A Taxonomy for External Support for Practice Transformation

Practice Facilitation to Address Unhealthy Alcohol Use in Primary Care: A Cluster Randomized Clinical Trial

Importance

Unhealthy alcohol use (UAU) is the fourth most preventable cause of death in the US. The US Preventive Services Task Force recommends that primary care clinicians routinely screen all adults 18 years and older for UAU; however, this preventive service is poorly implemented.

Objective

To determine if practice facilitation improved delivery of the recommended care for UAU compared to usual care.

Design, Setting, and Participants

This practice-level cluster randomized clinical trial was conducted across diverse and representative primary care practices throughout Virginia. A total of 76 primary care practices enrolled between October 2019 and January 2023.

Intervention

Practices received immediate (intervention) or 6-month delayed (control) practice facilitation, which included tailored educational sessions, workflow management, and tools for addressing UAU.

Main Outcomes and Measures

Outcomes included the increase in recommended screening for UAU, brief interventions, referral for counseling, and medication treatment. Data were collected via medical record review (structured and free text data) and transcripts of practice facilitator sessions and exits interviews.

Results

Of the 76 primary care practices enrolled, 32 were randomized to intervention and 35 to control; 11 789 patients (mean [SD] age, 50.1 [16.3] years; 61.1% women) were randomly selected for analysis, with patient demographics similar to Virginia at large. From baseline to 6 months after intervention, screening with a validated instrument increased from 2.1% (95% CI, 0.5%-8.4%) to 35.5% (95% CI, 11.5%-69.9%) in the intervention group compared to 0.4% (95% CI, 0.1%-1.8%) to 1.4% (95% CI, 0.3%-5.8%) in the control group (P < .001). Brief office-based interventions for the intervention group increased from 26.2% (95% CI, 14.2%-45.8%) to 62.6% (95% CI, 43.6%-78.3%) vs 45.5% (95% CI, 28.0%-64.1%) to 55.1% (95% CI, 36.5%-72.3%) in the control group (P = .008). Identification of UAU, referral for counseling, and medication treatment had similar changes for both groups. Qualitative analyses of transcripts revealed that few clinicians understood the preventive service prior to practice facilitation, but at the end most felt much more competent and confident with screening and brief intervention for UAU.

Conclusions and Relevance

This cluster randomized clinical trial demonstrated that practice facilitation can help primary care practices to better implement screening and counseling for UAU into their routine workflow. Effective primary care practice implementation interventions such as this can have a profound effect on the health of communities. Given the number of people that the participating practices care for, this intervention resulted in an additional 114 604 patients being screened annually for UAU who would not have been otherwise.

Trial Registration

ClinicalTrials.gov Identifier: NCT04248023.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022

BACKGROUND

Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes.

METHODS

We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes.

FINDINGS

Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions.

CONCLUSION

This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

Implementation strategies for large scale quality improvement initiatives in primary care settings: a qualitative assessment

BACKGROUND AND OBJECTIVES

The EvidenceNOW: Advancing Heart Health in Primary Care was designed to assist primary care practices in the US in implementing evidence-based practices in cardiovascular care and building capacity for quality improvement. EvidenceNOW, NCT03054090, was registered with ClinicalTrials.gov on 15/02/2017. The goals of this study were to gain a comprehensive understanding of perspectives from research participants and research team members on the value of implementation strategies and factors that influenced the EvidenceNOW initiative in Virginia.

METHODS

In 2018, we conducted 25 focus groups with clinicians and staff at participating practices, including 80 physicians, advanced practice clinicians, practice managers and other practice staff. We also conducted face-to-face and telephone interviews with 22 research team members, including lead investigators, practice facilitators, physician expert consultants, and evaluators. We used the integrated-Promoting Action on Research Implementation in the Health Services (i-PARIHS) framework in our qualitative data analysis and organization of themes.

RESULTS

Implementation strategies valued by both practice representatives and research team members included the kick-off event, on-site practice facilitation, and interaction with physician expert consultants. Remote practice facilitation and web-based tools were used less frequently. Contextual factors that influence quality improvement efforts include leadership support, access to resources, previous quality improvement experience, and practice ownership type (independent compared to health system owned). Many clinicians and staff were overwhelmed by day-to-day activities and experience initiative fatigue, which hindered their ability to fully participate in the EvidenceNOW initiative.

CONCLUSIONS

This study provides details on how the practice environment plays an essential role in the implementation of evidence-based practices in primary care. Future efforts to improve quality in primary care practices should consider the context and environment of individual practices, with targeted implementation strategies to meet the needs of independent and health system owned practices. Future efforts to improve quality in primary care practices require strategies to address initiative fatigue among clinicians and practice staff. External support for building capacity for quality improvement could help primary care practices implement and sustain evidence-based practices and improve quality of care.

TRIAL REGISTRATION

This project was registered with ClinicalTrials.gov on 15/02/2017 and the identifier is NCT03054090.

Getting to implementation: Adaptation of an implementation playbook

Introduction

Implementation strategies supporting the translation of evidence into practice need to be tailored and adapted for maximum effectiveness, yet the field of adapting implementation strategies remains nascent. We aimed to adapt "Getting To Outcomes"® (GTO), a 10-step implementation playbook designed to help community-based organizations plan and evaluate behavioral health programs, into "Getting To Implementation" (GTI) to support the selection, tailoring, and use of implementation strategies in health care settings.

Methods

Our embedded evaluation team partnered with operations, external facilitators, and site implementers to employ participatory methods to co-design and adapt GTO for Veterans Health Administration (VA) outpatient cirrhosis care improvement. The Framework for Reporting Adaptations and Modifications to Evidenced-based Implementation Strategies (FRAME-IS) guided documentation and analysis of changes made pre- and post-implementation of GTI at 12 VA medical centers. Data from multiple sources (interviews, observation, content analysis, and fidelity tracking) were triangulated and analyzed using rapid techniques over a 3-year period.

Results

Adaptations during pre-implementation were planned, proactive, and focused on context and content to improve acceptability, appropriateness, and feasibility of the GTI playbook. Modifications during and after implementation were unplanned and reactive, concentrating on adoption, fidelity, and sustainability. All changes were collaboratively developed, fidelity consistent at the level of the facilitator and/or implementer.

Conclusion

GTO was initially adapted to GTI to support health care teams' selection and use of implementation strategies for improving guideline-concordant medical care. GTI required ongoing modification, particularly in steps regarding team building, context assessment, strategy selection, and sustainability due to difficulties with step clarity and progression. This work also highlights the challenges in pragmatic approaches to collecting and synthesizing implementation, fidelity, and adaptation data.

Trial registration

This study was registered on ClinicalTrials.gov (Identifier: NCT04178096).

Identifying Contextual Factors and Strategies for Practice Facilitation in Primary Care Quality Improvement Using an Informatics-Driven Model: Framework Development and Mixed Methods Case Study

BACKGROUND

The past decade has seen increasing opportunities and efforts to integrate quality improvement into health care. Practice facilitation is a proven strategy to support redesign and improvement in primary care practices that focuses on building organizational capacity for continuous improvement. Practice leadership, staff, and practice facilitators all play important roles in supporting quality improvement in primary care. However, little is known about their perspectives on the context, enablers, barriers, and strategies that impact quality improvement initiatives.

OBJECTIVE

This study aimed to develop a framework to enable assessment of contextual factors, challenges, and strategies that impact practice facilitation, clinical measure performance, and the implementation of quality improvement interventions. We also illustrated the application of the framework using a real-world case study.

METHODS

We developed the TITO (task, individual, technology, and organization) framework by conducting participatory stakeholder workshops and incorporating their perspectives to identify enablers and barriers to quality improvement and practice facilitation. We conducted a case study using a mixed methods approach to demonstrate the use of the framework and describe practice facilitation and factors that impact quality improvement in a primary care practice that participated in the Healthy Hearts in the Heartland study.

RESULTS

The proposed framework was used to organize and analyze different stakeholders' perspectives and key factors based on framework domains. The case study showed that practice leaders, staff, and practice facilitators all influenced the success of the quality improvement program. However, these participants faced different challenges and used different strategies. The framework showed that barriers stemmed from patients' social determinants of health, a lack of staff and time, and unsystematic facilitation resources, while enablers included practice culture, staff buy-in, implementation of effective practice facilitation strategies, practice capacity for change, and shared complementary resources from similar, ongoing programs.

CONCLUSIONS

Our framework provided a useful and generalizable structure to guide and support assessment of future practice facilitation projects, quality improvement initiatives, and health care intervention implementation studies. The practice leader, staff, and practice facilitator all saw value in the quality improvement program and practice facilitation. Practice facilitators are key liaisons to help the quality improvement program; they help all stakeholders work toward a shared target and leverage tailored strategies. Taking advantage of resources from competing, yet complementary, programs as additional support may accelerate the effective achievement of quality improvement goals. Practice facilitation-supported quality improvement programs may be opportunities to assist primary care practices in achieving improved quality of care through focused and targeted efforts. The case study demonstrated how our framework can support a better understanding of contextual factors for practice facilitation, which could enable well-prepared and more successful quality improvement programs for primary care practices. Combining implementation science and informatics thinking, our TITO framework may facilitate interdisciplinary research in both fields.