence, they are implemented infrequently in the field. Implementation costs are important determinants for whether organizational decision-makers choose to adopt an intervention and whether the implementation process is successful. Economic evaluations, such as cost-effectiveness analyses, can help organizational decision-makers choose between implementation approaches for evidence-based interventions by accounting for costs and succinctly presenting cost/benefit tradeoffs.

Main text

This manuscript presents a discussion of important considerations for incorporating economic evaluations into implementation science. First, the distinction between intervention and implementation costs is presented, along with an explanation of why the comprehensive representation of implementation costs is elusive. Then, the manuscript describes how economic evaluations in implementation science may differ from those in medicine and health intervention studies, especially in terms of determining the perspectives and outcomes of interest. Finally, referencing a scale-up trial of an evidence-based behavioral health intervention, concrete case examples of how cost data can be collected and used in economic evaluations targeting implementation, rather than clinical outcomes, are described.

Conclusions

By gaining a greater understanding of the costs and economic impact associated with different implementation approaches, organizational decision-makers will have better transparency for future replication and scale-up. The use of economic evaluations can help to advance this understanding and provide researchers, purveyors or third-party intermediaries, and organizational decision-makers with essential information to facilitate implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00295-1.

Understanding implementation costs of a pediatric weight management intervention: an economic evaluation protocol

Background

Understanding the cost and/or cost-effectiveness of implementation strategies is crucial for organizations to make informed decisions about the resources needed to implement and sustain evidence-based interventions (EBIs). This economic evaluation protocol describes the methods and processes that will be used to assess costs and cost-effectiveness across implementation strategies used to improve the reach, adoption, implementation, and organizational maintenance of an evidence-based pediatric weight management intervention- Building Health Families (BHF).

Methods

A within-trial cost and cost-effectiveness analysis (CEA) will be completed as part of a hybrid type III effectiveness-implementation trial (HEI) designed to examine the impact of an action Learning Collaborative (LC) strategy consisting of network weaving, consultee-centered training, goal-setting and feedback, and sustainability action planning to improve the adoption, implementation, organizational maintenance, and program reach of BHF in micropolitan and surrounding rural communities in the USA, over a 12-month period. We discuss key features of implementation strategy components and the associated cost collection and outcome measures and present brief examples on what will be included in the CEA for each discrete implementation strategy and how the results will be interpreted. The cost data will be collected by identifying implementation activities associated with each strategy and using a digital-based time tracking tool to capture the time associated with each activity. Costs will be assessed relative to the BHF program implementation and the multicomponent implementation strategy, included within and external to a LC designed to improve reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of BHF. The CEA results will be reported by RE-AIM outcomes, using the average cost-effectiveness ratio or incremental cost-effectiveness ratio. All the CEAs will be performed from the community perspective.

Discussion

The proposed costing approach and economic evaluation framework for dissemination and implementation strategies and EBI implementation will contribute to the evolving but still scant literature on economic evaluation of implementation and strategies used and facilitate the comparative economic analysis.

Trial registration

ClinicalTrials.gov NCT04719442. Registered on January 22, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00287-1.

Time–motion analysis of external facilitation for implementing the Collaborative Chronic Care Model in general mental health clinics: Use of an interval-based data collection approach

Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time–motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time–motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time–motion data. Methods: We analyzed EF time–motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4–6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, “a two-week interval”) at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation’s beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation’s beginning, middle, and end differed from the interval data’s averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time–motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time–motion data.

Cost, cost-consequence and cost-effectiveness evaluation of a practice change intervention to increase routine provision of antenatal care addressing maternal alcohol consumption

Background

Implementation of antenatal clinical guideline recommendations for addressing maternal alcohol consumption is sub-optimal. There is a complete absence of evidence of the cost and cost-effectiveness of delivering practice change interventions addressing maternal alcohol consumption amongst women accessing maternity services. The study sought to determine the cost, cost-consequence and cost-effectiveness of developing and delivering a multi-strategy practice change intervention in three sectors of a health district in New South Wales, Australia.

Methods

The trial-based economic analyses compared the costs and outcomes of the intervention to usual care over the 35-month period of the stepped-wedge trial. A health service provider perspective was selected to focus on the cost of delivering the practice change intervention, rather than the cost of delivering antenatal care itself. All costs are reported in Australian dollars ($AUD, 2019). Univariate and probabilistic sensitivity analyses assessed the effect of variation in intervention effect and costs.

Results

The total cost of delivering the practice change intervention across all three sectors was $367,646, of which $40,871 (11%) were development costs and $326,774 (89%) were delivery costs. Labour costs comprised 70% of the total intervention delivery cost. A single practice change strategy, ‘educational meetings and educational materials’ contributed 65% of the delivery cost. Based on the trial’s primary efficacy outcome, the incremental cost effectiveness ratio was calculated to be $32,570 (95% CI: $32,566–$36,340) per percent increase in receipt of guideline recommended care. Based on the number of women attending the maternity services during the trial period, the average incremental cost per woman who received all guideline elements was $591 (Range: $329 - $940) . The average cost of the intervention per eligible clinician was $993 (Range: $640-$1928).

Conclusion

The intervention was more effective than usual care, at an increased cost. Healthcare funders’ willingness to pay for this incremental effect is unknown. However, the strategic investment in systems change is expected to improve the efficiency of the practice change intervention over time. Given the positive trial findings, further research and monitoring is required to assess the sustainability of intervention effectiveness and whether economies of scale, or reduced costs of intervention delivery can be achieved without impact on outcomes.

Trial registration

The trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01180-6.

Cost data in implementation science: categories and approaches to costing

A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs—the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.

Economic analyses of behavioral health intervention implementation: Perspective on stakeholder engagement

To provide full potential benefits to patients, behavioral health interventions often require comprehensive and systematic implementation efforts. The costs of these efforts should therefore be included when organizations decide to fund or adopt a new intervention. However, existing guidelines for conducting economic analyses like cost-effectiveness analyses and budget impact analyses are not well-suited to the complexity of the behavioral healthcare pathway and its many stakeholders. Stakeholder engagement, when used effectively with recent innovations in economic analysis, advance more equitable access to interventions for individuals living with behavioral health conditions. But early and ongoing stakeholder engagement has not yet been incorporated into best-practice guidelines for economic evaluation. We discuss our perspective, as researchers and clinicians in a large integrated health system, on how the integration of stakeholder engagement with existing economic analysis methods could improve decision-making about implementation of behavioral health interventions.

Reflections on 10 years of effectiveness-implementation hybrid studies

This article provides new reflections and recommendations from authors of the initial effectiveness-implementation hybrid study manuscript and additional experts in their conceptualization and application. Given the widespread and continued use of hybrid studies, critical appraisals are necessary. The article offers reflections across five conceptual and methodological areas. It begins with the recommendation to replace the term "design" in favor of "study." The use of the term "design" and the explicit focus on trial methodology in the original paper created confusion. The essence of hybrid studies is combining research questions concerning intervention effectiveness and implementation within the same study, and this can and should be achieved by applying a full range of research designs. Supporting this recommendation, the article then offers guidance on selecting a hybrid study type based on evidentiary and contextual information and stakeholder concerns/preferences. A series of questions are presented that have been designed to help investigators select the most appropriate hybrid type for their study situation. The article also provides a critique on the hybrid 1-2-3 typology and offers reflections on when and how to use the typology moving forward. Further, the article offers recommendations on research designs that align with each hybrid study type. Lastly, the article offers thoughts on how to integrate costs analyses into hybrid studies.

Moving beyond Aim Three: a need for a transdisciplinary approach to build capacity for economic evaluations in implementation science

BACKGROUND

Understanding the costs and economic benefits of implementation has been identified by policymakers and researchers as critical to increase the uptake and sustainment of evidence-based practices, but this topic remains relatively understudied. Conducting team science with health economists has been proposed as a solution to increase economic evaluation in implementation science; however, these recommendations ignore the differences in goals and perspectives in these two fields. Our recent qualitative research identified that implementation researchers predominantly approach health economists to examine costs, whereas the majority of health economists expressed limited interest in conducting economic evaluations and a desire to be more integrated within implementation science initiatives. These interviews pointed to challenges in establishing fruitful partnerships when health economists are relegated to the "Third Aim" (i.e., lowest-priority research objective) in implementation science projects by their research partners.

DISCUSSION

In this debate paper, we argue that implementation researchers and health economists need to focus on team science research principles to expand capacity to address pressing research questions that cut across the two fields. Specifically, we use the four-phase model of transdisciplinary research to outline the goals and processes needed to build capacity in this area (Hall et al., Transl Behav Med 2:415-30, 2012). The first phase focuses on the development of transdisciplinary research teams, including identifying appropriate partners (e.g., considering policy or public health researchers in addition to health economists) and building trust. The conceptual phase focuses on strategies to consider when developing joint research questions and methodology across fields. In the implementation phase, we outline the effective processes for conducting research projects, such as team learning. Finally, in the translation phase, we highlight how a transdisciplinary approach between health economists and implementation researchers can impact real-world practice and policy. The importance of investigating the economic impact of evidence-based practice implementation is widely recognized, but efforts have been limited due to the challenges in conducting team science across disciplines. Training in team science can help advance transdisciplinary efforts, which has the potential to increase the rigor and impact of economic evaluations in implementation science while expanding the roles taken by health economists.

Market viability: a neglected concept in implementation science

This debate paper asserts that implementation science needs to incorporate a key concept from entrepreneurship—market demand—and demonstrates how assessing an innovation’s potential market viability might advance the pace and success of innovation adoption and sustainment. We describe key concepts, language distinctions, and questions that entrepreneurs pose to implementation scientists—many of which implementation scientists appear ill-equipped to answer. The paper concludes with recommendations about how concepts from entrepreneurship, notably market viability assessment, can enhance the translation of research discoveries into real-world adoption, sustained use, and population health benefits. The paper further proposes activities that can advance implementation science’s capacity to draw from the field of entrepreneurship, along with the data foundations required to assess and cultivate market demand.

Cost analysis of a coaching intervention to increase use of transradial percutaneous coronary intervention

BACKGROUND

The transradial approach (TRA) to cardiac catheterization is safer than the traditional transfemoral approach (TFA), with similar clinical effectiveness. However, adoption of TRA remains low, representing less than 50% of catheterization procedures in 2015. Peer coaching is one approach to facilitate implementation; however, the costs of this strategy for cardiac procedures such as TRA are unclear.

METHODS

We conducted an activity-based costing analysis (ABC) of a multi-center, hybrid type III implementation trial of a coaching intervention designed to increase the use of TRA. We identified the key activities of the intervention and determined the personnel, resources, and time needed to complete each activity. The personnel cost per hour and the activity duration were then used to estimate the cost of each activity and the total variable cost of the implementation. Fixed costs related to designing and running the implementation were calculated separately. All costs are reported in 2019 constant US dollars.

RESULTS

The total cost of the coaching intervention implementation was $374,863. Of the total cost, $367,752 were variable costs due to travel, preparatory work, in-person coaching, post-intervention evaluation, and administrative time. We estimated fixed costs of $7112. The mean marginal cost of implementing the intervention at only one additional medical center was $52,536.

CONCLUSIONS

We provide granular cost estimates of a conceptually rooted implementation strategy designed to increase the uptake of TRA for cardiac catheterization. We estimate that implementation costs stemming from the coaching approach would be offset after the conversion of approximately 409 to 1363 catheterizations from TFA to TRA. Our estimates provide benchmarks of the expected costs of implementing evidence-based, but expertise-intensive, cardiac procedures.

TRIAL REGISTRATION

ISRCTN, ISRCTN66341299 . Registered 7 July 2020-retrospectively registered.

Programmatic Costs of the Telehealth Ostomy Self-Management Training: An Application of Time-Driven Activity-Based Costing

OBJECTIVES

Programmatic cost assessment of novel clinical interventions can inform their widespread dissemination and implementation. This study aimed to determine the programmatic costs of a telehealth Ostomy Self-Management Training (OSMT) intervention for cancer survivors using Time-Driven Activity-Based Costing (TDABC) methodology.

METHODS

We demonstrated a step-by-step application of TDABC based on a process map with core OSMT intervention activities and associated procedures and determined resource use and costs, per unit procedure. We also assessed per-patient costs from a payer perspective and provided estimates of total hours and costs by personnel, activity, and procedure.

RESULTS

The per-patient cost of the OSMT was $1758. Personnel time accounted for 91% of the total cost. Site supervisor and information technology technician time were the most expensive personnel resources. Telehealth technical and communication equipment accounted for 8% of the total cost. Intervention coordination and monitoring efforts represented most of the total time cost (62%), followed by the intervention delivery (35%). The procedures with the highest cost were communication via phone or virtual meetings (24%), email exchanges (18%), and telehealth session delivery (18%).

CONCLUSIONS

Future efforts to replicate, disseminate, and implement the OSMT intervention should anticipate funding for nonclinical components of the intervention, including coordination and monitoring, and consider how these activities can be performed most efficiently. For institutions without established telemedicine programs, selection of videoconferencing platforms and adequate staffing for participant technical support should be considered. Our step-by-step application of TDABC serves as a case study demonstrating how interventionists can gather data on resource use and costs of intervention activities concurrently with their collection of trial data.

Implementation science issues in understanding, collecting, and using cost estimates: a multi-stakeholder perspective

Understanding the resources needed to achieve desired implementation and effectiveness outcomes is essential to implementing and sustaining evidence-based practices (EBPs). Despite this frequent observation, cost and economic measurement and reporting are rare, but becoming more frequent in implementation science, and when present is seldom reported from the perspective of multiple stakeholders (e.g., the organization, supervisory team), including those who will ultimately implement and sustain EBPs.Incorporating a multi-level framework is useful for understanding and integrating the perspectives and priorities of the diverse set of stakeholders involved in implementation. Stakeholders across levels, from patients to delivery staff to health systems, experience different economic impacts (costs, benefit, and value) related to EBP implementation and have different perspectives on these issues. Economic theory can aid in understanding multi-level perspectives and approaches to addressing potential conflict across perspectives.This paper provides examples of key cost components especially important to different types of stakeholders. It provides specific guidance and recommendations for cost assessment activities that address the concerns of various stakeholder groups, identifies areas of agreement and conflict in priorities, and outlines theoretically informed approaches to understanding conflicts among stakeholder groups and processes to address them. Involving stakeholders throughout the implementation process and presenting economic information in ways that are clear and meaningful to different stakeholder groups can aid in maximizing benefits within the context of limited resources. We posit that such approaches are vital to advancing economic evaluation in implementation science. Finally, we identify directions for future research and application.Considering a range of stakeholders is critical to informing economic evaluation that will support appropriate decisions about resource allocation across contexts to inform decisions about successful adoption, implementation, and sustainment. Not all perspectives need to be addressed in a given project but identifying and understanding perspectives of multiple groups of key stakeholders including patients and direct implementation staff not often explicitly considered in traditional economic evaluation are needed in implementation research.

Bridging the research to practice gap: a systematic scoping review of implementation of interventions for cancer-related fatigue management

BACKGROUND

Cancer-related fatigue (CRF) is one of the most common and distressing symptoms in people with cancer. Although efficacy of interventions for CRF have been extensively investigated, less has been done to ensure successful translation into routine clinical practice. The aim of this systematic scoping review was to synthesise knowledge surrounding the implementation of CRF interventions, summarise the processes and outcomes of implementation strategies used, and identify opportunities for further research.

METHODS

PubMed, Cochrane CENTRAL, EMBASE and CINAHL databases were searched (up to December 2020). The Cochrane Effective Practice and Organisation of Care (EPOC) Group taxonomy and the RE-AIM Framework were used to guide the evaluation of implementation strategies and outcomes, respectively.

RESULTS

Six studies were included. Three used an implementation framework (PARIHS, KTA, Cullens & Adams' Implementation Guide) to guide implementation. Overall, the implementation strategies used across all studies were reported to have directly resulted in immediate changes at the clinician level (e.g., increased clinician behaviours, self-efficacy, attitudes, knowledge of CRF management). No clear relationship was found between the use of implementation models and the number or type of implementation strategies used. For outcomes, Effectiveness and Implementation were the most highly reported RE-AIM measures followed by Reach then Maintenance. Adoption was the least reported.

CONCLUSIONS

Despite the high prevalence of CRF and evidence-based interventions for managing CRF, there is limited evidence informing the sustainable implementation of these interventions. This systematic scoping review emphasises the lack of quality CRF implementation studies presently available in the literature leading to a disconnect between effective CRF interventions, routine clinical care, and cancer survivors at present. This review highlights the need for robust study designs guided by established frameworks to methodically design and evaluate the implementation of CRF management interventions in the future.

Brief alcohol interventions in U.S. medical settings: A systematic review of the implementation literature

This systematic review provides a synthesis of the literature on brief alcohol intervention (BAI) implementation in medical settings. We utilized the Proctor et al. (2011) taxonomy of eight implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability) to organize and describe the qualitative and quantitative literature regarding BAI implementation. An electronic search of the PubMed database identified 25 articles that met inclusion criteria. The study team independently assessed all articles for methodological quality, with the majority of studies rated as weak to moderate. Descriptive and narrative review of the included articles identified penetration and acceptability as the two most commonly reported implementation outcomes. Studies rarely reported other outcomes (e.g., fidelity, cost, sustainability, adoption). On average, studies utilized approximately six implementation strategies to facilitate implementation, with education (96%), quality management (64%), and planning (56%) strategies the most frequently reported. Promising evidence exists that patients and providers are accepting of BAI implementation efforts and implementation efforts are helpful in expanding the reach of BAIs. A theory-informed approach to selecting implementation strategies may enhance implementation success in future work. When reporting on implementation, all studies should provide detailed BAI descriptions and strategies to enhance replication efforts. We suggest study designs that balance practical outcomes with methodological rigor to maximize the quality of future studies and better inform implementation efforts.

Cost-Effectiveness Analysis in Implementation Science: a Research Agenda and Call for Wider Application

Purpose of Review

Cost-effectiveness analysis (CEA) can help identify the trade-offs decision makers face when confronted with alternative courses of action for the implementation of public health strategies. Application of CEA alongside implementation scientific studies remains limited. We aimed to identify areas for future development in order to enhance the uptake and impact of model-based CEA in implementation scientific research.

Recent Findings

Important questions remain about how to broadly implement evidence-based public health interventions in routine practice. Establishing population-level implementation strategy components and distinct implementation phases, including planning for implementation, the time required to scale-up programs, and sustainment efforts required to maintain them, can help determine the data needed to quantify each of these elements. Model-based CEA can use these data to determine the added value associated with each of these elements across systems, settings, population subgroups, and levels of implementation to provide tailored guidance for evidence-based public health action. There is a need to integrate implementation science explicitly into CEA to adequately capture diverse real-world delivery contexts and make detailed, informed recommendations on the aspects of the implementation process that provide good value.

Summary

We describe examples of how model-based CEA can integrate implementation scientific concepts and evidence to help tailor evaluations to local context. We also propose six distinct domains for methodological advancement in order to enhance the uptake and impact of model-based cost-effectiveness analysis in implementation scientific research.