An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up

BACKGROUND

High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years.

METHODS

The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis.

RESULTS

The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time.

CONCLUSIONS

The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

Informing Use of Telehealth for Managing Chronic Conditions: Mixed-Methods Evaluation of Telehealth Use to Manage Heart Failure During COVID-19

Background The COVID-19 pandemic forced Veterans Health Administration facilities to rapidly adopt and deploy telehealth alternatives to provide continuity of care to veterans while minimizing physical contact. The impact of moving to virtual visits on patients with congestive heart failure (HF) is unknown. The goal of this study was to understand how patients with HF and their providers experienced the shift to telehealth for managing a chronic condition, and to inform best practices for continued telehealth use. Methods and Results We identified Veterans Health Administration Medical Centers with high telehealth use before COVID-19 and sites that were forced to adopt telehealth in response to COVID-19, and interviewed cardiology providers and veterans with HF about their experiences using telehealth. Interviews were recorded, transcribed, and analyzed using team-based rapid content analysis. We identified 3 trajectory patterns for cardiology telehealth use before and during COVID-19. They were the low-use class (low to low), high-use class (relatively high to higher), and increased-use class (low to high). The high-use and increased-use classes fit the criteria for sites that had high telehealth use before COVID-19 and sites that rapidly adopted telehealth in response to COVID-19. There were 12 sites in the high-use class and 4 sites in the increased-use class. To match with the number of sites in the increased-use class, we selected the top 4 sites by looking at the months before COVID-19. We identified 3 themes related to telehealth use among patients with HF and cardiology providers: (1) technology was the primary barrier for both patients and providers; (2) infrastructural support was the primary facilitator for providers; and (3) both patients and providers had largely neutral opinions on how telehealth compares to in-person care but described situations in which telehealth is not appropriate. Conclusions Only 12 sites fit the criteria of high telehealth use in cardiology before COVID-19, and 4 fit the criteria of low use that increased in response to COVID-19. Patients and providers at both site types were largely satisfied using telehealth to manage HF. Understanding best practices for managing ambulatory care-sensitive conditions through virtual visits can help the Veterans Health Administration prepare for long-term impacts of COVID-19 on in-person visits, as well as improve access to care for veterans who live remotely or who have difficulty traveling to in-person appointments.

The effects of dehydroepiandrosterone and dehydroepiandrosterone sulfate on the reproductive and vital organs of male rats

Recent studies have documented that conventional administration (orally or injections) of DHEA (Dehydroepiandrosterone) or DHEAS (Dehydroepiandrosterone Sulfate) have induced alteration in tissues of the reproductive track of male rats. However, the exact mechanism of this physiological response has not been extensively studied. In addition, the route of DHEA or DHEAS administration has not been fully investigated. The specific objectives of this study were: (1) to deliver DHEA and DHEAS at a sustained level by means of TCPL delivery system, and (2) to evaluate the ultrastructural changes associated with sustained delivery of DHEA and DHEAS at the reproductive and vital organs level. A total of 12 adult male rats (BW 250-270 gm) were randomly divided into four equal groups. Groups 1-3 were implanted with TCPL ceramic capsules loaded with 200 mg DHEA (low dose), 600 mg DHEA (high dose) and 200 mg DHEAS, respectively. Aseptic surgical techniques were performed throughout the experiment. Blood (2 mls) was collected every other day for biochemical analysis. The weights were recorded bi-weekly. At the end of 21 days post-implantation, all control and experimental animals were sacrificed following standard lab procedure (overdose of Halothane). The reproductive and vital organs were collected, weighed, fixed, embedded, sectioned, and stained (H&E) for histological evaluations. Data obtained from this investigation suggest the following: (1) body weights between the experimental (DHEA and DHEAS) and control were unchanged, (2) weights of the reproductive were significantly different than controls, (3) kidney weights wee the only vital organ that was statistically different than controls, (4) prostatic tissue of the experimental group showed signs of atrophy, and (5) focal atrophy was also evident in the seminferous tubules and testes of DHEA and DHEAS treated rats. Overall conclusion of this study suggest that in male rats, the use of DHEA and DHEAS in a sustained delivery system seems to show some physiological changes in the vital and reproductive organs.

Histopathological evaluation of female reproductive tract exposed to sustained delivery of DHEA, and DHEA + E

Dehydroepiandrosterone (DHEA) is a hormone produced by the adrenals that serves as a precursor for numerous steroid hormones. Conventional modes of DHEA administration were limited to injections and oral routes, which result in several drawbacks. This mandates the desire for the development of a different route of DHEA administration. Sustained delivery of DHEA by bioceramic capsules has not been fully explored. The objectives of this study were: (1) to deliver DHEA, and DHEA + estrogen in a sustained manner using tricalcium phosphate-lysine (TCPL) bioceramic capsules, and (2) to evaluate the morphological changes of reproductive and vital organs using female rats as a model. A total of twelve adult female rats (220-250 g) were randomly divided into four equal groups. Rats in Groups 1 and 2 were implanted with TCPL capsules containing 200 mg DHEA, and 600 mg DHEA (DHEA-HD), respectively. Group 3 animals were implanted with one TCPL capsule containing 200 mg of DHEA and a second TCPL capsule containing 50 mg estrogen, (DHEA + E). Group 4 represented the control group. Aseptic surgical techniques were utilized during i.p. implantation of the capsules. After implantation, body weights were recorded and blood (2 ml) samples were taken biweekly for 21 days. Pap smears were taken daily. At the end of 21 days, the animals were sacrificed using an overdose of halothane. The vital and reproductive organs were harvested, processed, embedded, sectioned and screened for cellular changes. Data obtained from these procedures revealed slight hypertrophy of the heart and kidneys. In DHEA + E implanted rats, a statistically significant increase (P < 0.05) was observed in the weights of the tubules, cervix, and uterine tissues compared to the control animals. Data obtained from this study demonstrates that the proliferative effect of sustained delivery of DHEA on the reproductive organs (ovary, cervix, uterus, and tubes) of female rats. This study provides more insights regarding the physiological alteration induced by sustained delivery of DHEA.